Wake_Well Abandonment_20221114

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D.T. CHALMERS, JR. 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on IiiOier property) Formultiple injection or non-water sapply ivel/s ONLY with the same
constnictionlabandonment,you can submit one fornt.
4146A
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(t.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
I ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothemlal(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: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomlwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All well material removed and backfilled with hydrated
bentonite pellets to eAstin grade. RIP—(T' "�
fr-
4.Date well(s)abandoned: 11/5/2022 W �4
Sa.Well Location:
NCDEQ-Tackett Residence N/A Uri i�
Facility/Owner Name Facility ID#(if applicable) 8•Certification: ul atQ'u0�
13117 N. ROXBORO ST, ROUGEMONT,27572 November 8.2022
Physical Address,City,and Zip Signature of Certified Well Contractor or ell Owner Date
WAKE N/A By signing this form I hereby ceiT fy that the ivell(s)ivas(ivere)abandoned in
County Parcel Identification No.(PIN) accordance nvilh 15A NCAC 02C.0100 or 2C 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:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
36.22146888 N -78.92783392 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)if available. For multiple injection or non-water supply
well ONLYwith the same constnuction abandonment,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-05 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 Iniection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 4.25(in.) IOa 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: 15(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 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
6f.Inner casing/tubing length(if known): 5(ft.) county where abandoned.
6g.Screen length(if known): 10 (ft.)
S:\GINIIPROJEGTS\NCDEQ-SLP PROJECPS(ALL)_CDF\221052 NCDEQ SLP TACKETr RESIDENCE.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

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EDApproximate Location
of Former UST Basin WSW-9
Parcel Boundary
SquF�ce:Esri,Maxar, EarthstaS G MogCaphies5 andilthe G1 User Community
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 30 15 0 30 60
Feet
PROJECT TITLE FIGURE
TACKETT RESIDENCE
ATLIN 13117 US HWY 501 SITE MAP
CROUGEMONT, NC
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BYICHECKED BY
13145 221052 NOV 2022 AS SHOWN KMC/SJO