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HomeMy WebLinkAboutDurham_Well Abandonment_20221208 (2) 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 histher property) Fwmalap/e ayecnan ar,ma-»mc.nvrsv wrJtr OA'LYwah the x re caunrenon uhexlawuwm wu can.uAma ore juror 4146A NC Well Contractor Certification Number 7b.Approximate volume of water remaining hl we6(s): N/A (gal.) CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: Company Name 7e.Type of disinfectant used: N/A 2.Well Construction Permit 8: N/A 1:rl au applreablr.11 porn;&fce.Cmmty,stmr.Van..1q cri.et.)fb » 7d.Amount of disinfectant used: N/A 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Mumcipal/Public ❑Neat Cement Grout gBemorde Chips or Pellets OGembermal IHeiting/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑fry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) OConcrete Grout ❑Drill Cuttings ❑Irrigation OSpecialty,Grout []Gravel Non-Water Supply Well: ❑Bentonite Slurry DOther(explain under 7g) ■Monitoring ❑Recovery Injection Well: 71.For each material selected above,provide amount of materials used: ❑Aquifer Recharge OGroundwater Remediation Bentonite Pellets —25 lbS lbs. ❑Aquifer Storage and Recovery ❑Salinity Barrier OAquifer Test ❑Stamtwater Drainage ❑Experimental Technology ❑Subsidence Control ❑Geothenrel(Closed Loop) ❑Tsar 7g.Provide a brief description of the abandonment procedure: ❑Geothemial(Heating/Cooling Return) OOther(explain under 7g) 1 well material removed and backfilled wfth hydrated a: iientonite pellets to e)dsting grade. 4.Date welds)abandoned: 11/25/2022 oft13 2022 5a.Well Location: NCDEO-FORMER UL COUNTRY STORE S.Certification: FacilitylOwtrer Name Facility ml!(if applicade) 6606 LEESVILLE RD., DURHAM,27703 �4r��Cf/ December 1.2022 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owrer Date DURHAM N/A By signing/hisform I herebv certify that the wells)was(were)abandoned in Canty Parcel Identification No(PIN) accordance with 15A NCAC 02C.0100 or 1C Well Construction Standards and that a copy of this record has been provided to the well owner 5b.Latitude and longitude in degrees/mh.utesiseconds or decimal degrees: (if welt field,one lat/long is sufficient) 9.Site diagram or additional well details: 35.9340209 -78.7745463 �Y You may use the back of this page to provide additional well site details or well N abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELLISI BEING ABANDONED SIBMITTAL INSTRUCTIONS A11mhwe11Conntucttanrecord(s)tfawu1able Fwtwfnpfe iryaTimorrom ersappfv well ONLYwrih the same cwutnr ltan ahanlwmrem,ynu r mbmtt preform 10a.For All Weds: Submit this form within 30 days of completion of well 6a.Well ITN: TMW-04 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total wed depth: 15 (ft.) 1617 Mad Service Center,Raleigh,NC 27699-1617 10b.For Injection Wells: In addition to sending the foam to the address in 6c.Borehole diameter: 4.25(ln.) IOa above,also submit one copy ofthis forts,within 30 days of completion of well abandonment to the following: 6d.Water level below ground surface: NM(ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.fluter casing length(jf knows,): N/A 10c.For Water Sunnh&trajection"ells: 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(irknowm): 0(ft.) count'where abandoned. 6g.Screen length(dknown): 15(ft.) S\GD"ROIEMf NCDEQ-SLPPROJEM(A )_CD 1140_NCDEQSIPFORMERW.COI/MRYSfORE.GPJ Adapted from NCli N -DWR Fom GW-30 North Cuolw DeRumwnt ofEawo .tv.d Netmd Reworces-Diviam ofWuw Rew . Revied Aram 2013 TMW-03 N TMW-01 TMW-U4 APPROXIMATE LOCATION OF FORMER 1,000-GAL. UST MW-4R ® DW-1A APPROXIMATE LOCATION OF FORMER 550-GAL. UST MW-1C ® MW-6A TMW-02 i r>r 41 LEGEND MW-3R MW;5R ® Abandoned Temporary Monitoring Well (Type 1) 1 ® Monitoring Well (Type II) • Abandoned Monitoring Well (Type 11) , • Abandoned Monitoring Well (Type III) MW-7 s Approximate Location of Former USTs Parcel Boundary i■ E i, xar Ea hstar �eo rap as, and the GlS User Cornr ty NOTE:Well and tank locations were obtained from previous reports prepared by other consultants and are approximate. 