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Home My WebLink AboutMartin_Well Abandonment_20240918 (5) WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Justin Radford 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 3270 wells abandoned: 0 NC Well Contractor Certification Number 7b.Approximate volume of water 1 emahung in well(s): '38 (gal) Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: N/A List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)ifl nown 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/Public ❑Neat Cement Grout a Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings ❑hri ation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g) RMonitoring ❑Recovery Injection Well: 7f.For-each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 20 ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage Grout 15 ❑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) Pour as plaCenlent 4.Date well(s)abandoned: 04/1.7/2024 �• - ; , / 'mot 8 2024 5a.Well location: j ' Peele's Service Station 00-0-0000013895 , N; ; s:;; ,,_,2 UPA Facility/Owner Name Facility ID#(if applicable) 8.Certification: GrOia 2675 Old US Highway 64, Jamesville' , NC 04/17/2024 Physical Address,City,and Zip Signature of Certified Well Contractor,'or Well Owner Date Martin 6746-71-5500 By Signing this form, I hereby certify 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 this record has been provided to the well owner. 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: 35.8222805 N 76.8156861 W You may use the back of this page to provide additional well site details or well abandonment details. You may al'so'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-watersupply wells i ONLY with the sanV V mee`coonsstruction/abandonment,you can submit one form. 10a. For All Wells: Submit,this_form within 30 days of completion of well 6a.Well ID V'#• ' -1 1 abandonment to the following: i`. . i I' Division of Water Resources,Information Processing Unit, 6b.Total well depth: 14.00 00 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection Wells: In addition to sending the form to the address in 10a 6c Borehole diameter 6 fin-) above, also submit one copy of this form within 30 days of completion of well abandonment to the following: 6d.Water level below ground surface: 11.64 (fk) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service enter,Raleigh,NC 27699-1636 E i 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 6f.Inner casing/tubing length(if known): 4 (ft.) abandoned. j 6g.Screen length(if known): 10 (ft) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016 Geological Resources,Inc. SITE:INFORIVIATION ` Site Name: Peele's Service Station Date:04/17/2024 Project Number:2516 Completed By:L.Weathersby :DRILLING INFORMATION;_ Company: Geological Resources, Inc. License Number: 3270 Driller:Justin Radford � .. .. - WELL;ABANDONMENT,INFORIVfATION ��`�X:-• - Bentonite (lbs):20 Boring ID: MVV-�� Grout(lbs): 15 Total Depth Outer Casing 14.00 From (ft) To (ft) Length (ft) 0 10 Depth to Water Inner Casing 11 .64 From (ft) To (ft) Length (ft) 0 4 4 Water Volume(gal) Screen 0 .3 Qv From (ft) To (ft) Length (ft) 4 14.00 10 '.yn ham. ;� j..�.•'ti. 'Q M~•` y. C"� air z k, �Y;r�� YY� .,`►' �� ,`- �� _ ..`"NV Pre-Abandonment Post Abandonment i WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Justin Radford 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 3270 wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of wate i remaining in well(s):0.62 (gal.) Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: N/A List all applicable well construction permits O.e.UIC,County,State,Variance,etc)if known 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 ❑Neat Cement Grout a Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑ Specialty Grout ❑ Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g) RMonitoring ❑Recovery Injection Well: 7E For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 20 ❑Aquifer Storage and Recovery ❑Salinity Barrier []Aquifer Test ❑Stormwater Drainage Grout 15 ❑Experimental Technology []Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer ❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Pour as placement 4.Date well(s)abandoned: 04/17/2024 `'^ • ' .`,`.f SA , 5a.Well location: SEP 1 8 14 I Peele's Service Station 00-0-0000013895 Facility/Owner Name Facility ID#(if applicable) 8.Certification: 2675 Old US Highway 64, Jamesville, NC 04/17/2024 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Martin 6746-71-5500 By signing this form, I hereby certify that the well(s) was (were) abandoned in County Parcel Identification No.(PIN) accordance with 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: (if well field,one lat/long is sufficient) 9.Site diagram or additional well details: . 35.8222805 N 76.8156861 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 construction/abandonment,you can submit one form. I�A,I�, 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#• 'V'V�—9 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: .15.00 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617 I. 10b.For Infection 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: 6d.Water level below ground surface: 11.11 (ft) Division of Water Resources;.Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 276994636 6e.Outer casing length(if known): 0 (ft.) 10c.For Water Supply&Injection 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): 5 (ft.) abandoned. I 6g.Screen length(if known): 10 (ft) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 1 Geological Resources,Inc: SITE INFORMATION Site Name: Peele's Service Station Date:04/17/2024 Project Number:2516 Completed By:L.Weathersby _ DRILLING INFORMATION .' Company: Geological Resources, Inc. License Number: 3270 Driller: Justin Radford WELL ABANDONMENT INFORMATION Bentonite (lbs):20 Boring ID: MVV-s Grout(Ibs): 15 Total Depth Outer Casing 15.00 From (ft) To(ft) Length (ft) 0 0 Depth to Water Inner Casing 11 .1 1 From (ft) To (ft) Length (ft) 0 5 5 Water Volume(gal) Screen 0.62 From (ft) To (ft) Length (ft) VG 5 15.00 10 PHOTOS Pre-Abandonment Post Abandonment