Richmond_Well Abandonment_20230602 (3)

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 I GW-30 is needed. Indicate TOTAL NUMBER of
4300-B wells abandoned:
7b.A roximate volume of waterremainin s al..
NC Well Contractor Certification Number PP • g in well O' � )
Catlin_Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
NA f disco 7c:Type o ' ' fecta .nt used:
- 2.Well Construction Permit#:
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 uwd-(check all that apply): d.
❑Agricultural ❑Municipal/Public ElNeat Cement Grout -e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) .:❑Residential Water Supply(single) ❑ Sand Cemen-G,ront,1_a e � ❑ Dry Clay
❑h4.
tdustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
..
(]Irrigation ❑ Specialty Grout I ti O Gravel...
J I (� )
Non-Water Supply Well: ❑ Bentonite Slurry .Y l ` L 023 .®Other(explain under 7g)
eMonitonng ❑Recovery
Injection Well: 7f.For each material selected above:proYJAe.amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 16.67 lbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test' ❑StormwaterDrainage. Concrete
.. 16.67IbS
❑Experimental Technology ❑Subsidence Control
7g.Provide abrief a andon mentprocedure:
❑Geothermal(ClosedLoop): ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All Well material abandoned in place With hydrated
bentonite pellets to within — 1 foot of surface and
5/24/23
a.Hate 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) Certification:8.Certif n:
v
Lam..
416 ayettevi a oa _, .Roc- ing am, - 5/25/2023::
Physical Address,City,and Zip Signature ofCcrlified Well Contractor or Well Owner Date
Richmond 74731:0357941
b. By signing this form, I hereby certify that the ivell(s).ivas (were) 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 lat/long 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
Attach well constntciion records)ifavailable. For multiple injection or non-watersupply.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#: MM4 : "abandonment to the following: '
sion of Water Resources;Information Processing Unit,' .
18 D'V'
6b,Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Ob For Injection Wells: In addition to sending the form to the address in 10a
1 .., 1 s
8.25 abovei also submit one copy of this form within 30 days of completion of.well
6c.Borehole diameter• (in:)
abandonment to the following:
6d Water level below ground surface: 3.10 (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&Injection 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): 3 (ft.) abandoned.
6g.Screen 15,length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016 ....