Greene_Well Abandonment_20220805

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 1 GW-30 is needed. Indicate TOTAL NUMBER of
4330-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction pennits(i.e.UIC,Courny,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 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)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterReniediation Bentonite Pellets —24 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete —51bs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geotherma((Heating/Cooling Return) ❑Other(explain under 7g) Abandoned well in place with hydrated Bentonite
pellets to within 6 inches of surface and topped
a•Date well(s)abandoned: 8/2/2022 with concrete to existing grade.
5a.Well location:
NCDEQ-Twins Too NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1741 Hwy 58, Snow Hill, 28580 8/3/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Greene NA
By signing this form, I herebi+cerlify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 ll"ell Construction Standards
and that a copy of this record has been provided to the well otvner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.426560 N -77.637330 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
Annch fuel(constr+{coon rec•ord(s)tfmailable. Fa'nutltiple it jeclion or non-v+alersupply vrellr
ONLY with the same cm+.vb'uciioaiabandwunent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (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: 5.03 (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&Iniection Wells: In addition to sending the form to the
address(es)above,also�bp*p Qne copy of this form within 30 days of completion
of well abandomment totat ourlt hoJth,department of the county where
6L Inner casing/tubing length(if known): 5 (ft.) abandoned. �''l 4 VY0Q
6g.Screen length(if known): 1 (ft.) ON-(�Ci �. 2`�C
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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® Abandoned Monitoring
Well (Type II)
❑ Approximate Location of
USTs (Abandoned in Place)
Parcel Boundary
Source:Esn.Maxar, Earthstar Geographics.and the GIS User Community
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 20 10 0 20 40
jjjjj Feet
mo*cT mu: FIGURE
CATLIN TWINS TOO
1741 HWY 58 SOUTH SITE MAP
SNOW HILL, NC
Engineers and Scientists NaMNTW MN pUWWCWMD BY
B q
220277 38005 AUG 2022 r AS SHOWN IQrICBJA