Durham_Well Abandonment_ (14)

WELL ABANDONMENT RECORD For Irate nal Use ONLY
This form can be rued 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 hell on his0ner property) For atiriple injection ornoo-.sacrtupply wells oNLYwah the
Pwnhuclaw.boodonnrv,sou can avb,nil ore Joan
4146A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A foal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit k: N/A
Liss al/applicable weuR,m,a o e County.State,rang ee,tjecam eta.)irk. 7d.Amount of disinfectant used: N/A
3.Well use(check well me):
Water Supply Wen: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ®Bemonite Chips or Pellets
❑Geothemal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) OConerete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout OGmvel
Non-Water Supply Well: ❑Bentonite Slurry ❑Gther(explain under 7g)
■Monitoring ORecovery
Injection Wen: 7E For each material selected above,provide amount of materials wed:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets -25 lbs lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomarater Drainage
❑Experimental Tmhmlogv ❑Subsidence Control
OGeothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
OGeothemal(Heating/Cooling Return) ❑Other(explain under 7g) _ All well material removed and backfilled with hydrated
.11entonite Pellets to emsting grade.
4.Date wells)abandoned: 11/25/2022 _ 0 S 2022
5a.Well Location:
NCDEO-FORMER LIL COUNTRY STORE
Facility/Owner Name Facility IDk(if applicable) n.Certification: r�
6606 LEESVILLE RD., DURHAM,27703 d �Cf/ Drr�rter t.2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well CO r Date
DURHAM N/A By signing thaform I herebv certify that the wells)vans(were)abandoned in
County Parcel Identification No.(PM accordance with 15A NCAC 02C.0700 or 2C Well Construction Standards and
that a copy ojthis record has been provided to the well 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:
35.9338494 N 78.7744866 �y You may use the back of this page to provide additional well site details or well
abandonment details. You my also attach additional pages if nRressary.
CONSTRUCTION DETAILS OF WELUSI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well convrtcPlart lrcnld/t)Ifavalloble Fnr muhtple iryeclion m non-comer nyydv
wellONLYwnh lh tare[nralrsrlian abadoare a.ynu cas.n limit onr form 102.For An Wells: Submit this form within 30 days of completion of Well
62.Well iD#: TMW-02 abandonment to the following.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Man Service Center,Raleigh,NC 17699-1617
10b.For Injection Wells: in addition to sending the form to the address in
6c.Borehole diameter: 4.25(In.) 1 On above,also submit one co y of this form within 30 days of completion
of well abandonment to the fo lowing:
6d.Water level below ground surface: WOO Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NIA loc.For Water Suuah &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
6E Inner casingitubing length(if known): 0(ft.) county where abandoned.
6g.Screen length(if known): 15(ft.)
S\CP ROIKTSNCDEQ-SUPROIECrS(A )_COFl lit NCDEQSIPPoRNERW.COLNrRYSrORE.GPI
Adapted from NCDENR-DWR Form GW-30 North Carolina Deparmsent ofEnvuorumm and Natural Resource,-Division of water Rea . Revived A"2013