Wake_Well Abandonment_ (15)

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 ofwells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
constructionlalwndonment,you can submit one form.
4146A
7b.Approximate volume of water remaining in well(s): N/A (gal.)
NC Well Contractor Certification Number
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
Listall applicable well permils(i.e.County,State,Variance,injection,etc.)ifkaown 7d.Amount of disinfectant used: N/A
3.Well use(check well use): j
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑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
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7E 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 ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) All well material removed and backfilled with hydrated
bentonite pellets to eyisting gradje, _
4.Date wells abandoned: 11/5/2022
5a.Well Location: NOV I
NCDEQ-Tackett Residence N/A
8.Certification: Inf` m�-ia;i3n Rrn,,,sz,uK,,
Facility/Owner Name FacilityIDft(ifapplicable) ) URcd
13117 N. ROXBORO ST, ROUGEMONT,27572 y 1 November 8.2022
Physical Address,City,and Zip Signature of Certified Well Contractor or&11 Owner Date
WAKE N/A By signing.thisform I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15ANCAC 02C.0100 or 2C Well Construction Standards and
that a copy ofthis record has been provided to the mvell owner.
5b.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:
You may use the back ofthis page to provide additional well site details or well
36.22135487 N -78.92777856 W
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 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#: TMW-04 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.) IOn above,also submit one copy ofthis 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 IOc.For Water Supply&Iniection Wells: In addition to sending the form
to the address(es)above,also submit one copy ofthis 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.\GwnpROJEcrSWCDEQ-SLP PROJECTS(ALL)_CDFt221052 NCDEQ SLP TACKETT RESIDENCE.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Avast 2013
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