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Home My WebLink AboutGuilford_Well Abandonment_20221222 WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of wells abandoned: 4330-B NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.) CATLIN Enginners and Sciei!ttLcCs-,, ° �1 y� FOR WATER SUPPLY WELLS ONLY: Company Name t 2 20Z2 n � 7c.Type of disinfectant used: 2.Well Construction Permit#: NA 1r;A List all applicable well construction permits(t.e. 'etc ifknown 1 r�A►i(�� 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout a Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings OIrrigation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑ Bentonite Slurry a Other(explain under 7g) eMonitoring ❑Recovery Injection Well: 7f.For each material selected aho%c,pruc ide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets - 40 Ibs ❑Aquifer Storage and Recovery ❑Salinity Barrier Concrete - 5 Ibs ❑Aquifer Test ❑StormwaterDrainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) pellets to within 6 inches of surface and topped a.Date well(s)abandoned: 12/5/2022 with concrete to existing grade. Well shield 5a.Well location: put back in place. NCDEQ-Shumakers'Grocery 0-026457 Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1601 Lee's Chapel Rd., Greensboro, 27405 12/22/2022 Physical Address,City,and Zip Signature ofCettified Well Contractor or Well Owner Date Guilford NA By signing this form, /hereby certify that the well(s) was (were) abandoned in County Parcel Identification No.(PIN) accordance with 15A NC.9C 02C.0100 or 2C.0200 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 lat/long is sufficient) 9.Site diagram or additional well details: 36.142603 N -79.770355 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record(s)ifavatlable.For multiple injection or non-water supply wells ONLY with the same constructioniahandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: M W-1 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 19.5 (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: 8.25 (in.) 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: 12.18 (ft) Division of water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): NA (ft) 10c.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 6E Inner casing/tubing length(if known): 9.5 (ft.) abandoned. 6g.Screen length(if known): 10 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD For Internal Use ONLY I.Well Contracdor Information: WELL ABANDONMENT DETAILS Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning we la on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of 4330-B I _ -_` wells abandoned: .�t t NC N'cll Contractor Certification Number i.`. �." .° 7b.Approximate volume of water remaining in well(s): (gal.) CATLIN Enginners and Scientists ncr 2 2 2022 FOR WATER SUPPLY WELLS ONLY: Company Name It1SJfMa"i?� Ut' 7c.Type of disinfectant used: 2.Well Construction Permit#: NA lDkNQr50G List all applicable well construction permits(i.e.IYC,County,,State,Pariance,etc.)ifknown 7d..lmount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings olrrigation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑ Bentonite Slurry a Other(explain under 7g) eMonitoring ❑Recovery Injection Well: 7f. For each material,elected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets - 25 Ibs ❑Aquifer Storage and Recovery ❑Salinity Barrier Concrete — 5 Ibs ❑Aquifer Test ❑StormwaterDrainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) pellets to within 6 inches of surface and topped a.Date well(s)abandoned: 12/5/2022 with concrete to existing grade. Well shield put sa.Well location: back in place. NCDEQ-Shumakers'Grocery 0-026457 Facility/Owner Name Facilit)ID#(tfappltcable) 8.Certification: 1601 Lee's Chapel Rd., Greensboro, 27405 12/22/2022 Physical Address,City,and Zip Signature ofCettified Well Contractor or Well Owner Date Guilford NA By signing this form, 1 hereby certify that the well(s) was (were)abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. Sb.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: 36.142603 N -79.770355 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)tfavadable.For multiple injection or non-water supply wells ONLY with the same conrtntetionabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: MW-2 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 17.9 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 8.25 (in) 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: 11.34 (ft.) Division of water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): NA (ft.) 10e.For Water Supply&Infection 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): 7.7 (ft.) abandoned. 