Wilkes_Well Abandonment_20240507

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- - WELL ABAND.ONNIENTRECORI) N : For!Menial UsCONLY: •
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'Illii'form can be used for sinutior milli&wells
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• I.Well-Catitractrir Information:' " WELL ABANDONMENT DETAILS • • .
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. Stefari'Smith ' . . .. . . . " . • . -• • • - • la.Nriniher dwells being ahandaneth 1 - • • • , , •
welteoidLiorNani,,(omilia,,,,,,,i,s4,14.dia,ki,„i„44„,:,,,ii on ji.o.,ift„,•„,p.,13,) .. . Fur ettflopie litterituti co' .roiHrafe'r ngle!). .stells-. ONLY with ill e
)Ott caw sphinit sYsAfitriu;
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. • • 3576A .
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" • . • '7h.APpriiSiiistelvoinine of liana-tont:fining in ivell(s):. • ,c.taL) . .
• 'NC Well Contractor din ificatioti Nullifier. - , • ". • 1
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• • • - •• . FOR WAsprrkx WTLLS.ONLY;•- • . .
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SAEDACCO . . .
Oa nsmny Name-. • ' 7e.`Eyp,e of,disinfeetain Used: . • . • ,
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. . .... . 2.Wdll•Construction Ilermit 8:? , • • .. . . • . . . - -" .•
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: • .Lis!oil,);r1litth.fewell peprzfirtitt:tlett*-4.1afinirldiztqltierlido..40 likuBin) " Id.Adount or tiisittreciani•usi.4:- . •
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" . 3:Well ose(eitee4yrell tre): ' , . - --- . - - • , . .
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- • - - Water Supply Well:• . , : • .. . ". •. . • - • , -le-scaling 1"4611411 .14(c40W;illt.i114t!OPPiY);.• .• .
0400140.4i . . - - . itiMnMeipal/Public.• • ' (1 Nati Cement groin- : 511 Bentonite Chips or Pellets-
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' •- • • -0.0eotlicneal(HeatingiCeoling'SipplY)-' ••-LItlesirletrtial Water.Soindy( agle) . 'El SOnd.,..fenrent G tern - .,,• - Cl•Diy Cy . .
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•". !.. ... ' .'" -0111thiStrialkornMer6oi" " ' Ellicsi(knilla Waier*1.4;14).--(s6 (1).. El Concrete - . •.• '
,-El DrilIciittings" • !• ' .- ' . -- ••
-El Irrigation. • . . . . . . , . .• ., CI Special6,'urout ' . ' •,LI Gravel' _•. .
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• . NonAVater Supply Well: • "' Cl Bentonite Sluay . . I • El Oilier(explairt tinder 7g). - -
Monitoring • .. . .• . . Okecovety. : - . . •• • • . .
• ' ,, Injection Well: • • . . -._ . . ., - . , . • ! ., .7f,For cacti tnateriid seleCtethabow,'proside attiount of Materials used
' •• ElAninfer.Reck:main • ' . LIOriniulnater lleineriiiiiion . . •• • . • I
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0:Aquifer SMorge and Recovery . - tiSalinitv Barrier • • • • • . .
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. • . Bentotiite.:391b ,Wtr:gal
ElArisiteri.TeSt. . • - . CIStrinnwater..Drairiane
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J:3E:vision:am!Technolouv• • PISubsidetice.Conliel. • • 7g.Provide a brief dc'eription of the-airairtfoinniszpritet,thVer_, . ' • • •
EIGeothettnal(Closed Loop) _ • . CITracer • . . ' ' " - ' '...''''' ..:-.L••••i',.."':i V
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.0Geohernal(Heating/Coaling Return) 00ther(explainunder 7g} . • ' ' I •!...MAY 0 7.2024 ,•- . .. . . -
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. • . 4.-Date well(t)nhandOncd:.4/9/24 , . • • • •
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. • - - 1 r•••fc.:cr,-..k.i'•!--;-; F.),,..",,r--7.-,Aq-,..,,,,.111,-:d . .
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.. . • . . . . •location , .DWC :13C:g..D .. - ' . . . .
