Durham_Well Abandonment_20230419 (2)

WELL ABANDONMENT 1 RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Core Futral
y 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
4300-8 wells abandoned:
2
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): .45 (gal.)
CiATLIN Engineers.and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)iit known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public El Neat Cement Grout S 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: ❑ Benton ite Slurry a Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite -37.5Ibs.
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete ^25 IbS
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
pellets to within.6,inches of surface and,topped
a.Date well(s)abandoned; 4/3/2023 with concrete to existing grade.
5a.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 -
purham 0862-79=08-1663 B signing this form, I hereby certify that the wells was were abandoned in
y � g f v .� (). ( )
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 IaUlong 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 records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same consrruchotdabandonment,you can submit one forma 10a. For All Wells: Submit this form within 30 days of'completion of well
6a.Well ID#: MW=01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total welldepth:
20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.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 4.94'. (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-W(i
6e.Outer casing length(if known): NA (ft) 10c.For Water Suooly&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 Qf_.the_eounty where
6E Inner casing/tubing length(if known). 10 (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
APR 1 q 2023
Revised 2-22-2016
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources