Moore_Well Abandonment_20230406 (6)

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
4300-13 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): Unknown (
gal.) '
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e. UIC;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 ❑Graver r
Non-Water Supply Well: ❑ Bentonite Slurry a Other(explain under 7g)p
CMonitoring ❑Recovery /lFR )
Injection Well: 7f.For each material selected above,provide amount of materials used: 2023
❑Aquifer Recharge ❑GroundwaterReinediation Bentonite —12.5 IbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage TOpS011 ^60 IbS
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed —5 feet of PVC and stick up. Concrete
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) .
around well removed. Blockage fell to —10' BLS -
4.Date well(s)abandoned: 03/16/2023 When stick up was removed. Bentonite from obstruction
5a.Well location: to— 1.25' BLS where PVC terminated.Topsoil to bring to grade.:
NCDOT-Moore Co. Maint. Facility NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
993 Priest Hill Road, Carthage, NC 28327 (� 3/28/23
Physical Address,City,and Zip - Signature of Ccrtified.Well Contractor or Well Owner Date
Moore County 858800616166
By signing this form, I hereby certify that the wells) was (were) abandoned in _
County Parcel Identification No.(PIN) accordance ivith 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.345323 N -79.381575 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 records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandomnem,yoti can submit one form.
:10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 53 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection WellsE 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: Unknown (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.) loc.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 fif known): 33 (ft) abandoned.
6g.Screen length(if known): 20
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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®MW-3
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FORMER DIESEL FORMER GASOLINE MW-5
UST(6,300 GAL:) UST(6,330 GAL.)
MW-4( J GAS HOUSE
FfUST(10,OOOGA
7.,
RMER DIESEL QFORMER GASOLINE ,
UST(10,0(10 GAL.)
'111111111C PIT- ?RMER KEROSENE ..��
UST(1,000 GAL.) (E) —-
r, _ MW-1
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FORMER GAS-LINE
UST(10,000 GAL.)
MW-6
LEGEND
® Monitoring Well z • r
(Type 11) o
OMonitoring Well
(Type III) �4
❑ Approximate Location
of Former LISTS
❑ Parcel Boundary '
.I
Source. s ,Maxar. GeoE e. Earthstar Geographies.CNES/Airbus DS,
USDA. U= � =,Ae oGRID. IGN. d thi'e1GIS'User Co muri,
NOTE:Well and tank locations were obtained from previous reports 80 40 0 80 160
prepared by other consultants and are approximate.
All well abandoned on 3/16/2023. mmmoollFeet
PROJECT TITLE FIGURE
NCDOT MOORE COUNTY
ATLIN MAINTENANCE FACILITY SITE MAP
C993 PRIEST HILL ROAD
Engineers and Scientists CARTHAGE, NC
INCIDENT NO JOB NO I DATE SCALE DRAWN BYICHECKED BY
9719 220257 MAR 2023 AS SHOWN KMC/SJO