• . • - ' Sa..Well : • . - - • • - •
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•• . College'Park Citgo • • • . ' • . •, .- . . . - . • •- •
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• . . . FaellitylOwNr Name . - ' • . Facility Mir tipplicable) •8'' ification
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1204 River St,.. Wilkesboro, NC 28697 Aktp$4 . 4/16/2024 - -
.. - ,Pliilical.,.iddrcis„City.aid Zip .. - . .5.- -illiFe.,..,c;ettinod wo(....08*gtor or WicilOrrvr .• .13AV
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. .. . • , Wilkes . . - - By sighing this km; I hemby certfk-litat the'reli(s)yds(were)ahatitioneil in
, - - •Counts - - ' ' • . •Parcel IdestifiLithui No.(PIN ttaxitdaitta With.15A-:WCiICIO2C.010.or 3C:0260 Welt atitsttuction Stnnektix4 • ,-. . •
• . - • • . . and/hal a 04Tc/this record hai•heed provided(011te wel 1 Owner:.
Sh.,Latitude and longitude in degrc e-Stinittuteifscroods or 4011prd:degrees:-- ,' ." - • ." - - • • ' i, . . .
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. . (if not one latiliiisIlgatriactA) . 9..Site tiiagrain oi•additional well'details: . •
' - . ' .• You may use the back of hits page to.prOyide additional well site derails or well .. .
. ,. . . N . .• . 36.141850 . 81.176753
• ' __, _ W ,Aliaridoitute.19,iletails..You May also*tail addiiionattiages if iteciary. • ' • . .
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. • - CONSTRLICTION DETAILS OF WELL'S)BEING ABANDONED- ' . „SURNIITTAL INSTRUCTIONS, '• . .
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Much 4'4 uointruitimi rummil(s)be dvattaltie. .Fos'multiple iitiemiud up Minorahr sup01. . • -
wells Q11141'"II ibe."n1"!Llgt' ucti"4156;"16 "e"'PHI '`NI s"1"1101w Af"!• • 10a.-Far All.Wells:• Submit•this.form Within 30 dii of• onipletion of well • . --
- • • ' • •a eil ID# . •abandonment to the-following:
• . . 6 .%V :Tmcq71 • • - I ,
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• • • . . DOI:lido of Water Resimiec*Information•Fropisdag Unit, . • - ' •
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' 6b Total well depth: --
1 n•. '. " (ft.). . - ' •
. - 1617 Mail SerVice Cen lektr ter;Ra ,NC 27699-16 L7 .-
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- . 10h.For-hilt-0km Wells:'hi addition to sending the fornite•the address iu 10a
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• • . above:also submit one Cum'of this!faint within 30 day S of completion of well r
6e.Borehole diameter:2 •. CUL) .
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'abinntonittein to di following;
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• - . • • Division of Water RtsouriLs;Underground injection co itt 6)1 Fragrant, '• ..
• .6th Water livel.below ground surface: 17 . (rt.) • . 1636 Mail Servicerenter,Italefgh,NC 27699-1636 -- • .- .-. -
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• - • •• IOC For,Water Swint..-,V:Liked-nal S4•0'-e'Ill: In additionto sending the fomr to
6e..Outercaiing1CnOh(if Immo); 9 . (ft) the.address(es) above.'also stibmit.;Otie••copy of this.fottn.within 30 days of .. .
. . completion of well ahandoisnr.nt to the county health department of the connty
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where abandoned. -
. . 6f.tuner easing/tithing teogth(if known): • • (Fi'd . . .
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• • 6g.Screen length(if laiown):19 •- - (ft.) • , .
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Form GW,";0. North Camtlm Depatimont of EnviroinrCnt and 1.14urat Iicsaiires-CylvisiTt Of Water ill.!n tures Retried Aigust2011, • .
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WELL ABANDONMENT RECORD.- . For Intone'1.7. ONLY: • . . .
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This form can be used fOr single or totiltitile7ells. . . .
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I,WcU Cauti'actor Information:. . - -WELL ABANIIONMENT.DETAILq ' • . •
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Stefan'smith . . .. . . . „ . , -7a,Ntiniber tif uells being abandonetli.'," • • •, .
. . . Well totinohiNauto(ornolltiN NISC191:14.:16:111 :111itt.noll on Iliad:Cr tin:pony) " Far ren'ffople nye.enon .or ,R0151,1i,i1(4 [sup'ply la-ells'-:ONLY .'1,inb Ilk-..iovi
OnishircnomiltbillkININJOI4)Wri MP 57JIYIlif fYlefirm,
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, 3576A . • .' .
• - .74.ApprMiintaM,mirtme ofliatia'reirtabilnst iit itell(s):- , --• • • (0.)
