Richmond_Well Abandonment_20230602

WELL ABANDONMENT RECORD For Internal use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Core D. Futral
y... 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-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate.volurrie of water remaining in.well(s): (gal.)
Catlin.Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
NA 7c:Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ii known
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 GrOu't,' .• 5: °: ,Dry C-lay,
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout I 1�! ❑ Drill Cuttings
❑Irrigation El Specialty Grout JUN 6 2J 20231 Gravel ..
Non-Water Supply Well: ❑ Bentonite Slurry' IN Other(explain under 7g)
®Monitoring. ❑Recovery g uE,
Injection Well: 7f.For each material selec[eWt"0* e;0ovide amount of materials used:
❑Aquifer Recharge: ❑Groundwater Remediation Bentonite 37.5 Ibs
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer.Test' ❑StormwaterDrainage Concrete. 16.67IbS
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) comer(explain under 7g) All well material abandoned in place with hydrated
bentonite pellets to within — 1 foot of surface and
5/24/23
a:Date well(s)abandoned:, topped with concrete:to existing grade. .
5a.Well location:
NCDEQ_Starflite Food Store 272 NA
Facility/Owner Name Facility,ID#(if applicable) 8.Certification:
1416 Fayetteville Road, Rockingham, NC % 5125/2023:
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
-Richmond 747310357941
By signing this form, 1 hereby,certify that the ivell(s) was.Oere) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards .
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and.longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) 9.Site diagram or additional well details:
34.945485 N -79.754974 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
Aaachwellconsirrrctionrecord(s)ifm,ailable. Pormuhipleinjectionornotr-iraterstrpplywells
ONLY ivitlt the same construction/abandmnnent,you can submit one forma
10a. For All Wells: Submit this form within 30 days'of.completion of well
6a:Well ID#: MW 3'_' abandonment to the following:
Division of Water Resources,Information Processing Unit,
18 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth:
0b For Injection Wells: addition to sending the form to the address in 10a
1 . . 1 In g
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: 3.22 (ft) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC.27699-1636
'"NA 10c.For Water Supply&Injection Wells: In addition to sending the-form to the
6e.Outer casing length(if known):
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): 3 (ft.) abandoned.
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016