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Home My WebLink AboutAlamance_Well Abandonment_20241014 WELLT ABANDONMENT D �..�7�. . �7��T�+ nor.. n�. .. C .. •' , WELL t1DLil\lJOl\lYli'iN RECORD. Far-Intemal.Use_ONLY:__:;;__�__. -- -- — 'I.Well Contraetor.Information:. ".• WELL ABANDONMENT DETAILS `..' 'GarySi mcox 7a.For'Geoprobe/DPT or Closed-Loop.Geothermal Wells haling the same Well ContractorNade(or well owner personally abandoning well on hider property)'.'. well construction/depth;only l Gwm30 is needed: Indicate TOTAL'NUMBER of r---=-- - --- - ned:l- - - -i •- ; . 29446 �.. wells abando� . . ' .. .. • .� "'�•. . NC.W611 Contractor'Certification Number 7b.:Approximate.'volume,)f water remaining in well(s):i 5 (gal.) .aS&M E, Inc. t FOR WATER SUPPLY WELLS ONLY: 7c.Type'of.disinfectant used:i �t • ' '.Company Name • �-- - 2.Well Construction Permit — Lisrall applicable xel/conslruclion permits(i.e.UIC;.County,State,'{!ariance,'etc.)ifknown 7d.Amougt"of disinfectant used:. IY •. -3.Well use(check well'use): Water Supply Well: :: : . 7e.Sealing materials used.(check all thataPPly) ❑Agricultural": -,dMunicipal/Public ',• ' . ❑Neat:Ceihent Gfout •' 0 Bentonite Chips br Pellets ❑Geothermal(Heating/Cooling Supply): ❑Residential Water Supply_(single)_ ❑Sand Cerrient Grout' ❑Dry Clay' DlndtistriaUComrirercial ' '. OResidential Water,Supply(shared) ❑,Conerete.Grbut :: ❑Drill Cuttings : ., . . ❑Irri ation :- ❑'Specialty Grout ❑'Gravel Non-Water Supply Well w^1 �M `'�?:y; f°„ a - 0 Benioitite Slurry 0 Other(explain under 7g) ... _ . SiMoniforing it .�, -.. _.:,a L.: Ol eco rj_''.. Injection Well: . . " 7f.For each material selected.above,provide amount of materials used:. f..��24 , - Aquifer Recharga. ❑fir 40oundwater Rerirediatiou - } -' --- - - OAquifer$forage and R11 QveiyY_z�; ?;,:E]zSal�nity BartZef ❑A 4uifer Test : ;,:� . . Di ; q �'��i,Z'1 C]SLormwaterDramage' OExperimental_Technology. : . ❑Subsidence Control 7g.'Provide:a brief description of the abandoninentpr ocedure: ❑Geothermal.(Closed Loop). '❑Tracer ' r. -- -- _T—_- ------ ❑Geotliermal.(IIeatin Return ❑Other.ez iainunder:l' Filled well casing with bentonite chips and g/Coolie. g ) ( P g)' a hen hydrated. Removed top two-feet of well a.I)ate.well(s)abandoned:9/2/24, casing and protective.cover. 5a.Well location_: ,Carolina Biological Sup �. •Facility/Owner Name 'Facility 1D#(if applicable) S;Certiricationq 2700 York Road, Burlington, NC 9 ; . ::9/26/24 i Physical.Addresss ity;end Zip Signature of Certified Well Contrectoror Well Owner Date ancBy signing this form,1'hereby:certify;lltal the wells)was;(ivere)abandoned in' County Parcel:tdentificatioreNo..(PIN) • accordance with 15A NCAC.01C.0100 or2C.0100 Well Constructioh'Standards and that p copy df 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 __ 9.Site diagrain'or additional well details: ; '. . o !�_-�✓n� }. o � n Yon may page P 36 06 20.24 '179 29 17.21 �' y use'the back'of this a e,to fovide additional well"site details or well. i N r 1W, • ."abandonment details:.You'may also'attach additional if necessary.' _ CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED PPY A&achsvellconstructionrecords i iavailable..Formult lein'cdonornon-n»'tirsu l v,elis SUBMITTAL INSTRUCTIONS,' ()f .. P J .. ONLY with the same construction/abandonment_you can submit one form: r--- 10a. For All Wells:.. Submit this form within'30,days of completion of well 6a.Well ID#:DW-1 `. abandonntentto the following: _ Division of Water Resources,Information Processing Unit; 61i.Total well depth:24.4 '(ff.) .• 1617 Mail Service'Center,Raleigh;NC,27690-1617 . -'--"'--'--'- , 10b, For Iniection Wells: hi addition to sending the form to the address in IOa 6c:Borehole diameter: (in.) pY Y P 1 all ove;:also submitone.co ,of this form within 30;da s of com letion of well . . ., abandonment to the:following: 2.12 ft Division of Water Resources,Underground Injection Control Program, 6d.Water level.below ground surface:-. ( ) . 1636"Mail Service Center,Raleigh;NC 27699-1636: 6e.Outer casing length(if_lmown):-� }(o 10c.For Water.Su.my&Injection Wells-.In addition to.sending the form to the. addresses)above,.also submit one copy of this form within 30 days of completion { of Well.abandonment to the.county.health department ' .the.the.county.where ;6f.Innencasin tubin lee th rf(mown• ft. abandoned. 