Wake_Well Abandonment_20230327 (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Simcox 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
2944B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'1 (gal.)
S&ME, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:_
2.Well Construction Permit#:
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)ifknowrr
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Pubhc ❑Neat Cement Grout ■Bentonite Chips&Tellers
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings MAR 2 7 2023
❑Irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slung ❑Other(exiJbin Yg✓1.
Monitoring ❑Recovery tom"
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 30lbS
❑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
(Heating/Cooling❑Geothermal Return) ❑Other(explain under 7g) Filled well casing with bentonite chips and
then hydrated. Removed manhole cover and
,.Date well(s)abandoned:3/7/2023 pad. Cut off well casing approximatley 12" below
Sa.Well location: existing grade and backfilled with top soil.
East Wake Landfill
Foeilrty1OwnerName Facility m#(ifapplicable) 8•Ce1•tifleation: �� =;__
600 Three Sisters Road, Knightdale, NC 3R/2023
Physical Address,City,and Zip Signature ofCci ified Well Contractor or Well Owner Dale
Wake 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:
(dwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35° 47' 54.50" N 78° 26' 06.80" 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)ifamilable.For multiple injection or non-water supply Hells
ONLY with the same constructionlabandonmeni,you can submit one form.
LOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well UM:MW-24 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19.1 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniectiou Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (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: 12.32 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016