Wilson_Well Abandonment_20220531 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple Injection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
C - 4421 � 3.25
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION,INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits I'l.e.County,State,Variance,etc.)ijknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement G t F,. Clay
❑Concrete Grout Prof Cuttings
❑Industrial/Commercial ❑Residential Water Supply(shared) g
❑hri ation ❑ Specialty Grout MAY 3 1 202213 Gravel
Non-Water Supply Well: 21 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery lnfww,,3�30 Pr ::,w_: ,.g Und
Injection Well: 7E For each material seleCK41",&&ovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
5a.Well location:
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(ifapplicable) 8.Certifrcation:
1313 WARD BLVD WILSON 27893 '"'"` 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON By signing this form, I hereby cert6 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 43' 15.22° 770 56' 09.20° You may use the back of this page to provide additional well site details or well
N �1 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)If available. For multiple injection or non-,eater supply
ivells ONLY with the some construction/abandonmem,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-4 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: -(in.) abandonment to the following:
6d.Water level below ground surface: 5.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
611 Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department ofEnduonment and Natural Resources-Division of Water Quality Revised March 2013

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i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 1 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
C -4421 construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 10.5 (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits f.e.County,State,Variance,eta)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 ❑Neat Cement Grout _ ❑Bentonite Chips or Pellets
(Heating/Cooling pp y) pp y(single) ❑Sand Cement Grou;"�) F 9l
❑GeothermalSupply) ❑Residential Water Supply i Y
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Mauttings
❑bri ation ❑ Specialty Grout MAY 3 120W,-ravel
Non-Water Supply Well: 16 Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
In¢ortt;�x�l f ra ; , sn3 UN.
Injection Well: 7E For each material selecteWa%94e pQide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 11.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
5a:Well location:
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1313 WARD BLVD WILSON 27893 �""�r'� """"` 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON By signing this form, 1 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 43' 15.22" 770 56' 09.20" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-4D abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 67.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (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: 3.5 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): (ft.) Where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department ofEnvironment and Natural Resources—Division of Water Quality Revised March 2013