Granville_Well Abandonment_20221111 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steven R. Gerrald 7a.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4309-B wells abandoned:-'
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 8 (gal.)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY: i ti
Company Name
7c.Type of disinfectant used: 22
2.Well Construction Permit#: NSA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: I(liOfR1321C;1 Pr UrA
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring NRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips - 175 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g)
Gravity pour bentonite chips monitored using weighted
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 10/21/22
5a.Well location:
Jack's Best Buy Jack's Best Buy Incident No.39227
Facility/Owner Name Facility ID#(if applicable) 8.Certification: /
315 Central Avenue, Butner, NC 27509
Physical Address,City,and Zip SiSi a�n�'ture ofXrrtified Well Contractor or Well Owner Date
Granville
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.13454 N 78.75931 W You may use the back of this page jto provide additional well site details or well
abandonment details. You may also:attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: RW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 23 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 1" / 6" (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface:
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10.9 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): 3 (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): NA (ft) abandoned.
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6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steven R. Gerrald 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4309-B wells abandoned:3
NC Well Contractor Certification Number 7b.Approximate volume of water rIemaining in well(s): 0 (gal.)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name E C E I V E ID
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown N O V 1 12022
7d.Amount of disinfectant used:
3.Well use(check well use): 1
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips - 50 IbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Gravity pour bentonite chips monitored using weighted
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 10/21/22
Sa.Well location:
Jacks Best Buy Jack's Best Buy Incident No.39227
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
315 Central Avenue, Butner, NC 27509
Physical Address,City,and Zip Signature ofCertified Well Contractor or Well Owner Date
Granville By signing this form, I hereby certY that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.13454 N 78.75931 W You may use the back of this page jto provide additional well site details or well
abandonment details. You may alsolattach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the some construciion/abandonment,you can submit one form.
10a. For All Wells: Submit this!form within 30 days of completion of well
6a.Well iD#: VP-1, VP-2, VP-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 10 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
NA Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10 loc.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): NA (ft.) abandoned. i
6g.Screen length(if known): 10 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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