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Home My WebLink AboutChatham_Well Abandonment_20230602 (5) WELL ABANDONMENT RECORD., For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: WELL ABANDONfIENT DETAILS JAMES'MO.RRISON 1 7a..Nuniber of wells being abandoried: Nell Contractor Name(or Drell owner personally abandoning well on his/her proper}•) bor nntlliple itjec•tion or non-ii areri supply ut ells QVI,F with ihr cunro catrstruclion abandonment.Vol,con subudl one luau. C - 4421 , '7b..Approximate volume of icater re l,aining in well(s): 0.5 NC'%.'ell Contractor Certification\umber - - GEOLOGIC EXPLORATION FOR'VATER.SUPPLYWELLSONLY: C'on,pany Name 7c.Type ofdisinfectant used: 2.Well Construction Permit d: l.i+t ull opplrcabh,troll canetruc•liun perttrit.c(i.e.Cotngv.Rlatt•. I.OritrnCe•erc.)i1 known 7d..Amount of disinfectanl used: 3.Well use(check well use): '1'atcr Soppy'"'elf; ic.Sealing materials used(check all that apply): 11A2rictdtura1 0N1UTIIcipaI/Public ❑ Neat Cement.Grout ❑ Benton ite 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 ❑hri°ation ❑Specialty Grout ❑ Gravel NonrWater Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g) 21Nlonitorine ❑Recovery injection Well: 7L For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation 4.75 GALLONS -'Aquifer Storage and Recovery ❑Salinity Barrier ❑Atjuifer Test JStorm,rater Drainage ❑[:x'perimetifal Technology " ❑Subsidence Control 7g;Provide a brief description of the abandonment procedure: n.Geod,ermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH AQUA GUARD EiGeothermal(Heating/Coolln_Reittmy ❑Other(explain under 7g) a.rate„' li( 05/15/23 e s)abandoned: � -5a.Well location: JUN (il 29 2023 CAPE FEAR STEAM PLANT. S.Certification:: InfOf19SSo:n:3f1 �f^C it 5++!',�i.[ ` . Facility/Owri&Name Facility ID9(ifapplicable) Pr 500 C P AND L ROAD MONCURE 27559 ' +tr 05/23/23 I Physical Address..C'ity,and Zip Signature of Certifier)Well,Contrector or Well Owner Date .. - . CHATH_AM By signing This fount. I hereby-certfi,that the irell(s) was.(were) abancloned in Counh Parcel Identification No.(PIN) accordance with 15A NCAC 02C:01 o0 or 3C.0200 Well Construclion slanclarces and drat a copy of this record has been provided io the tcell ou-ner. 51).Latitude and.longitude in degrees/minutes/seconds or decimal degrees: (if well field,one laulone is sufficient) 9.Site diagram or:additional well details: 35° 35° 16.29" 79° 02' S1.60" ", You may use the.back ofthis page to provide additional well site details or trell abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DE'I'AiLS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS o"Ch yell e'an irla i�ur record(s)it crrailahle. Vor iuultiple itycoin I or non;ti'oler supply 11r11%O.VLPur1h.thesurn•construc•lionnhnndontiretn,t•nuc•anstrhmm�tn•/"fO1' 10a. For All \''ells: Submit this tiwni withiit,30 days of completion of-v.-ell. CHATH-075-P102 abandonment to the follo%tiing: 6a.'l ell Division of Water Quality,Information Processing Uriif. 29.0 1617. [ail Service Center,Raleigh,NC 27699-1617 Gb."fol al.,-ell depth: (ft.) lob.-For infection)Yells: In addition to sending the torn to the address in Wit fie.Borehole diameter: n.) 2,0, above, also submit one copy of this form within�30 days of completion of„till (i abandonment to the following: .. 6t1.'Pater level belo,r ground surface: 25.9 Division of Water Quality,Undergroundanjection Control Progratit, (It') 1636 Mail Service Center,Ralei-Ill,NC 27699-1636 6e.Outer rasing length(if kno,vn):. (ft.) IOe.For Water Supph & Infection Wells: In addition to sending the form to the address(es) abgde, also submit one copy of this form within 30 dajs ol. completion of%t,ell abandonment to the county health department of the.eoimi. 6f.loner casing/htbing'length(if known): (ft.) where abandoned. 