Brunswick_Well Abandonment_20230706 (22)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.%N ell Contractor Information: WELL ABANDONMENT DETAILS
Bill Mabie 7a.For Geoprobe/DPTor Closed-Loop Geothermal Wells having the same
well Conn for Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
3137-A wells abandoned:wA
NC Well ConnactorCertiScation 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.UArrR14i111 ;hilt.
�;��p L. 1' i✓ 7d.Amount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: _ 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Pu4lic: U. a Neat Cement Grout III Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 15RO�i�tjk j�)Oly�(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01ni tion ❑ Specialty Grout ❑Gravel
Non-Water Supple Well: III Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: ''If.For each material selected above,provide amount of materials used:
[]Aquifer Recharge OGroundwaterRemediation 48 Ibs of Portland Type 1,111 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 the ahandonment procedure:
❑Geothermal(Closed Loop) OTracer Portland Type 1/II was combined with Bentonite Chips and
❑Geothermal (Heating/Cooling Return ❑Other(explain under 7a) —
mixed into a slurry that was both free poured and tremied
4.Date well(s)abandoned: 5/23/23 into the well until the slurry mix displaced all groundwater
5a.Well location: in the well and the slurry was seen exiting the well.
LoP44oll.d�aup«rund Sim/Honeywell Inlemationlid Im. N/A ^/�
William,IV1 Wilitallysignedby
Facility/Owner Name Facility 1D4(if applicable) 8.Certification: William.Mabie
636 John L. Riegel Road, Riegelwood, NC 28456 able Da5:15 3.07.05
11:35:1 S-04'00'
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Brunswick County N/A
By signing this form, 1 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
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34* 21' 33" N 78* 12' 33" N 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 constructiowabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.well ID#: M W-12A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b. Fotal well depth: 18.2 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.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: 12.0 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft) 10c.For Water Suooly&lniection 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): 8.2 (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
Form G W-30 North Carolina Department of Fnvimmnental Quality-Division of Water Resources Revised 2-22-2016