Chatham_Well Abandonment_20231215

WELL ABANDONMENT RECORD For internal Use ONLY: `
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-L lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only i GW-31 is needed. indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: 'II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknotrn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing m teiialg tiled Ph�tk all lhatap,ply):
❑Agricultural ❑Municipal/Public ❑Neat Cementlto t K"'� �ii Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement t tl' ^ ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout l• ❑ Drill Cuttings
❑lrri ation ❑ SpecialolittnSuti�tP�ii i�lGt�.ciGk9? (,ryq Gravel
Non-Water Supply Well: ❑ Bentonite Slurry VWW12CK� ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —45 pounds
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite chips were poured into the well and tamped
until chips rose to top of well casing. Casing was
4.Datewell(s)abandoned: October 10, 2023 then capped with original locking cap.
5a.Well location:
CPF, LLC Not Applicable
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Moncure Pittsboro Road & NC Highway 87, NC 27559 rs - 2-11-2023
Physical Address,City,and Zip Signature of Certifie Well 96ntractor or Well Owner Date
Chatham 95729 By signing this form, 1 hereby certify that the ivell(s) ivas (were) 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 well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
(ifwell field one lat/long is sufficient) 9.Site diagram or additional well details:
35.692759 N -79.169751 W You may use the back of this pagelto 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 ornon-u,alersupply hells
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#: M W 2R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 8 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: —24.7 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Supply&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 of the county where
6f inner casing/tubing length(if known): 20 (ft.) abandoned.
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6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016