Johnston_Well Abandonment_20230428 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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) wel I construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:- I
NC Well Contractor Certification Number C�� a U 7b.Approximate volume of water remaining in well(s): 0.87 (gal.)
AECOM OR N23 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.'Type of disinfectant used:
2.Well Construction Permit#: �-
'_1rU��r s"�GB�+J �1''
List all applicable well construction permits(i.e.UI( 'YeW)ft ,Variance,etc.)if known
7d.Amount of disinfectant used: N/A
n V/A
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑ Bentonitc 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
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRernediation Portland-13.16lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquifcrTest ❑StonmvatcrDrainagc Water-0.73 gallons
❑Experimental Technology ❑Subsidence Control 7g_Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Tremie grouted with a portland mix.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 03.28.2023
5a.Well location:
Kinder Morgan SE Terminals LLC N/A
Facility/Owner Name Facility I1311(if applicable) 8.Certification: "y
4086 Buffalo Road,Selma,27576 `"' 04.25.2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Johnston 260502-86-5063 } g f y fy ()
B�signing this form, I hereby certify that the wells was were abandoned in
County Parcel identification No.(PN accordance with 15A A'CAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.55140 78.30035 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages irnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well consuvction record(s)ifavailable.Fornndiiple it jection ornon-water supply wells
ONLY with the same cmuvnutimt,nbandonmant,you can submit one form.
� 10a. For All Wells: Submit this forni within 30 days of completion of well
6a.Well ID#: M V A��-8 abandonment to die following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 7'0 (ft)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (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: 1.65 (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 Sunaly&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
6E Inner casing/tubing length(if known):2.0 (ft.) abandoned.
6g.Screen length(if known): 5.0 (ft.)
I
Revised 2-22-2016
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcl s