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Home My WebLink AboutBurke_Well Abandonment_20230112 (4) II WELL ABANDONMENT RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: WELL ABANDONMENT DETAILS DAVID HALL I 1 7a.Number of wells being abandoned: Well Contractor Name(or well owner personally abandoning well on his/her property) I•'or ntttltiple injection or non-water, supply wells ONLY with the satire A - 4459 construction/abandonment,you can subnrt-t ope form. NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.0 (gal.) I, I GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: 6• List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: 'I �� ✓ 3.Well use(check well use): +'3 U::i:f r.., 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) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings ❑Irri ation ❑Specialty Grout ❑ Gravel Non-Water Supply Well: IZI Bentonite Slurry j ❑ Other(explain under 7g) ElMonitoring ❑Recovery Injection Well: 7E For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation 3.0 GALLONS ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage El Experimental Technology ❑Subsidence Control 7g,Provide a brief description ofthe abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4.Date well(s)abandoned: 12/21/22 — _ - -— Sa.Well location: —— - - -- - — -�' ---- - — - KNOB SERVICE CENTER Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: 1145 US - 70 CONNELLY SPRINGS 28612 01/09/23 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date BURKE By signing this form, I hereby certify that the ivell(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 ivell owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one fat/long is sufficient) 9.Site diagram or additional well details: 350 44' 21.23" 810 29' 54.97" You may use the back of this page to provide additional well site details or well N W abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction records)if available. !or multiple h jection or nor-water supply wells ONLY with the same construction/abandontnent,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: i. Division of Water Quality,Information Processing Unit, 6b.Total well depth: 19.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Injection Wells: In addition to sending the form to the address in l0a 2.0 above,also submit one copy of this form within 30 days of completion of well 6c.Borehole diameter: (in•) abandonment to the following: I' 11.0 Division of Water Quality,Underground Injection Control Program, 6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 loc.For Water Summly&iniectionl Wells: In addition to sending the form to 6e.Outer casing length(if known): (ft.) 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 abandoned. 6E Inner casing/tubing length(if known): (ft.) 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Qualilty Revised March 2013 I i I WELL ABANDONMENT RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: WELL ABANDONMENT DETAILLS DAVID HALL 7a.Number of wells being abandoned: 1 Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-rv�ter! supply wells ONLY with the same A -4459 construction/abandonment,you can submit one form. 7b.Approximate volume of water le remaining in well(s): NC Well Contractor Certification Numberi. 3'0 (gal.) GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: Company Name e 7c.Type of disinfectant used: . 2.Well Construction Permit#: JA11: t ry List all applicable well constructionperntits(i.e.County,State,Variance,eic.)ifknoum 7d.Amount of disinfectant used: V y 3.Well use(check well use): �•1 ��, L M1 Water Supply Well: 7e.Sealing materials used(check all that apply): "O Q;6 to Urg, ❑Agricultural ❑Municipal/Public ❑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 ❑Irri ation ❑ Specialty Grout i ❑ Gravel Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g) RlMonitoring ❑Recovery Injection Well: 7E For each material selected above;provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation 5.0 GALLONS ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4.Date well(s)abandoned: 12/21/22 5a.Well-location: KNOB SERVICE CENTER Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: 1145 US - 70 CONNELLY SPRINGS 28612 69 01/09/23 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date BURKE By signing this form, 1 hereby certify that the ivell(s)was (were) abandoned in County Parcel Identification No.(PIN) accordance ividt 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: (if well field,one]at/long is sufficient) 9.Site diagram or additional well details: 350 44' 21.23" N 810 29' 54.97" 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)if available. For multiple injection or non-water supply wells ONLY with the same cwrstruction/abandoninent,you can submit one form. 10a. 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 Quality,Information Processing Unit, 30.0 1617 Mail Service Center,Raleigh,NC 27699-1617 6b.Total well depth: (ft.) 10b.For Infection Wells: In addition to sending the form to the address in 10a 2.0 above,also submit one copy of this form within 30 days of completion of we]I 6c.Borehole diameter: -(in.) abandonment to the following: I 6d.Water level below ground surface: 1 1'0 (ft.) Division of Water Quality,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 10c.For Water Supply&Iniection!Wells: In addition to sending the form to 6e.Outer casing length(if known): (ft.) 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 6E Inner casing/tubing length(if known): (ft.) where abandoned. i 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013