6g:Screen length(if mmown):�^ lof ). '616 Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources'; Revised 2-22-2 I WELL ABANDONMENT'RECORD: : :: Ferintemal:Use oriiv.: I.Well Contractor.Information: WELL ABANDONMENT DETAILS Ga mcox .. I ry Si i."•7a.For'Geoprobe/DPT or Closed-Loop.Geothernial Wells having the same Well Contractor Name(of well owner personally abandoning well on his/her property)'," 4/depth;only 1 GW-'Ail;is needed: Indicate TOTAL NUMBER of 2944Blls well constructio • ' .. aban .. 7b.:A roximate'volume of water- in well ! al. NC.WeII Contractor Certificatioo"Nwhber :. "• PP g ($)� (g ) .'§&ME, Inc. FOR WATER-SUPPLY WELLS ONLY: .Company Name. : �' �i 2:Wgh Construction Permit#:'I 7c..Type"of disinfectant used: List all applicable well construction permits(i.e.UIC,,'.County,State,',Variance,'etc.)ifknown .. ff ..• ': 7d.Amount disinfectant"used f. I.Will use(check well"use): Water Supply Well: 7e.,Sealing materials used:(check all that aPP1Y) fjAgricultural': : OMunMpal/Phblic" .," ❑'Neat:Cement Grout - _, ■Bentonite Chips or Pellets " '[]Geothermal(Heating/Cooling Supply) '❑Residential Water Supply(single)'.. El and Cement Grout: ❑Dry Clay- - Dlndustrial/Commercial .. OResidential Water,Supply(shared) ❑.Cone te.Grouf ❑_Drill Cuttings ❑hii ation : 1"n "" ��.T ❑ Specialty Grout ❑Greve!. Non-Water SupplynWelL ..t,,+�.,.sr.. , r - t � a" - •• 0-Bentonite Slurry O Other(explaip under 7g). , Monitoring," : '❑Recovery .. : . Injection Well: . . �_ [ 7f.For each material selected:above!provide amount of materials used: :. ❑Aquifer Recharge OGroundvJater'Remediation- 25-lbS . 0Aquifer.Siorag'dUik' '8z e-* ,OSafihi-.13arrier !k ❑Aquifer Test : ❑Stormwater Drainage ❑ExperimentafTechnology . .- ❑Subsidence"Control .. • - _-- -- 7g:P f the aban -_ -- rovide:a brief description o donlnent procedure: '❑Geothermal.(Glosed Loop)_. ' : -." ❑Tracer1. : ❑Geotfiermal.(HeatinglCooling Return) .❑Other(explain under.7g)" ,Filled wellcasing withbentonite chips and" then hydrated. Removed top two feet•of well " O 9/2/24 casing.and protective cover. 4.bate wells abandoned:+ j . I 5a.Well location: _ .,Carolina Biological Sup •Facility/Ownei Name Facility 1D#(if applicable) -S:Certification: 2700 York Road, Burlington, NC ----' _;9/26/24 Physical Address,City;and Zip .� _" _._ Signatuie ofCertified Well Contractor•or. Well Owner Date- ' Alamance. si"qin this"orm,I hereli certify.that the wells was"were abandoned in' County ParcelldentificationNo..(PIN)•, y g g I y: " (I ( J accordance with 15.4 NCAC 02C'6100 or 2C•.0200 Well Construction Standards and thdt p copy of this'record has-been provided to the well owner."" 56.Latitude alid.16ni&ude in degreeslminutes/seconds or decimal degrees: (if well feld,one lavlong is sufficient)"'.. t !. r--= - -- --- 9:Site diagrain:or additional well details: �36' 06' 20.21"`" iv 79° 29' 17.23" ��," You may use'the back of this page topiovide additional well'site details or well" abandonmentdetails:,Yournay also attach additional:pages ifnecessary: CONSTRUCTION DETAILS OF WELLS)BEING All :- SUBMITTAL INSTRUCTIONS Attgchivelleonstructior record(s)ifavarlable.Fgrmuliipleinjeclionornon-watersupplywells - . ONLY with the same constructionlabandonment;you can submit one form: ' r--- ----< - 10a. For All Wells: Submit.this'form within 30 days of completion of well Mw-1'6a.-Well ID#: , abandonment to the following: :.. . i. c6s,Information le ation rocess1617 Unit, Division of Water t; 6b.Total well depth 115 2 (rf j 1617 Mail-Service Center, —w - 106.For Infection Wells:,.m addition to sending the form do;the address in l0a ; 6c:Borehole diameter: (in.) copy;of days of otppleti Above,-'also submit one this form.within 30 c on of well abandonment to the following: j . Division o_f Water Resources,pRoerground Injection Control Program, 64.Water I vel.below ground surface:"11 69 - - (ft) iter,Raleigh;NC 276 0-1636" "1636'Mail Service�Cen : n 0c;For Waier.SuppN&Tnjection Wells: in addition to.sending"the form to the. a 6e.'Outer caging'length(if known): (ft.) addresses)above,.also submit one copy of this form within 30 days of completion - '-- do t to the county health department of the county.where .-_! of well.abandonnien - : 6E Inner casing/tubing length(if known):I� �(ft.).' abandoned. i • 6g.Screen length"(ifknown):( Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I; :. Revised 2-22-2616-