Brunswick_Well Abandonment_20220719

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT.DETAILS
Corey D: Futral 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
wells abandoned:
4330-B
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): (gal.)
CATLIN Engineers and Scientist FOR WATER SUPPLY WELLS'ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.OIC,Comgv,State,Variance,etc.)ii known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(checklall that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 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 9 Other(explain under 7g)
IMMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets —25 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer.Test ❑StormwaterDrainage Concrete �5IbS
❑Experimental Technology El Subsidence Control
- 7g.Provide a brief description of!the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer All material completley removed. Abandoned with
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
hydrated bentonite pellets to within 6 -
a.Date well(s)abandoned: 7/14/2022 inches of the surface.':Topped with concrete
5a.Well location: to existing grade.
NCDEQ-Lucy Grant Unknown
Facility/Owner Name Facility ID#(if applicable) 8.Certification: r\
1370 Stanbury Rd. SW, Supply 28465 <�ft OF IW 2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner
Brunswick Unknown JUL 19 aM
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.0/00 oi-2C.020Q 6 V1l vrl4i?y�>!jon Standards
and that a copy of this record has been provided(gjh�g t'!,l•aI r-r'�I`9�71�t1 i
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:
33.945170 N -78.285269 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach hell constructiotn-ecord(s)ifavailable.Formultiple injection or non-uvaersupply ivells
ONLY with the same construction✓ahandonnien/y6u can suhmit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: B-1 abandonment to the following:-
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (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: 8.25 (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: 7.56 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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 cobnty health department of the county where
6f,Inner casing/tubing length(if known): 2 abandoned.
6g.Screen length(if known): 1 (ft.).
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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