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Home My WebLink AboutGranville_Well Abandonment_20221111 (6) WELL ABANDONMENT RECORD For Internal Use ONLY: 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:s NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.1 (gal.) Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: RECEIVE 2.Well Construction Permit#: NSA NOV 1 1/ Z022 List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 7d.Amount of disinfectant used: 3.Well use(check well use): DWOOOG Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑ 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) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation Portland cement- 5 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/Cooling Return) 11 Other(explain under 7g) Air sparge injection wells. Gravity pour portland cement to surface. 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#(ifapplicable) 8.Certification: 315 Central Avenue, Butner, NC 27509 �� f/�j/�2 ZA Physical Address,City,and Zip Aiguature of ertified Well Contractor or Well Owner Date Granville By signing this form, I hereby cert�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. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwelI 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 to 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 constructionrecord(s)ifavailable.For multiple injection or non-water supply wells ONLYwith the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this;form within 30 days of completion of well 6a.Well ID#: SP-1, 2, 3, 4, 5 abandonment to the following: Division of Water Resources,Information Processing Unit, 17 1617 Mail Service Center,Raleigh,NC 27699-1617 6b.Total well depth: (ft.) 10b.For Iniection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 2.25 (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: 11 (ft,) Division of Water Resources,U4nderground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 16 (ft.) 10c.For Water Supply&Iniectio E 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. 6g.Screen length(if known): Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources k Revised 2-22-2016 i WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Steven R. Gerrald 7a.For Geoprobe/DPT or Closed-hoop 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:, 00 NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.1 (gal.) l Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY: (' Company Name C `/ 7c.Type of disinfectant used: 2.Well Construction Permit#: N/A NUV 1 202 List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: l'g UrIA 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑ 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) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation Portland cement- 5 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/Cooling Return) 9 Other(explain under7g) Air sparge injection wells. Gravity pour portland cement to surface. 4.Date well(s)abandoned: 10121/22 Sa.Well location: Jack's 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 of ertified Well Contractor or Well Owner Date Granville By signing this form, 1 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 and that a copy of this record has been provided to the well owner. 5b.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 to 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 record(s)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 fonn within 30 days of completion of well 6a.Well ID#: SP-6 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 12 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: 2.25 (in.) above,also submit one copy of this form within 30 days of completion of well abandonment to the following: i; 6d.Water level below ground surface: 11 (ft) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 10 (ft.) 10c.For Water Supply&Iniectio 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 courity health department of the county where 6E Inner casing/tubing length(if known): NA (ft) abandoned. 6g.Screen length(if known): 2 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 i I WELL ABANDONMENT RECORD For Internal Use ONLY: 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:5 NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY: RECEIVE CompanyName 7c.Type of disinfectant used: E 2.Well Construction Permit#: NSA NO V 1 1 2022 List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: M 3.Well use(check well use): B� Water Supply Well: 7e.Seating materials used(check all that apply): ❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑ 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) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Portland cement- 5 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/Cooling Return) 11 Other(explain under 7g) Air sparge injection wells. Gravity pour portland cement to surface. 4.Date wells)abandoned: 10/21/22 5a.Well location: Jack's Best Buy Jack's Best Buy Incident No.39227 Facility/Owner Name Facility ID#(ifappheable) 8.Certification: 315 Central Avenue, Butner, NC 27509 A� �,� ((/�/2Z Physical Address,City,and Zip Signature of Certified 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 and that a copy of this record has been provided to the well owner. Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one latAong is sufficient) 9.Site diagram or additional well details: 36.13454 N 78.75931 W You may use the back of this page;to 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 record(s)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#• S P-7, 8, 9, 10, 11 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 17 (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: 2.25 (in.) above, also submit one copy of this form within 30 days of completion of well abandonment to the following: 11 Division of Water Resources,Underground Injection Control Program, 6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 15 (ft.) 10c.For Water Supply&Iniectio{ 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 couu�ty health department of the county where 6f.Inner casing/tubing length(if known): NA (ft.) abandoned. 6g.Screen length(if known): 2 (ft.) c Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 i I WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Steven R. Gerrald 7a.For Geoprobe/DPT or Closed-hoop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of 4309-6 wells abandoned:t NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0'1 (gal.) Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY: ! Company Name 7c.Type of disinfectant used: RECEIVED 2.Well Construction Permit#: NSA NOV V 1 j 1 List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)if known Iv 202� 7d.Amount of disinfectant used: j 3.Well use(check well use): Water Supply Well: 7e.Scaling materials used check all that apply): DWQ/3-OG PP Y g ( PP Y)� ❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑ Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) El 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) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation Portland cement- 5 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/Cooling Return) IN Other(explain under 7g) Air sparge injection wells. Gravity pour portland cement to surface. 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#(if applicable) 8.Certification: 315 Central Avenue, Butner, NC 27509 1Z7- Physical Address,City,and Zip SrgnAure of Ce6ified 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 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well 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'to 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 record(s)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 1,form within 30 days of completion of well 6a.Well ID#: S P-12 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 14 (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: 2.25 (in.) above, also submit one copy of this form within 30 days of completion of well abandonment to the following: I 11 Division of Water Resources,Underground Injection Control Program, 6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 i 12 10c.For Water Sunaly&Iniection 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 6f.Inner casing/tubing length(if known): NA (ft) abandoned. 6g.Screen length(if known): 2 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 I I WELL ABANDONMENT RECORD For Internal Use ONLY: i 1.Well Contractor Information: WELL ABANDONMENT DETAILS h 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 I GW-30 is needed. Indicate TOTAL NUMBER of 4309-B wells abandoned:-' h 0'1 NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):_(gal.) Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY: 1�r Company Name 7c.Type of disinfectant used: l�M— �� 2.Well Construction Permit#: N/A DI List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: NOV 1 2022 3.Well use(check well use): p i oration Prxaseirg Unh Water Supply Well: 7e.Sealing materials used(check all that apply): DWQ/B:G ❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑ 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 ❑Irrigation ❑ Specialty Grout ❑ Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation Portland cement- 5 Ibs ❑Aquifer Storage and Recovery El 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/Cooling Return) 9 Other(explain under 7g) Air sparge injection wells. Gravity pour portland cement to surface. 4.Date well(s)abandoned: 10/21/22 Sa.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 z ---�� It If Physical Address,City,and Zip Signature of ertified Well Contractor or Well Owner Date Granville By signing this form, I hereby cert�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. Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well 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!to 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 record(s)ifavailable.For multiple injection or non-water supply wells ONLY with the same constructiow/7bandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well m#: SP-14 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Injection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 2.25 (in.) above, also submit one copy of thus form within 30 days of completion of well abandonment to the following: i, 6d.Water level below ground surface: 11 (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 13 10c.For Water Supply&Injection 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 6L Inner casing/tubing length(if known): NA (ft) abandoned. 6g.Screen length(if known): 2 (ft.) Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016