Brunswick_Well Abandonment_20230706 (30)

WELL ABANDONMENT RECORD For hnemal Use ONLY:
1.)N ell('ontractor Information: N'ELL 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 We0 Conti or Certification Number 7b.Approximate volume of water remaining in well(s): 0.0 (gal.)
WSP USA Environment and Infrastructure, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7a Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.)if brown
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 all Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial qR Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
ir� r�i
❑Irri tion ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: J I I 0 r ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring 1 ery
Injection Well: 7f.For each material selected above,pros ide amount of materials used:
❑Aquifer Recharge ) 'RSA?.nPm.,' 'NdI, rRemediation 48 Ibs of Portland Type 1)11 5 gallons of water
C1.Qi$L
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 50 Ibs of Bentonite Chip:;
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn ❑other(explain under 7 Well was already abandoned or destroyed. Casing
was almost completely filled in. Grouted casing to the top.
4.Date well(s)abandoned: 5/22/23
5a.Well location:
LCP,Hohrad. suv«mnd sib,Homywell Int—imal Inv. N/A
W i l l i a m. Digitally signed by
Facility/Owner Name FacifitylD#(ifapplicable) 8.('ertification: William.Mabie
Dat636 John L. Riegel Road, Riegelwood, NC 28456 abie 11:1 202"00'5
9 9 �1:1427-0a'oo�
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 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrces/minutes/seconds ordecimal 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)ifavadable. For multiple injection or non-water supply wells
ONLY with the same construction-abandonment,you can submit one form.
10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-NUS4R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: N/A (ft.) 1617 Mail Service Centtr,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: NIA (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: N/A (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if knows):
N/A (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
6E Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Ion..G%\-,u North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016