Greene_Well Abandonment_20221208

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Robby Gene Phillips 7a.For Geoprobe/DPT or Closed iLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW1 30 is needed. Indicate TOTAL NUMBER of
wells abandoned: ONE
3519-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 185 (gal.)
Pearson Pump Sales& Service, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7a Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance;etc.)if known
7d.Amount of disinfectant used:!'1 #
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check I611 that apply):
❑Agricultural dMunicipal/Public 1-ONeat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
01ndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑hTi ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite.Slur y_ _ ❑ Other(explain under 7g) .
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 50 cu ft
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) pumped neat portland;cement into well through
1-1/2"tremie Pipe until full
4.Date well(s)abandoned: December 2, 2022 LZ a ki 1
5a.Well location:
nu o s �p?�
Jason Water Corp Well#1
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: a
Pri;;--Azxc::j Unix
215 Free Gospel Road, Goldsboro NC 28580 12-2-2022
Physical Address,City,and Zip Signa ure of Certified Well Contractor or,Well Owner Date
Greene County By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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: f
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional welt details:
35.4375 N -77.79094 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
Attach well construction record(s)ifavailable.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#: #1 Shines abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 283' (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 X 4'in.) above, also submit one copy of this'form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: 132' (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&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): 250' (ft.)
abandoned.
250'-254'
''-270
6g.Screen length(if known): 262 (ft.) �
277'-281'
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016