• 'NC WO COrifict6rCeniticationNo4ci
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SAEDACCO • •
FOR WATER SUPPLY ATLAS 0,N1-Y:- • - . '• •
Camtiaay Name, , • • . , • . , • 7e.Typ of illsiofettantiimedi - • . • . . • • . •
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WLII Construction Permit ft:, ,- •• - • - • ,. .
• •f..0faii.PpiAyivrde.ti.f.yermo.s 0.e..C.Lea.o.,b'tate7yi.trHauce;Infealiati,lettij ff kauwa , .• .. 7diAituiutit or tutititvcciini:ued: : . -- • - . - • , . • . •
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• 3.%Veltu Se(cficd9icll use):, . .
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. . Water Supply Welit • . • • • • • .7e.Scaling materials:oted(check that atip0:•.. . • • .
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•. -: E3Agricultittat • - EINitinitipal/Publio;. : ' El Nad:Centent Grout - . - •• -• It Bcriteaiite Chips or Pellets, .•.. .
• • .. * ElOcothcrotil(tiCating/COoling"Srippl)- Eittcsiikritint Miater,Sripply(single)'• -1:-S;04:- Cement 9r* , . • '•" n.DY ClkY .. -., . -. -.. . - ... • .
•:...-• , OlndititfiallCOMnicm rat ': • • ' : bticSideurial Wateri8upply(bared) .121f ctifi4d1ff,.. roig - • -" • .. ;• -b-Ditilpillings ;. ., .• ' - , .. ••• --.
11Iltrigation- • . - - .. • • ,•, El Specialt,Omni ! • El..Gravel . . .
. • - Nop-Water Supply Vdr:11:' , .. . . " • . . . • .tp bentonite shirty • ain. - •
• El"Other(e.xpl tinder 7g) . .
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'• . . fl9Monitorine.. . • . .. • . , pRecovev . . .. • . •, • : - ' . ,. .
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• " Injcetiott Wql; , .• . • - 7f.For•each Materlal selci:tcfabow,proiide itutontit Of.Materials uSed: .
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7' ClAquifer Recharge ElOrtittrulnater Rentedialion
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. . . lt*olfer Stoptieotid itecovery' - 138aliiiity Barrier - . . -. • . . • • - - . .
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: • . Bentonite.:3 91b ,ittr:gal. : .' • . : ' ' . .
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. '. • 13Aguifer Test • • - • .. pstOrtmniter Orairiaao •
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. . • E1Expirimental Technology - •rlubs'idelice4"1401 • . ', 7g.-P rovide a brkf d6cription Of,tIO'al.tandonment.proctd urm
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• . . ElGeothennot(Closed Loop) ' _ ' • Eltracer . • • . • ' . "• ".. ' • - -
. - • -.; 7'47:.'-'"r---
.C1Goothermat(HeatinaCooling Return) • tlOther(explain under 7n) • • • • . 't.'-...',_-e...... ..' ..-..'..1..) . • .
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. , . .4.•Dale:weU(s)ghtuttioned: 4/9/24 • . .. . . .
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. • •Sa,Welllocation: • • • • ' •
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VVVVVV
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. . College Park Citgo . .. - . . . . . • •
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• 8,CertifiCation:
, FaciligiOnn:rNamo . - . . FaciW LIM.tiropOlicabIc) • . • • V4 - • ,
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.1204:River. St,. :Wilkesboro, .NC'28697_. , . -, . ...VI ., . •. - , ! •4/16/2024
' , - • -physkoAddress,City,-and Zip • -- ' -. . ..S....• lore,.C.!:.rtiport W911;coonanor or Wsi!Ovrt;r
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-... Wilkes. . . • .. • ily signing.gns fortn; 1 hemby. certiktlint the Iteili's)Ive$(Fere)abandoned in .. •
Coatio. -. -.. . . • .•. - ' Porte]!derail-tabu No..glithli • • .m.voidance iv flit ISA"A'Ciid eik'.0101.or 2e,07,00 Feltetyishatclittn Starukk4
mid that a copy afar&record has bee)provided.(a the u'ell thfner. • . - : , -
, . • sh.Lstitude and longitude In qcgOcetitati9litWscionds.ortlecii9;at degivesi • ' . . • • ' • . i, ••'• . . . ,
• . (irAvii rpt(t,one IsMs'egis siiMc ) • ' ' • V • 9.Site diagrain or additional well derails: .
