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HomeMy WebLinkAboutRichmond_Well Abandonment_20240205 (6) WELL ABANDONMENT RECORD For Internal Use ONLY: ff I 1.Well Contractor Information: WELL ABANDONMENT DETAILS Jeffrey Grant 7a.For Geoprobe/DPT or Closed-LI op 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 4328-B wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water r I ml ining in well(s):.3 (gal.) JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: None 2.Well Construction Permit#: N/A List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown None 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 a Neat Cement Grout 19 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 ❑ Other(explain under 7g) FlMonitoring ❑Recovery Injection Well: 711 For each material selected above,provide amount of materials used: []Aquifer Recharge ❑Groundwater Remediation Neat Cement Grout 7 Gallons ❑Aquifer Storage and Recovery []Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage Bentonoite 20 Pounds ❑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) Grout well in place. Remove manhole and concrete pad. 4.Date well(s)abandoned: 1-22 & 1-23-24 5a.Well location: CSX Transportation-Hamlet Yard ,� w� z ,Fig.r, v�q•��•• Facility/Owner Name Facility ID#(if applicable) 8.Certification: FCd 2024 803 NC Hwy 177, Hamlet, NC 28345 1-24-24 Physical Address,City,and Zip Signature of Certified ellCotrtiab'tnrni�Vell:O,wne� , Date Richmond Dtw� "=sir;" By signing this form, I hereby certify DiiW the ivell(s) was (were)abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well oivner. 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: 34.894380 N -79.689101 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)ifavailable.For multiple injection or non-water supply wells ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: MW-21 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Injection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well abandonment to the following: I' i 6d.Water level below ground surface: 30 (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): None (ft) 10c.For Water Supply&Injectiod 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 couityi health department of the county where 6E Inner casing/tubing length(if known): 35 (ft) abandoned. i 6g.Screen length(if known): 15 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016