Alamance_Well Abandonment_20240423

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Timothy D. Leatherman 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
2888A wells abandoned:
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• NC Well Contractor Certification Number 7b.Approximate volume of water rl[ruining in well(s): (gal.)
Pyramid Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name !'
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
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 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑
Indus trial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 35 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Portland Cement ; 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) Slow pour bentonite and porltand cement.
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4.Date well(s)abandoned: April 16, 2024
5a.Well location: •
Plaza 66/Payne Oil Co. Incident#44211 1, r
Facility/Owner Name Facility ID#(if applicable) 8:Cerf tea on:
2105 N. Church Street, Burlington, NC 27217 _ 04/16/2024
Physical Address,City,and Zip Signature of Certified AFell Contractor or Well Owner Date
Alamance 8885132349
By signing this form, 1 hereby certify that the well(s)was (1vere) abandoned in
County Parcel Identification No.(PIN) accordance ivith 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: I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.094201 N -79.401985 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 WFI1(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-water 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#• M W 1 A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (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: 6 (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: 18.22 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
0 (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
6E Inner casing/tubing length(if known): 15 (ft) abandoned.
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6g.Screen length(if known): 15 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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Monitoring Well
8-inch Steel Manhole Abandonment Detail for
Set in 2 foot square pad(8 inches thick) MW-1 A
Surface
Well Screen : 2-inch diameter SCH 40 PVC
Well casing : 2-inch diameter SCH 40 PVC
Well Grout:
Portland Type II Cement
with 5% bentonite
4 feet
Bentonite Layer
13 feet
15 feet Well Sand Layer Well Sand : #2 well sand (DSI)
30 feet
30 feet
Monitoring Well Abandonment Detail
Former Plaza 66
2105 N. Church St., Burlington, NC 27217
PYRAMID ; NCDENR Incident #: 44211
ENVIRONMENTAL&ENGINEERING, P.C.