Nash_Well Abandonment_20230109 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY: C
it
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Wesley J. SOrreIIS 7a.For Geoprobe/DPT or Closed,Ll op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on_h_is/he_r progerty)� well construction/depth,only I GW-30 is needed: Indicate TOTAL NUMBER of
•
dwells
` lls abandoned:2
1.49 1.49
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): ' (gal.)
"AN o 9 2oz3 ,
Terraquest Environmental Consultant
s FOR WATER SUPPLY WELLS ONLY:
Company Name
t-�.:. �•� 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,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 a Neat Cement Grout ' ❑ 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
❑Irrigation El Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.5 Gals Water
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑StormwaterDrainage
47 Lbs. Portland Grout
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
Poured Portland Cement through tremmie pipe from the bottem of well to surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
I:
4.Date well(s)abandoned: 12/21/2022
is
5a.Well location:
L&L Food Store#8
Facility/Owner Name Facility ID#(if applicable) 8.Certification: '
2558 Hunter Hill Road, Rocky Mount NC G�� �e 12/22/22
Physical Address,City,and Zip Signature of Certif9d Well Contractor or Well Owner Date
Nash I;
By signing this form, I 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.
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:
35.984424 N -77.837748 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 1
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.
10a. For All Wells: Submit this form within 30 days of completion of.well
6a.Well ID#• Al5t µW abandonment to the following:
f
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 10a
6e.Borehole diameter: 6.25 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I ,
i
5.84,5.88 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
5 , (ft.) 16c.For Water Supply&Iniecfr In 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 coulnty health department of the county where
6f.Inner casing/tubing length(if known): (ft.)
abandoned.
M !
I
6g.Screen length(if known): 10 (ft.) 1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' I Revised 2-22-2016

41
I
WELL ABANDONMENT RECORD For Internal Use ONLY:
kI
1.Well Contractor Information: WELL ABANDONMENT DETAIIi S
Wesley J. Sorrells 7a.For Geoprobe/DPT or Closed-Lloop 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
3577 - wells abandoned:2 1
tF... z..::.. ;
NC Well Contractor Certification Number �n. = ty 4n 7b•Approximate volume of water remaining in well(s): 1.49,1'54 (gal.)
Terraquest Environmental ConsultantAN q 2021 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit
#: znt�
List all applicable well construction permits(i.e.UIC,County,State,Variance,era:�{n:tc.)if;Lown
7d.Amount of disinfectant used:
3.Well use(check well use):
' I
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agribultural ❑Municipal/Public a Neat Cement Grout ❑ 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
❑Irrigation El Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.5 Gals '' Water
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 47 LbS. Portland Grout
❑Experimental Technology ❑Subsidence Control 1.
7g.Provide a brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Poured Portland Cement through t�emmie pipe from the bottem of well to surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
I
4.Date well(s)abandoned:
12/21/2022
5a.Well location:
L&L Food Store#8 /
I
Facility/Owner Name Facility ID#(if applicable) 8.CertifiFation•
2558 Hunter Hill Road, Rocky Mount NC 1/�t�// e 12/22/22
Physical Address,City,and Zip Signature of Certi ed Well Contractor of Well Owner Date
Nash 1.
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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well'details:
35.984424 N -77.837748 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.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS I;
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonmem,you can submit one form.
���(ry/����j��, 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: �"^�wt �'�/� Jkw I AW 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
I,
lob.For Injection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 6.25 (in) above,also submit one copy of tliis form within 30 days of completion of well
abandonment to the following:
I i
5.89,5.57 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) �
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length'(if known): (ft.)
5 10c.For Water Supply&Iniecti�n Wells: In addition to sending the form to the
address(es)above,also submit one coby 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): N/A (ft) abandoned. i
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016