20 10 0 20 40 Feet MoEa FORMER LIL TI%E FIGURE COLINTRYSTORE CATLIN 606 L ESVIILLE RD SITE MAP DURHAM, NC 1 Engineers and Scientists NO. tale WG p WNB XKMD BY 9990 221140 DEC 2022 AS SHOWN KMC/SJO WELL A$ANMNMENT RECORD For lntemal Ux ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: WELL ABANDONMENT DETAILS D.T.CHALMERS,JR. 7a.Numberofwells being abandoned: N/A Well Contractor Name(or well owner personally abandoning well on his/her property) Fwmuhrplem c/e non o.non-amer.npt4y urlls ONLY with the rarrre earvrrucnonto m,you can svdmir one form 4146A NC Well Contractor Certification Number 7b.Approximate valiant of water remaining inwelks): 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 8: N/A Lstal/appllcade writ Mono,01 Cowry.SO".ran—rc IIY"an,IX)Il non, 7d.Amount of disinfectant used: N/A 3.Well use(check wed use): Water Supply Well: 7e.Scaling materials used(check all that apply): ❑P.gicultual ❑Municipal/Public ❑Neat Cement Grout NBentonite Chips or Pellets ❑Geothemul(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay ❑tndustial/Cotmercial ❑Residential Water Supply(sharcd) ❑Concrete Grout ODrill Cuttings ❑Irrigation ❑Specialty Grout DGravel Non-Water Supply Well: ❑Bentonite Slurry ❑Oder(cplain under 7g) ■Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge OGroundwater Remediation Bentonite Pellets -25 lbs lbs. OAquifcr Storage and Recovery ❑Salinity Barrier OAquifer Test ❑Stommater Drainage ❑Experimental Technology ❑Subsideace Control OGeotlermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure: DGeothemml(Heating/CcolingReturn) ❑Other(e immder7 - ". / ,qll well material removed and backfilled with hydrated bentonite pellets to eAsting grade. 4.Date welgs)abandoned: 11/25/2022 DEC 0 8 2022 5a.Well Location: InCOf>ru:isa ?rc;a:.>r:r.g Ur.:. NCDEQ-FORMER LIL COUNTRY STORE 0-033'F a'*-,3'—G Facility/Osmer Name Facility IDM(if applicable) S.Certification: 6606 LEESVILLE RD., DURHAM,27703 171�� December 1 2022 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Ower Date DURHAM N/A By signing this form I hereby certify that the wells)was(were)abandoned in County Parcel Identification No.(PIN) accordance with l SA NCAC 02C.0100 or 2C Well Contraction Standards and that a copy of this record has been provided to the well owner. 5b.Latitude and longitude in degreeslmmutes/seconds or decimal degrees: (if well field,one Iavlong is sufficient) 9.Site diagram or additional well details: 35.9340853 N -78.7746515 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 WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well convochon re d(s)fanoilable For mtdnple oyeRton or rwn-wriernor well ONLY.&the.smne co 1,wrlon ahmalarweru.wit con"'hoot one form IOa.For All Wells: Submit this form within 30 days of completion of well 6a.WeR IDN: TMW-03 abandonment to the following: Division of Water Resources,Information Processing Ling, 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 6c.Borehole diameter: 4.25(in.) IOR 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: NM(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 SuoDly&IniectRip 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(d laown): 0(ft.) county where abandoned. 6g.Screen length(if known): 15(ft.) S\FROIECNVCDEQ-SIP PROTE7TS(AIL)_CDF1221140NCDEQSIP FORMER Id.000NTRY SfORE.GPJ Adapted firm NCDEt4R-DWR Form OWJO North Carolw Depvmient ofEnmainent and Natal Rewwces-Diviaim of Water Resource, Revised Augior 2013