Durham_Well Abandonment_20221114

Vi1.1.L E�t5L�1rLV1r1V11�.1V1 KL(,(�K� For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
C�sA+,, l>+s s� '� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well ow+°r personally abandoning well on his/her property) well cons truction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
pCr , ,t tr )�'Jt Va�&_L fir— FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e. U/C,County,State, Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply)-
❑Agricultural ❑Municipal/Public El Neat Cement Grout entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Indusuial/Commercial UXeesidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrication ❑ 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
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑1'raccr 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
.
4.Date well(s)abandoned:
5a.Well location: V y ? 2022
Facility/Owner Name Facility ID#(if applicable) 8.Certification: lih`vfPlliJ.lES�f rDc.3C3gykrti,j Uray
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laao �, < �s�v DIY,
Physical Address,City,and Zip ¢ L �- __1�1 (JC t_21'
Signature of Certified Well Contractor or Well Owner Date
By signing this fornt, l 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
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a ropy of this retard has been provided to the well owner.
(if well field,one ladlong is sufficient) 9.Site diagram or additional well details:
N 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 we11 consn7+ct+on record(s)ifavailable. Forn+altiple injection or non-watersupph wells
ONLY with the same construction/abandonment,you can submit au jarm.
10a. For All Wells: .Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (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: (in,) above, also submit one copy of this form within 30 days of completion of well
r� abandonment to the following:
6d.Water level below ground surface: s. )S_ (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (pt) loc.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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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Public Health
ENVIRONMENTAL HEALTH DIVISION
AR11 ication for Well Repair or Abandonment
APPLICANT INFORMATION:
Applicant Name�an +�d �p �`T, �� Address 4 �— �
City t�_�_c� d� State tJ�C Zip a'7 7 (3
Applicant E-maill?k �n. t)cl orri and �Q fYaL .cq Phone
Owner Name ( O2�PC '-10 a- (����3,� Address � �d 9 _.�. .��s--L—
City State t� 'L Zip
Owner E-mail' e�i y. � C(��o � c , Phone )4 i �' 13
Property Location 1a 0-7 1 6U 'i -!S . �t S+Zf'1 R,.Cr\\)P— 11)y P-�cu,�, N C,
Parcel ID# /S'7 ! Sv PIN#D 73 9 - _ 7 -- d 1�s' -a 4n 0 01 'S A INN
1 :5- ') 114 'c 6 .739 3 -7 - 1- - 19 1-a 0'7 .9 1s'hr`H
• Type of Repair: ❑ Extend above grade Liner/packer El Drill deeper
Other(please explain)
• If abandonment, type of well: Drilled oBored/Hand Dug
ENVIRONMENTAL HEALTH REQUIREMENTS FOR PERMIT:
• SUBMIT A SITE DRAWING OF THE.PROPERTY NOTING WHERE THE WELL IS LOCATED AND
ANY EXISTING BUILDINGS,DRIVEWAY(S),OUT BUILDING(S),ETC.
• WELL CONTRACTOR IS TO NOTIFY ENVIRONMENTAL HEALTH FOR AN INSPECTION
APPOINTMENT AT LEAST 24 HOURS PRIOR TO INSPECTION.
I have read this application and certify that the information provided herein is true, complete and correct. Authorized county
and state officials are granted right of entry to conduct necessary inspections to determine compliance and applicable laws and
rules. I understand that I am solely responsible for the proper identification and labeling of all property lines and corners and
making the site accessible so that a complete site evaluation can be performed.
Signature , Date U ti a Owner/ Uwner's Agent _
Rev. 09/2021 Page 1 of 1
Environmental Health Division
Human Services Building 1414 East Main Street, Durham, North Carolina 27701
Nealb '
[phone] 1 Fax[phone] dconc.gov
Equal Employment/Affirmative Action Employer

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Public Health
ZOO
ENVIRONMENTAL HEALTH DIVISION
414 E. Main Street, Durham, NC 27701
Ph 919-560-7800 Fax [phone]
[e-mail]
PERMIT TO REPAIR OR ABANDON A WATER SUPPLY WELL
Applicant: Donald and Joyce Odom Owner: Same as applicant
Property Address: 4209 S Alston Ave City: Durham Zip: 27713
157150 0738-37-17-0445 Parcel ID: � PIN# Subdivision:
House: ✓I Mobile Home: Business:
Permit Issued by: Patrick Eaton REHS 2112 Date: 10/14/2022
REPAIR:
Contractor: Certification #:
Existing Casing Length: Length of Casing Extension:
Liner Depth: Grout Method: Well Depth:
Tap: Y I N Vent Pipe: Y/ N Well Tag: Y/ N Pump Tag: Y/N Well Log: Y/ N Chlorine: Y/N
CERTIFICATE OF COMPLETION: Date:
ABANDONMENT:
Type of Well: Drilled Method: Bentonite Chips
Contractor: R. Scott Hilliard - Reece Pump Service Certification#: 2763-B
Inspected By: Date: !01 i 1-1 A o z 2-
Permit Notes: Sketch: (or copy of site map attached)
Permit to abandon drilled
well. House is served by
public water.
r
Rev. 09/2020
Environmental Health Division
Human Services Building 1 414 East Main Street, Durham,North Carolina 27701
` .� [phone] 1 Fax[phone] dconc.gov
k:,. Equal Employment/Affirmative Action Employer