Robeson_Well Abandonment_20230818 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. We rl ey 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
3344-A wells abandoned:o^a
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.34 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoun
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 a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑[ndustriaUCornmercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite - 25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑StonmwaterDrainage Neat Cement-35 lbs.
❑Experimental Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothenmal(Closed Loop) ❑Tracer
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed bentonite chips from 20' to 5' bgs
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 08/09/2023
5a.Well location: AUG
G 1(+8 ?m
Lon W,(150Jack-)WW,LLC,aDelawareiimWiiaeinyw,m ny NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
150 Jackson Court Lumberton, NC 28358 ,� �' "31 1.2023
Physical Address,City,and Zip Signature ofCertitied Well ContactorZ)Well Owner Date
Robeson 939384512500
By signing this.1brm, /hereby certify that the we//(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 o/7his retard has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaUlong is sufficient) 9.Site diagram or additional well details:
34.66812377 N -79.00559091 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
Attaclnrellconsurtctionrecord(s)ifavailable. Formultiple injection ornon-natersupplvrrells
ONLY frith the same construction/abandonment,you can submit onefornt. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW05 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 M.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to die address in 10a
6c.Borehole diameter: 6 (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: 5.69 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA 10c.For Water Supply&Iniection 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): 5 abandoned.
6g.Screen length(if known): 15
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016