Alamance_Well Abandonment_20240423 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contracior.Information: WELL ABANDONMENT DETAILS
Patrick.Beccaria'. 7a.For Geoprobe/DPT or Closed-Loo'p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well consttuction/depth;only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:' .
4543 ;
4.1
NC Well ContractofCertification Number 7b.Approximate volume of water remaining in well(s):
SR&R Environmental FOR WATERSUPPLY WELLS ONLY:
Company Name Y
7c.Type-of disinfectant used: I
2.Well Construction Permit#; a'
1
List all applicable,weUconstruction permits(i.e.-UIC,..County,State,Variance,etc.)ifknown
7d.Amount'of disinfectant used:.
3.Well use(check well use): I,
Water Supply Well:, 7e.Sealing materials used.(check all that apply):
❑Agricultural' ❑Municipal/Pablic, a Neat.Cement Grout a Bentonite Chips or-Pellets
❑Geothermal.(Heating/Cooliiig-Supply): '.❑Residential'Water Supply(single). : ❑ Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial ❑Residetitial Water;Supply(shared)':. ❑.Concrete:Grout. ❑Drill Cuttings
❑hri Irrigation : ' ❑ Specialty.Grout ❑Gravel
Non-Water Supply Well: - . ❑ Bentonite Slung 11.Other(explain under 7g)',
eMonitoring DRecovery
Injection Well: . . • If.For each material'selected.above;pioAde amount of materials used:.
❑Aquifer.Recharge: ❑Groundwater Remediation h'ti
. 50 Ibs:bentonite c i s: '
❑Aquifer Storage and Recovery P Salinity Barrier
❑Aquifer Test . : ❑Stormwater Drainage
' 20 :Ibs neat,cement!, . . .
DExperimental:Technology []Subsidence Control
bGeothermal(Closed Loop) ❑Tracer 6 5�t0'3''
7g.Provide a.brief description of the abandonment procedure: .
❑Geothermal.(Heating/CoolingRettun) ❑Other.(explainunder-79) GraVlty.pour:and.hydrate bentonite,chipsfrom'3- . ,
Gravity pour neat cement grout.from.3'.to surface
!� ,1
4.Date wells)abandoned: 02�1.6�2024 ;
5a.Well location:..
� :r. Va a
Central Park BOrIM&1n LAC NC7210020544. . „
Facility/Ownei Name 'Facility ID#(if applicable) 7 '
S Ce ca' n: APR' 2. c O 4
204 N Graffaryl=Hopedale Rd,.Burlington,.NC 27217. 024
Physical Address,City;and Zip Signature of Certified W0Co-Aon-,WVI-"-
6g. Contractorll Owner' Date
I
Alarnance. . 139757
By signing this form,I hereby:certifyi that the well(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 thffrecord has beenl provided to the well owner,,
56.Latitude and longitude in degrees/minutes/seconds or'decimal degrees:
(if well Feld one)at/long is sufficient) 9.Site,diagram or additional well details:
36.098065 N 79.407746 W You may use the back of this page to'provide additional well.site details or.well-
abandonment details..You may also attach idditional.pages.if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-watersupply wells'
ONLY with the same cons!ructionlabandonmment,'you can submit one'form: '
1�t1,tt'' ..10a. For All Well's:. Submit.this form within 30 days of completion of well
6i.Well ID#: M V V-120 abandonment to the following:
Division of Water Resouices;Information Processing Unit,
36.5 16.17 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) �
10b.For Iniection:Wells! In addition to sending-the form to the address in 10a
12 / 5.875 above,"also submit one copy"of this form within 30 days of completion of well
6c:Borehole diameter: (in.)
abandonment to the following: -
i
1.1 Division of Water Resourecs,.Underground Injection Control Program,
6d.Water level below ground surface: 00
1636 Mail Service Center,Raleigh,NC 27699-1636
25 10c.For Water Supply&Iniection Wells: In addition to sending the form to the.tie.Outer casing length(if known): (ft) address(es)above,also submit one copy of this form within 30 days of completion
G of well abandonment to the county health department of the.county where
6L Inner casing/tubing.length(if known): 36'`� (ft) abandoned.
Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources } Revised 2-22-2b 16

ARCADIS WELL CONSTRUCTION LOG- TYPE III
0
Project Grocr Tip NIp Well MW-1W
LAND SURFACE Town/City RX4,!M in
Loj
tttt inch diameter County State NC
drilled hole
Permit No.
L'��kG.
casing, Land-Surface Elevation and Datum:
Inch diameter, feet ❑Surveyed
/ ❑Estimated
. fjInstallation Date(s)po 111 Drilling Method25-
Drilling Contractor
Inner Well casing
2 Drilling Fluid
inch diameter.
lit 27 S ft' Development Technique(s)and Date(s)
4p ❑sluff, 7— I1— 17
Bentonite
le
s ft. A.Ilets �`�i / d IOr•C
Lof
31
ell Screen.
Z Inch diameter
A slot
Gravel Pack �}
®Sand Pack
Formation Collaspse 1
.36•S` n•
Measuring Point is Prepared by
Top of Well Casing
Unless Otherwise Noted.
• Depth Below Land Surface
G:\Env\Common\Fleld Forms\Well Const-Type Ill.As