Durham_Well Abandonment_20240507

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steven Gerrald 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 I GW-30 is needed. Indicate TOTAL NUMBER of
4309 wells abandoned:.'
7b.Approximate volume of water remaining in wells 14.2 al
NC Well Contractor Certification Number , PP I• g O• (gal.)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
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 19 Neat Cement Grout I N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grbulc �._:E,._.,} :;'' fit]"Dry,Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
�Iirt a to- - - --"--- -"- --'" "-'-"- --❑-Specialty Grout� � GravelJ'" - --- - '-
Non-Water Supply Well: ❑Bentonite Slurry ther(explain under 7
eMonitorin ❑Recove `� �p i_.
Injection Well: 7f.For each material selected`ali6ve,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat cement- 282 Ibs
El Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite chips - 75 Ibs
❑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) Neat cement placed by combination of tremie
tube and gravity pour from 163.5 to 40 ft BGS.
a.Date well(s)abandoned: 4-24-2024 Bentonite chips gravity pour to ground surface from
5a.Well location: 40 - 0 ft BGS.
Novo Nordisk Pharmaceutical Industries LP
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
5235 International Drive, Durham 27712 ��iC 4-25-2024
Physical Address,City,and Zip Signature of ertified Well Contractor or Well Owner Date
Durham 0845-02-46-8342
By signing this form, I hereby certify that the tivell(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.103397 N -78.849011 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.Ibr multiple injection or non-water supply wells
ONLY with the sane construction/abandonmem,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• TW-01 abandonment to the following:
fD7ivision-of-W.ater Resources,Information Processing Unit,
153.5 L16L7-Mail,Servicc Cents,Raleigh,-NC 27699-1617 j
6b.Total well depth: (ft.)
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 �
6d.Water level below ground surface: 65 (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 Suaaly&Iniecti i n 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): 63.5 (ft) abandoned.
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6g.Screen length(if known): 90 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016