Durham_Well Abandonment_20230419

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS ,
Corey Futral 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
4300-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1,85 (gal.)
CATLIN Engineers and Scientists - FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
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 ❑MunicipaUPublic ❑Neat Cement Grout a 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: ❑Bentonite Slurry N Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite -16.67
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Topsoil -•45
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment p'roeedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) .. OOther(explain under 7g).. Well abandoned in place With hydrated bentonite
pellets to Within.6.inches of surface and.topped
4.Date wells)abandoned: 4/3/2023
with topsoil to existing grade.
Sa.Well location:
Larry L. Ricks 00-0-0000015461
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
5801 Cheek Road Grocery, Durham- NC 27704 . 4/4/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Durham 0862-79-08-1663
By signing this form, I hereby certify that the ivell(s)was (1vere)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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.029159 N -78.773377 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)ifm,ailable.:For multiple injection ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 drays of completion of well
6a.Well ID#• MW-05. 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
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter- 8.25 (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:
3.68' Division of Water Resources,Underground Injection Control Program,
(ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
NA. 10c.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one copy of this-form within.30•days;ofcompletion
of well abandonment to the county:health departtrierit'gf fife county where
6f.Inner casing/tubing length(if known): 5 abandoned.
(ft.) AP
D 20���v
6g.Screen length(if known): 10, (ft.) APR
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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Water Supply Well 1b
— Electric Lines
— Unknown Lines
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Approximate Location of 1
Former UST/AST System
Parcel Boundary
Source: -sri Maxar. Earthstar Geographics and,the GIS User Community
NOTE:Tank locations were obtained from previous reports
prepared by other consultants and are approximate. 40 20 0 40 80
Feet
PROJECT TITLE FIGURE
CHEEK ROAD GROCERY
ATLIN 5801 CHEEK RD SITE MAP
CDURHAM, NC 2
Engineers and Scientists
DENT NO JOB NO DATE SCALE I DRAWN BVCHECKED BY
33873 221007 APRIL 2023 AS SHOWN KMC/SJO