Durham_Well Abandonment_20230419 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS q.
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 Contractoi Certification Number 7b.Approximate volume of water remaining in well(s): 1.80 (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:NA
,
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
F
Supply Well: 7e.Sealing materials used(check"allthat apply):
ultural ❑Municipal(Public _ ❑Neat Cement Grout a Bentonite Chips or Pellets
hermal(Heating/Cooling Supply) ❑Residential WaterSupply(single) ❑Sand Cement Grout ❑Dry Clay,
strial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
ation. ❑Specialty Grout ❑Grave
Non-Water Supply Well: ❑Bentonite Slurry 11 Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount:of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite —16.67
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Topsoil ^ 0lbs
❑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) DOther(explain under 7g)..
pellets to Within.6 inches of surface and topped
a:Date wen(s)abandoned:.4/3/2023 with topsoil to existing grade.
5a.Well location:
.Frank Clemmensen 00-0-0000015461
Facility/Owner Name" Facility.ID#(if applicable) 8..Certification:
5714 Cheek Road Grocery, Durham, NC 27704 4/4/203
Physical Address,City,and Zip Signature of Certified.Well Contractor or Well Owner Date
Durham 0862-02-79-2014 B signing this form, I hereby certify that the wells was were abandoned in
y sn g f y fy ().' (Were)
County ParcOldenti&cation 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 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 additiona_1 well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaach well construction record(s)ifmailable.For multiple injection or non-crater supply wells
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#: MW-04 abandonment to the following:
Division of Water Resources,Information Processing Unit, .
13' 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth:
10b.For Infection 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:
1.98' Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 276994636
NA 10c.For Water Supply&Injection 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 of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 3 (f.) abandoned. -' " ;;;
qn
6g.Screen length(if known): 10, AP 1 :Q
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resb cesl J ` i� S'. , Revised 2-22-2016