Rockingham_Well Abandonment_20230120

<< WELL A37H.NJ.1Vl\MLN RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hislher property) well wristruction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Sf/f(I/C,f 11CG FOR WATER SUPPLY WELLS ONLY:
Company Name _ 1 / 7c.Type of disinfectant used:
2.Well Construction Permit#: �T/ !/V PO�-0 0/
List all applicvble well construction permits(t.e UIC.Counh;.State.flariance,eta)iflarown
7d.amount of disinfectant used;
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural 17Municipal/Publie ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(HeatinglCooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) <Concrete Grout O_Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well; ❑Bentonite Slurry ❑Other(explain.under 7g)
❑Monitoring tORecove y
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundivater Remediatiort �-
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AgitiferTest ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geotheimal(Closed Loop) ❑Tracer Cr��l���l� t� 4(
❑Geothermal(Heating Cooling Return) ❑Other(explain under 7g) ✓` 7��
2ems a
4.Date wells)abandoned: - --,�T .
n Gila- �v 2023
'52.Well location:
' ,�7_///J // //_��/{/ (��y C1RR
-` / Z �`V/ '1��17'ff�^ VI t :Mb.i4M.�'iY .
Facility/Owner Name Facility ID4(if applicable) 8.Certification: —77
Physical Address,C' and Z' -�y City, � Signature of Certfi Well Contractor or Well iwner )ate
QC°y//_��. B��A-t 79'7�62- 7,7q . g
,iSy signing this forte I hereby certify that the well(s)was(were)abandoned in
County .Parcel Identification No.(PIN) accordance with 1 SA NCAC OX.0100 or 2C.0200 WeU Construction Standards
5b.Latitude and longitude in degrees/minutes/secottds or decimal degrees: and that a copy of this record has been provided to the well owner.
.(if well field.one lab long is sufficient) 9.Site diagram or additional well details:
�/ V You may use the back of this.page to provide additional well site details or Nell
Y Q� yI-e N 772,S71 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCHON DETAILS OF WELL(S)BEING ABANDONED :SUBMITTAL INSTRUCI71ONS
.attach well construction record(s)ijavmlable For mtiltiple injection or non-watersitpplr wells
ONL Fwltlr the sane cons wcuonlabandottnenl sou can submit one fomt
10a. For All Webs: :Submit this form within 30 days of completion of well
6a.Well IDI#: abandonment to the following:.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) -1611 Mail Service Center,Raleigh,NC 27699-1617
�-f 10b.For Injection We1Ls: In addition to sending the form.to the address in 10a
6c.Borehole diameter. K/ (in.) above, also submit one copy of this form within 30 days of completion of well
/•I abandonment to the following:
64.Water level below ground surface—AO AQ (it.) Division of Water Resources,Underground Injection Control Program,
///1 1636 Mail Service Center,Raleigh,NC 27699-]636
6e.Outer casing length Cif known):M t�//�r //y t! (ft.) 10c.For Water Stioniv&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
d
6E Inner casirg#tubirrg length(if known): ft( ) abandoned.
6gy Screen length(if known): /YL qL)
Form GW-30 North Carolina Department of Environmental Quality-Division.of Water Resources Revised 2-22-2016

r
Rockingham County Department of Health and Human Services
,l Environmental Health Section
Phone#: [phone] Fax#: [phone]
Well Construction Permit
Expiration September 13,2027 Pin# 797602779154
Application Type Well Abandonment Owner/Agent PATRICK FOLEY
Permit# EHWP2209-001 Mailing Address 800 TAYLOR ST
Location 0 HANCOCK(OFF)RD DURHAM,NC 27701
Subdivision SANDS RUBY-J SURVEY Phone# [phone]
Sec Email PFOLEY@STRATACLEAN
Lot ENERGY.COM
Facility Type Non-Residential Foundation N/
Setback
Septic System
Setback N/A
Surface Water N/�}
Setback
Potential Source of
Contamination
PERMIT CONDITIONS:
Bored well to be abandoned according to 15A NCAC 02C .0113(c). Well abandonment must be done by
a NC Licensed Well Driller,submit Record of Completion to this office after abandonment.
No quantity or quality of water is guaranteed by the department. This permit must be on site at all times while
construction is in progress. This permit may be suspended or revoked at any time for failure to comply with North Carolina well Construction
Laws and Rules. This well site may not be changed without pennission from an authorized agent of the department.
I
See attached diagram
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Authorized State Agent: G Date:
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9308
9254
Bored Well to be abandoned 9236
A, 9230
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ROCKINGHAM COUNTY ENVIRONMENTAL HEALTH r HWP2209-001
(behind)9308 NC 87
lh"rlume.1tmbn&h-(awry"bAlwl bebeblc r"-n ---t"dma Ibn,nAud",ma,o(om,.uun,eamnu"aon.mns We Abandonment
n,m.r+�nR��rm,+m„mnn#�,,,ns„brtt.•, 1 inch= 200 feet VV Permit

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