Brunswick_Well Abandonment_20230706 (12)

WELL ABANDONMENT RECORD For lnoernal Use ONLY:
1.11'ell Contractor Information: WELL ABANDONMENT DETAILS
Bill Mabie 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
3137-A wells abandoned:wA
NC Well Contractor Certification Number 7b.Approximate volume ofwater remaining in Nell(s): 0.0 (gal.)
WSP USA Environment and Infrastructure, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name lc.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.U1C County,State,Variance,etc.)jbrown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e,Sealing materials used(check all that apply):
❑Agricultural ❑MimicipaUPublic a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial /''1L..jN t1,-" r Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri tion 1L•• �•: ❑ Specialty Grout ❑Gravel
:Von-Water Supply Well: o I I p r, 2023 19 Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Ytecovery
Injection Well: In(G;tY C 1.�r. Ur* 711 For each material selected above,provide amount of material,used:
❑Aquifer Recharge �C,%J,,0g6rMdwaterRemediation 48 Ibs of Portland Type 1/II 5 gallons of water
❑Aquifer Storage and Recovery ❑Salinity Barrier --
[]Aquifer Test ❑StormwaterDrainage 50 Ibs of Bentonite Chips_
❑Experimental Technology ❑Subsidence Control 7g Provide a brief description of tte abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return ❑Other(explain under 7 Portland Type 1/II was combined with Bentonite Chips and
mixed into a slurry that was both free poured and tremied
4.Date well(s)abandoned: 5/22/23
into the well until the slurry mix displaced all groundwater
5a.Well location: in the well and the slurry was seen exiting the well.
tCP 5.0�,­d Silo t H.-y-4i Int—t-1 N/A
William.M illly signed by
Facility/Owner Name FacihryllNt(ifapplicable) 8.Certification: Williaiam.Mabie
Date 02 5636 John L. Riegel Road, Riegelwood, NC 28456 abie 11:17-01 "00'
Physical Address,City,and Zip Signature ofCertified Well Contractor or Well Owner Date
Brunswick County N/A
By signing this form, /hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34*21' 33" N 78* 12' 33" 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 record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: PZ-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6h.Total Nell depth: 14.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 9.0 (ft_) Division of Wafer Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A 10c.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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): 4.5 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016