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Home My WebLink AboutLee_Well Abandonment_20230113 (3) 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 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-wale a supply wells ONLY with the saute construction/abandonmem,you can submit one form. A -4459 NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'0 (gal.) I , GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used 2.Well Construction Permit#: JAN List all applicable well construction permits(i.e.County,State,Variance,etc)ifknown 7d.Amount of disinfectant used $ ~ ZO2 r7' 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): "`s��. r '� •{ ❑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 ❑ Gravel Non-Water Supply Well: [a Bentonite Slurry ❑Other(explain under 7g) ElMonitoring ❑Recovery Injection Well: 7E For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation 5.75 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: 12/07/22 5a_Well location: -_ - - — CIRCLE K- 2720355 Facility/Owner Name Facility ID#(if applicable) S.Certification: 429 EAST WEATHERSPOON STREET SANFORD 27330 01/09/23 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date LEE 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 well owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details: 35e 29' 17.32" 790 10' 05.17" 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 record(s)if available. For multiple U jection or non-water supply we/is 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#: M W-2 abandonment to the following: Division of Water Quality,Information Processing Unit, 6b.Total well depth: 35.0 (ft•) 1617 Mail Service Center,Raleigh,NC 27699-1617 lob. For Infection Wells: In addition to sending the form to the address in 10a 20 above,also submit one copy of this form within 30 days of completion of well . 6e.Borehole diameter: (in.) abandonment to the following: , I 5.0 Division of Water Quality,Underground Injection Control Program, 6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 10c. For Water Supply&Injection 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. 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013 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 7a.Number of wells being abandoned: 1 Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple h jeetion or non-waIlerj supply wells ONLY with the sauce construction/abandonment,you can submit ale form. A -4459 7b.Approximate volume of water remaining in well(s): 2'0 (gal.) NC Well Contractor Certification Number GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: .� Company Name 7c.Type of disinfectant used: `, 2.Well Construction Permit#: J�~ JAlv List all applicable well construction permits O.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: 2I+2 3.Well use(check well.use): 7e.Sealing materials used(check all that apply): Water Supply Well: ❑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 ❑Gravel Non-Water Supply Well: 21 Bentonite Slurry ❑Other(explain under 7g) ElMonitoring ❑Recovery Injection Well: 711 For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation 3.25 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: 12/07/22 - 5a:Well locations- --- CIRCLE K- 2720355 Facility/Owner Name Facility ID#(if applicable) 8.Certification: 429 EAST WEATHERSPOON STREET SANFORD 27330 01/09/23 Physical Address,City,and Zip Signature ofCertified Well Contractor or Well Owner Date LEE By signing this fonn, 1 hereby certi&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]at/long is sufficient) 9.Site diagram or additional well details: 35e 29' 17.32" 790 10' 05.17" 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 we/l construction record(s)if available. For mulliple injection or non-crater supply wells ONLY with the same constructionlabandonment,you can submit one fonn. 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 Quality,Information Processing Unit, 6b.Total well depth: 20.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b. For Infection Wells: In addition to sending the form to the address in ]Oa above,also submit one copy of this form within 30 days of completion of well 6e.Borehole diameter: 2'0 (in.) abandonment to the following: 5.0 Division of Water Quality,Underground Injection Control Program, 6d.Water level below ground surface: (ft.) 1636 Mail.Service Center,Raleigh,NC 27699-1636 10c. For Water Supply&Inieeiion 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 611 Inner casing/tubing length(if known): (ft.) where abandoned. � 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water ' Quality Revised March 2013 f 1 � i WELL ABANDONMENT RECORD For Internal Use ONLY: This form can be used for single or multiple wells i 1.Well Contractor Information: WELL ABANDONMENT DETAILS DAVID HALL 7a.Number of wells being abando I ed: 1 Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-u•aterj supply wells ONLY with the same construction/abandonment,you can subnu one form. A - 4459 11 NC Well Contractor Certification Number7b.Approximate volume of water remaining in well(s): 2'0 (gal.) f GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: `t"�•�" ^,-�-r-�. 2.Well Construction Permit#: _. List all applicable well construction perm (i its .e.County,State,Variance,etc.)ifknown AU r. i', l 7d.Amount of disinfectant used: 1 •• 9(19J 3.Well use(check well use): f7+0i;s-r; t; 7e.Sealing materials used check all that apply): Water Supply Well: g ( , ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellet?;' ❑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 ❑ Gravel Non-Water Supply Well: 71 Bentonite Slurry ❑ Other(explain under 7g) OMonitoring bRecovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation 3.25 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: 12/07/22 tea.-Well location:- CIRCLE K- 2720355 Facility/Owner Name Facility ID#(ifapplicable) 8•Certification: 429 EAST WEATHERSPOON STREET SANFORD 27330 01/09/23 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date LEE By signing this form, I hereby certify that the tvell(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 29' 17.32" N 790 10' 05.17" 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 constructionlabandonntent,you can submit one form. 10a. For All Wells: Submit this;form within 30 days of completion of well 6a.Well ID#: MW-4 abandonment to the following: I; Division of Water Quality,Information Processing Unit, 20.0 1617 Mail Service Center,Raleigh,NC 27699-1617 6b.Total well depth: (ft.) 10b.For Iniection Wells: In addition to sending the form to the address in 10a above,also submit one copy of this form within 30 days of completion of well 6c.Borehole diameter: 2'0 (in.) abandonment to the following: 5.0 Division of Water Quality,Underground Injection Control Program, 6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 i loc.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 where abandoned. 611 Inner casing/tubing length(if known): i 6g.Screen length(if known): (ft.) ' I!I Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013 I