6g.Screen length(if known): 10.2 (ft.) North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 Form GW 30 Q ty P WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of 4330-B } / Dells abandoned: NC Well Contractor Certification Number - 7b.Approximate volume of water remaining in well(s): (gal.) CATLIN Enginners and Scientists �� 2 220 FOR WATER SUPPLY WELLS ONLY: Company Name )�a, ��lJ 7c.Type of disinfectant used: 2.Well Construction Permit#: NA �� List all applicable well construction permits(i.e.U1C',Counttt State,t'artance,etc.)1J'known 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout a Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings ❑Ini ation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑ Bentonite Slurry N Other(explain under 7g) RMonitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets - 25 Ibs ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage Concrete — 5 Ibs ❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) pellets to within 6 inches of surface and topped a.Date well(s)abandoned: 12/5/2022 with concrete to existing grade. Well shield put 5a.Well location: back in place. NWEQ-Shumakers'Grocery 0-026457 Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1601 Lee's Chapel Rd., Greensboro, 27405 12/22/2022 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Guilford NA By signing this form, 1 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 and that a copy of this record has been provided to the well owner. Sb.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: 36.142603 -79.770355 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)ifavadable.For multiple injection or non-water supply wells ONLY with the same constntction'nhandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: MW-3 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 17.2 (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: 8.25 (in) above, also submit one copy of this form within 30 days of completion of well abandonment to the following: 6d.NN ater level below ground surface: 9.95 (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): NA (ft) 10c.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): 7 abandoned. 6g.Screen length(if known): 10.2 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL:16ANDONMENT DETAILS Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of 4330-B -- a � Is abandoned: E;'a' ' s 9� 7b NC Well Contractor Certification Number Approximate volume of water remaining in well(s): (gal.) CATLIN Enginners and Scientists 9C r 2 2 FOR WATER SUPPLY WELLS ONLY: Company Name 1��;,y,;la;t c. ype of disinfectant used: 2.Well Construction Permit#: NA DV-(y30G List all applicable well construction permits(i.e.UIC,C,amn%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 ❑Neat Cement Grout S Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings ❑Irri ation ❑Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry a Other(explain under 7g) eMonitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: []Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets — 25 Ibs []Aquifer Storage and Recovery ❑Salinity Barrier []Aquifer Test ❑StormwaterDrainage Concrete — 5 Ibs ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: []Geothermal(Closed Loop) ❑Tracer ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) Well abandoned in place with hydrated Bentonite pellets to within 6 inches of surface and topped a.Date wells)abandoned: 12/5/2022 with concrete to existing grade. 5a.Well location: NCDEQ-Shumakers'Grocery 0-026457 Facility/Owner Name Facility ID#(ifapplicable) 8.(ertitication: L,V 1601 Lee's Chapel Rd., Greensboro, 27405 12/22/2022 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Guilford NA By signing this form, 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 and that a copy of this record has been provided to the well owner. Sb.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: 36.142603 N -79.770355 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)ifavailable.For multiple injection or non-water supply wells ONLY with the same construction abandonment,you can submit one form. Ills. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: M W-4 abandonment to the following: Division of Water Resources,Information Processing Unit, 61).Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 8.25 (in.) 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: 8.64 (ft) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): NA (ft) 10c.For Water Supply&Infection 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 6E Inner casing/tubing length(if known): 5 abandoned. 6g.Screen length(if known): 15 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 I r � N 2 r� MW=3 v FORMER 4;000-GAL. r GASOLINE USTs 11AW�1 ® IV ,n FORMER DISPENSERS Q� LEGEND ' f �s Abandoned Monitoring ® Well (Type II) Approximate Location of Former UST System Parcel Boundaryl Source Esq. Mazar. EA54 tar :;eographics and the GIS laser CommunIlly NOTE: Well and tank locations were obtained from previous reports prepared by other consultants and are approximate. 30 15 0 30 60 Feet PROJECT TI`-E FIGURE SHUMAKER'S GROCERY ATLIN 1601 LEE'S CHAPEL RD SITE MAP CGREENSBORO, N, Engineers and Scientists INCIDENT NO JOB NO j DATE SCALE DRAWN BYICHECKED BY 10765 221078 DEC 2022 AS SHOWN KMC/SJO