• ••• You.tual.use the back of this page to pros ide additional wellsite'details-Or well • . .
. .. : .36.141850 . rc . 81.176753 • •. w • a6atco
a innenl details.,You roily also altach additional pog,es if necessary.- ."' - . •
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CONSIRIICTION.DETAIEN-till WELL(S)REIN d ABANDONED ., . stnotriTAr,iNsTRucTroNs. ' . ' •
:Wadi well recvni(s)if abatable. :Far imilaple injecneT or•tn,..ivon-r.sinvgj. ' • - , , • • • • -
... • ,wells QNLi loth the SIMI ti!tof ts tnittiqitiab curfler to v.1 a alp mbar:a aaajbaa.,.. ' • 10a:'Far All-Wells:• Submit-this emu 1tithin 30 days of completion of well • .- -•• .-. . 60.Well 1D#tTb1w72 ' - , ..
• •abitudOnnicirt to•the folloWing:
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. - • - • Blvisitin of Water Resaurers,Infortn:iiion,Prscesing Unit,
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. • 61i.Tetatwela depth: 24. - ••
(10 . . •. .• . • 1617 NMI Service tenter;Raleih,NC.27699-1 ..617
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lob.For-1n leellon Wells: -in addition to.sendittg the form to the midtesilu tga •- -
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• Om). • • abo‘e4 nisei submit one.copy of tins foriii Within'30'daYS of'completion Of well - •
• - 6c.Borehole dh enteter:2' • . . •
Shinifotintria to the rationing:. •. '. ':-, . _• • - • t 1 . .
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• • Divisio.rt of Witter Resourersi'Underground Ifideellon Control Program
• .•.- 6d.Water liccl.heinw'Otid surface: 17: (ft.) ,)•• • • - • ' • 1636 Mail Scrvicerdtcr,Italcighi NC 27699:1636
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• • 110c..Foe Water Sunnis'&btfeerin4 Wells: In addition to •snding the fomt to - •
• 6c.Outer casing lenpth(if lontwa):. 14 •- •
- (ft) . . • ,• the address(es) aboVe... also stibmit.one rthpy of•this forth within 30 days of
- . completion-of well kantIrtisnentro the county heath depIrktment of the county
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. . where tiblt;:lonal,. - .
. 6f.Inner'easinititubtrig•torMth(if.tatawn)i . . (ft.) •
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6,1I,Street;lettgllt(if ktiott.n):1° . . - (ft.) 3 . •
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FOIRIGW-38. • Nonh Camara 11.1ccortnrcd ofpvirclisient and NOural 12.csotsres-plvisios of Watisites Hires - ketiscil Augusi 2013' '.
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• WELL ABNNI AND.4 EN.T RECORD For Moral the ONLY; • , . . .
This form can be used for single or multiple yells { .
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1.Well Cvntractor infotmatitin: ' • WELL ABANDONMENT DETAILS •
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• Stefan Smith . . . . 7a.Number dfirellslicingahandaned a
. RcltCadraetorW nie ornrllanr natl;.abanciohdrigaani:athi9tiier r'. . . For rrintop? nycctinr or- eon-uttra supply �ae&S 'O,VLY . lob the .some
3576A . 1
• 1JC Well Contractor CcititiQiiioti North r •
'71r.Apprtixinute volume of tinter rtynaining in well(a) •.: - (01.)
S EDACCo FOR WATER SUPPLY WELLS ONLY: '
ConpattyName' I.
7c Typt tiPilisinfectant uyerlg .
2:;WeltConstruction Permit ii:, , ,
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IdiT aR o q!kn5 urfl}auniiLr(i.c_Curnh,-St r!mtie.fnJuiirnrL.vtc)Ohms! ?d Attto wr Uf t1LSInfectsltlt'use11: ' .
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' • 3:Weil qsr(check tell use):. •
Water Supply Well; - -" 7c.scaling itt;tce;ads:nsed(cncei:all that apply):
. IJAgtrctdtutai• l7MtirucipallPublie I]Neat Cement Geout - •' • t!a 13c-ittonite Chips or Pellets.
