Bertie_Well Abandonment_20230706

WELL ABANDONMENT.RECORD For Internal Use ONLY`.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steve Hudson 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
wells abandoned:
A. roximate volume of water'remaining s al.
NC Well Contractor Certification Number 7b PP eiig in well� O' (g )
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)fit 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 X Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout El Dry Clay
❑lndustrial/Commercial. ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings.
ElIrrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply.Well: ❑ Bentonite Slu 9 Other(explain under 7
,.,� nY... ( P g)
eMonttoring ... :.(5 r / "C]tteGbvery
Injection Well: y" 7f.'For each material selected above,provide amount of materials used:
OAquifer Recharge (' Groundwater Remediation
q i , 2Q2� Bentonite 3 Ibs .
J_: 4
❑A uifer Storage recovery ❑Sal' ty Barrier
❑Aquifer Test In(zn"Pfit�' N1�r����surf t Topsoil .37.5 lbs
tormwater Drainage
❑ExperimentalTechnology ❑Subsidence Control
7g.Provide a brief description of.the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) . ❑Other(explain under 7g) Hydrated b.entOnite to �6 inches below
land surface.Topsoil used to bring o enin to
6/15/23 p 9 P 9
4.Date well(s)abandoned: grade. Concrete pad and metal removed.
5a.Well location: PVC Was left in place.
Eli Gofield.Jr. Heirs NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1814 US HWY 17, Merry: Hill, NC 27957 6/29/23
Physical•Address;City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie County 684.3852597
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.01,00 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 diagrain or additional well details:
36-.026521 N -76.807380 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.ifnecessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED.: SUBMITTAL INSTRUCTIONS .
A[tachrvel(consn•uc(ionrecord(s)ijavaildble.:Formu/(ipleinjectionornon-7vatersupplywells
ONLY with the same construction/abandonment,you can subinii one form. 10a. For All Wells: Submit this form within 30 days of completion of well '
6a.Well ID#: D W-1. abandonment to the following:.
Division of Water Resources,Information Processing Unit,
6b.Total well depth- 25 (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Infection Wells: 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• >4.0 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
22 (ft.) 10c.For Water Suaaly&Infection 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): 25 (ft.) abandoned.
6g.Screen length(if known): 5
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcies Revised 2-22-2016
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