Pender_Well Abandonment_20220601

WELL ABANDONMENT RECORD For Internal Use ONLY:
RECEIVED
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joseph L. Zuncich MAY 0 6 2022 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
3324-A NG DEO/DWR wells abandoned:
NC Well Contractor Certification Number cl-Affik omw 7b.Approximate volume of water remaining in well(s): 0.3 (gal.)
Applied Resource Management, P.C. 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. VIC,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 ❑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) ❑ Concrete Grout ❑ Drill Cuttings
[Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
i- Injection Well: - 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips 15 LBs
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Measure well depth and water level.
Remove PVC casing to 1' below ground surface.
a.Date well(s)abandoned: 4/25/2022 Seal well with bentonite chi s,p, d hj/drate.
5a.Well location: r * 7 %s'jrn
Daniel Barber N/A :IUN 0 12022_
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
323 Aster Place, Hampstead, NC 28443 :>�:��� r /25/2022
Physical Address,City,and Zip Signat of Cert' ed Well Contractb'b Vl>dIC'Owner' ' Date
Pender 3292-87-0468-000
By signing this form, I hereby certify that the well(s) ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has.been provided to the well owner.
(ifwell field,one)at/long is sufficient) 9.Site diagram or additional well details:
34 22' 04.24" N 77 40' 51.28" 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
A(tach well construction record(s)ifavailable. Forinultiple injection at-ton=water supply wells
ONLY with the same constt7iction,abandotuuen(,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9.6 (ft.) 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: 4 (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: 7.70 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer easing length(if known): 7.6 (ft,) 10c.For Water Suoaly&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): N/A (ft,) abandoned.
6g.Screen length(if known): 2 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016