' - lGeot ennal(1lcadngtCooling Supply) I]itcsidentint Water Supply(single) . a Sand Cement Gtnut - ❑Dry Clay - --- - _
- 'OEndiistriaUConnncrcial ' OlRcsidentinl Water Suppl)(slttirtd). •ITOh ietICrout.' - . : i,. •O DrillCulliig;--
l7ini thou • . 17 Specialty Ghoul []Gravel
Non Water Supply-Well:- . . El Bentonite Slutiy Ci Other(explain.miler.7g) .
i8Monitoring • . 17Recovetr. '
• injection Wort; . .. 71:For-each Material sctcetcd above,provide amount.of•i niterials t ed:
•OAgnifer Recharge , L1Grounthvuer Rentediaiion• - -
- • . DAquifer•Stange and Recovety CIS:dinity Daffier• -
13Aguifer.Test EISlonmcater Drainage
Bentonite.:391b ;Wtr:gal.
• oG�eiinterual Teelmnta�� [7Stdrsideuct Comm!. 7g.Pradde'a brief description of the abandonment procedure: • .
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' ClGeothennal(Closed Loop) . ®Tracer i c
C1Geothermal(Heating/CoolingReturn) DOtber(x-plain under 7g) • ,- . T. !r' ,_
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. ' . 4.•ilatenclt(s).ahandoned:.4/9/24 MAY rJ i LU24 •:
►fr .3i` N:+r
College Park Citgo ' . ' - . •
' Facility/On:1erName • facility 1135(ifupplicabtc)" 8:Cetilllc stoq: _ '
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1204.River, St,, Wilkesboro, 28697. . . li)`� s sr - 4/16/2024
• PlsysicatAddres.City.andZip •• • hue JC.enif�dWellfbntiactororWcllOhs•or • Date ,
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Wilkes, . 13y+$iguing Ihrs fnrnr; 1Irereby certify•rhat the well(s)rhos(were)abandoned ire .
. Coauty . - • . . Panel liLaiitEratlnuNo,(PINT ' • ac at*wtc With ISA N.CAC.02e,0I00.or 2C:0200 tt%ell:GAY:r tction*Stwuhirels
and that a copyaf this record kas been provided i'o theli'ell owner.- .
S6.I:atitndo and longitude in �deealntiuittes/seconds'or deciniat'degreesi. . •
• (itn•i.lrim,one milibitg is slinit a t) 9.Site diagram or additional welt details: - •
You,tuay.ute:the back of this page to:proside additional mil site details Aar well
. . 36.141850 N •81.1.76753 . . W. "abntidottittettt"details..You tuay also attach adttitional•pagges if neCessan'-.-' ' ' '
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CONSTRI1CTtt'lN DETAILS OF WELLtS)BEING ABANDONED 51111RiriTAt.iNS•TRUCTIONC
Atte h nicii cvinim iirur r>;Lurdfs)if gvailtiti. ,FiAr trrnlnptr ijecfiept..or inn•nxu x sufph. '
Welk ONLY u-ltIft he'sunte cp.mtrurrimditbatdoi lrrrt..)uu a in"bnifl cure f ire. 'Oa::Nor Ali-Wr1Ee:' Submit•this form within 30 days'of Completion of well . -
6a.Well 1D#:TMW-3 ' . ' abandonment to the following: -
• • - Dts'isionof Water Resirtirets,Information-ProcesaingChit, '
ih.Totalivcll depth: 24' (ft:} E617 Mail Service Center;Raleigh,I C,27G99-1617
• 10h.Far.finleetiatt Wells: In addition to sending the form to the Oiliest in-IOa .
:tboti e;also submit.one Copy of this'fowl within 30 days of completion in'Well
. 6c.Roteltole diameter:2 (hi.) I •
ab6ndomhtin,f to the following: ,
6d.Watcrievcl.bctow' tendsurfitce 17• •tfP)• Division or Water Resonres,Under•ground injection Control•Fnigratu,
• . 1636 Mail Service CcAstr,Raleigh,NC 23699-1636 , •
tic.()utce caliinr length(if 1pnSrn);,14 (ft:) 10c'Fn0 W;iter Stennis.&iidecttnl Welts: In addition to.sendinj the fort to
the address(es) above also submit"one copy of this,fottti within 30 days of
completion of well abandonment to the county health department of the county " -
6f.Inner easin /ttshcngkngah(if larown): • (B:) ttihcmo '�dai�d. '•
6g.Screen length(if 1©totin):10 - (ft.)
• Fona GW-30. Noah Camillo Departrncm of Es ironer ant Ninural Resources—Division of P,atcr Recounts • Revised Aqua 2013