6..Screen length(if kno+vn): (ft.) I ' Form GN1'-30 North Carolina Department of Etviroameut and Naatral Resources-Division of WaterQualily -Revised,March 2013, I i I WELL ABANDONMENT RECORD For Internal Use ONLY: This,form can be used for single or rnbltiple wells 1.Well Contractor Information: 1VELL ABANDONMENT IDETAILS JAMES-MORRISON I 1 7a.Number of wells being abandoned: Well Contractor Name(or well owner personally abandoning well on his'lier property) 1'1"r• +nrthiple iryee•tiotr nr non-troter dapp/i• vu/lc QN1.Y with the s ww cunvtnrc•nun C - 4421 uhurt<Irinnrent,you cun.su6mu nlieJnrnc 1. \C Well Contractor Certification\'umber 7b.Approximate volume of ureter rerhaining in well(s): 75 (gal,) GEOLOGIC EXPLORATION FOR NVATER.SUPPLY WELLS ONLY: Compnn.•Name - - 7c.Type of disinfectant used: 2.Well Construction Permit k: 1.,i idl uppLruhlr r,rl!cnacrruenon pernuis tt.e•.C'nynrl'.Stale, I2rnewce,ere•,/i/nnuuot - 7d.Amount of disinfectant used:_ 3.Well use(check ive,ll.use): Water Supply Well: 7e.Sealing materials used(check all that apply): ElAgricultural ❑Municipal/Public _ ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets ❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement-Grout ❑ Dry Clay ❑Industrial/Commercial- ❑Residential Water Supply(shared) .❑ Concrete Grout ❑ Drill Cuttings ❑Irrigation ❑ Specialty Grout ❑ Gravel N6101'ater.Supply Well: ❑ Bentonite Slurry El Other(explain tinder 7g) RI Nlonitori ng ❑Recovery Injection Well: 7C For each material selected above,provide amount of materials used:. ❑Aquifer Recharge ' ❑Groundwater Remediation 2.5 GALLONS ❑Aquifer Storage and Recovery ❑Salinity Barrier - - ❑Aqui ter Test ClStormmater Drainage ❑Esperimc:ifal Technology QSitbsidence Control 7g:.Proyfdca brief description of the abandonment pirocedilm DGeothermal(Closed Loop) ❑Tracer. ABANDONED VIA TREMIE PIPE WITH AQUA GUARD ❑Geothermal(Ileating/Coolin,6 Return) . ❑Outer(explain under7g) •j• ,` •t..Daie well(s)abandoned: . 05/15/23 ZOZ3' JUN (l 2. !;a.11'ell location: fly%+=« CAPE FEAR STEAM PLANT G°NO SOG Facility/Oivrier Name Facility IDS(if applicable) $..Certification: .500 C P AND L.ROAD MONCURE 27559 05/23/23 Physical Address,City"and Zip Signature ofCertified Well Contractor or Well Owner Date CHATHAM By signing this form. I hereby certify that the irellts)eras (here) abdtxlarted irr Parcel Identification No.(PIN) ' accordance with 15A t1"CAC 02C.0100 or 2C.0200 WWI Construction Standards and!hat a copy of this retard has,been provided to the rrgl/ow ie•. ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f will field,one tat/loins is sufficient) 9.Site diagrani or additional well details: 350 35' 16.15" 790 02' 51.40" You may Use the back Or this page to provide additional well site details or Hell W abandonment details. You may also attach additional pages ifnecessary. CONSTRIfTION DETAILS OF 11•ELL(S)BEING ABANDONED SUBMITTAL LNSTRUCTIOVS .-Irracfr well cauvrnc•linn record(s)if arui/uhlc. For mtdtiply D je�tion nr nun-voter supp(t. . uz/?c U.)'/.)'u't+?t fir•rante cnnxtructinn rrhmx/innnent.ina can ruhnrit Dire fnrrn. 10a. For All Welk. Submit this form within'30 days of Completion of"well 6a.Well lDr: CHATH'-075-P103 abandonment to the following: Division of Water Quality,Information Processing(nit. 6h."1"otal tt ell depth: 1 S.0 (fit) 1617:hail Service Center,Raleigh,NC 27699-1617 l0b..For Infection Wells: In addition to sending the tbnn to the address in 10a 6c.Borehnle diameter: 2.0 (in.) above, also submit one copy of this fixm within�30 days of completion of%cell abandonment to the following: Gd.Water.level below ground surface: 4'0 {Ft) Division of Water Quality,Underground Injection Control Program, 16M flail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): (ft.) 10c. For 1Yater Sunnk & Injection Wells: In addition.to_sen.ding the iorm to the address(es) above:, also submit one copy of this form within 30 days oC completion of%dell abandonment to the cotmty health department of the county where abandoned: 6f.Inner casing/tubing length(if knoan): 6g.Screen length(if known): (ft.) Foun Gli'-.i0 North Carolina Department ot'Environment and Natural Resources-Division of Water Quality Reiised\larch 2013 '