Brunswick_Well Abandonment_20231113

WELL ABANDONMENT RECORD For fiveTnall3scONLY-_
This,fohikawbe used-thr single ar.mulliplevit-Ils' I ;
!.Welt'to ntraetiar;lofortnation: )YELL ABAND(?ARENt'DETABLS`
Stefan Smith. Ia.N mbcrofwell}being bandonl-di.
Nell CattrictarNamr(orw�lloutxrpct5oti�lly;il:amtanin etll an9iis11icrprblic[ty'). �N n�rrfnole rrtteelfon W;.aoiHrria'er�4gpp , weM FATLY will; MV swui.
' � iQrtYl'71YCf1(XL�rshrarctrrrirrl«af,IYlrr'cyms,rferUf'cvr�frrm, '
3576A I �9
A.Approi:inwtc vainme of matey eentatning in
NC well ConlraporC�nifiaitiou Ntini7cr .
SAEDACCO • FOR-NVATFRSUPPI,YwlgLt<SO�NO.Y:.
C4n,"I EyNamc
7c Type of tlis9nfictani us¢d:-None
2:�Vel[Consnvcfioa Pcrtuit#:, f,
LGl eNl upr�lfavble+r:»11 farmitr�,u.Ccc�nh',Sraty:l oirttmca.L1ea r;uM err l.fJt u3wt+ 7d:Amount of dlsin(i`ctatit n5�11:"
3.R`�1 use(cltccl:q'cll.usc}: � �,
water.Snppl.V Well: 7c.Scaling tit itcoi:Els tiscd•(shc�[-'a11+61t�t apply):
pAaricnttciml I7h9unic pil(Pitblic• f2 Ngtt Ccnicnt.Gt0 t j' to Hcwottitc:Chili§or Pellets '
pCcothcmvil(HcatinrlCooling"Supply) Mcsidcrrti:El Water Supply(sinSlc) >a Sand Cetiteni Cron D My Clay
I7htdusidallCcimtncicial l3RcsidcntLd\Vatcr Supply(share!) 17 Concrete Grout t7 Dtill-Clittin,
❑ ti tion - �'SpcciuJlj.Grout El Gra fel
NORAVater Supply NYell: 0 96touite side' ;' 0 Uther(explain under 7s1.
�Matiltutiitg 17Rc�cat�eti' �,
Ncetion NYcll: - X For each material selected abosr,�proside antinto obtiaterials mcd:
0Attuifer.Rccharie I743tp4ndnhlerRettieduUian Neat.Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:.gal.
bAquiferStoral;e'utxi,Recovek LiSalinity Darticr
❑A Tesf DStontni'tter Drsin:tgc. .
Bentonite.:31b ,Wtr:gal.
iluifei
�EretimeuWi Tcrintala�ti pStibsidet>sti'CotNnrl
- 77,Pruiidc a brief dciiripdan of the:tbaacErtnmcnt pnEatilun: .
13deodiennat{Closed Loop) CiTMcer
-
Pulled entire well and pressure grouted bore using Portland
®Geothean>altHeEtinu/C_oalinxRetu_rn) 00(ficr.(cw1ainunder.71
T cement and bentonite grout:.
1rDateirdt(3).:ibandonccle 10-17-23
Sa.'�Yl'll tal'atl0n: i, c•..�@.. ..s i� '�„� ����",�+ -
ExxonMobil VI •'
} +1D tC6ppiiG•rlils S.�eidRcutiau: '
Faoitit llJn`i>rrNuira Failit} �+` 1 i'
,?,h
lkS River Road SE,'Leland, 28479 �. aj, Gr;;a� d,10J26/2023
Physical Addrem.Citv:and Zip 5 nti`r.CCdit3 l lV�tl Ccmtradnr nr tifCf)d}rYn r Dale
Brunswick fij+;y�g111ng,1h?s jiorel, l Ilemhl'Cei•flfy41ud ille well(s) wax prom)ohmidoned in
County' l+acrct IJcotifeciitmtNo.(P(N) neCuirliilai'e lvillr'1:'trl'MAC OX;01dd dr 2C.6200 R':clf C�iirsJrtfitlura Shirrikrrds
rrrtrl that ri iOff affids record-14Y beer,,jrrvyie.ed-• 1re.1411 oir'nem
Sb.f atitadeand hingitudc:in de co slistluutcslscciiritls or�lsxitii.�l dE lmces:. '
iifircll field.OtrC l It/iDll iS371fflC6CW)- 9.SIW diagrarn or add(tlnnat ovIl dctalls:
You niu}:iuc tlte.Gacl�of tilts page to"pto,,,j e additiotu�E dii U sitg.details ar trail
34.181343' ,h 77.9,8890 1 �V. a6atidoiututtt dti(iils. I'ou umy a[sa attack udditiotutl pages if'lice ess
aq'"
Et'ONSTR0I&II624•DETA6t!i QFWELL4Sk BEiN(.ABANfi0NED. (TBA1iTi,i,IRTSTRLTt'Tlf!}TS, �.
:that,}Vrl1 ctrrstraietron n�Yaril(SJ�aibitmrilc. •Ibr rirylnpf�irrf�ttlure ur!vn•nwtb--�rgplp I
nefli;UNLr uitPi fhv�vnr�rvh+nrAtrgrr'arwmt2rr;�Ml!you cnn sidrrcit.wrr G1nrr t0a; For Al %Vctk: Submit'Il>�famr ttithin 30 dikVs of catnplction of it-ell.
alinndouuicnf to'th0 foli4Wi
Ge.%%,Cg m#:MW12. ng;
MYisicm of Water Rmurce I s.in6i tion I!tvc:Ari'ATnit,
6b:Total hell depth: 12 ,E 1G17 AL•iil Stnim Center,Rakt>yti.1tiC 27699-1617
t lh.Frit in lactlart W�IIE;: In addi(iou-lo sending tie fornt to the addto.,a ltt 103
6c:Bocmhoic dianictcr:2 (p•y above also submit we avy of this fiirm.ivilltiit 36 diVs of cotEtplt'11G16 of 11e11
abnmlaunkid to tb:,fglldwint .
.Biiilsion.of Wieser Rescui vest,Indggrdund itij��ctlontoiitrol Nvigram.,
�it8 �Yritcr lcF'el'.bctow Srrfcetid'snrtacc '4 (ft:) id Mail SecficC Ccuier;lialvi;;h,1lC 27699-1636
i ,
6c.Outcr Ming icttrh"(i$imnrra): 4 (ft) 10e i,'nrAMISerSrmntt.,f EnFgj1 a.3 eES In addition toscndig the forntto
tlEe:addtoss( sj abaeo. also
-sohniit one copy of this fbtnt ivithitt 30 daps of
completion°of iNtill abatdtuuMM to the Lc miy hrahh dcjiarttttcia at the eotmtt
6f:Inner casifiWtubta'ten (if lataiyn):
ii•Itcrc abaridoncd. �
i
Qg:SCUk4I Icn#&(if knoiitt):10 ( .)
Fomt GW;30 Nonh Cawum Depsnrucm of Enrlronnicnt ad Natural Resomecs-Dividonof PlaterRcsoftires i Revised Aivq 20 t_t
I
I
p "

i .
WEILL•ABANDONNIENT RECORD FotInicnia.IUsedNLY;, G, i
ibis fpini.caatie ttsed foe sirigEo or ntultipletcells I I
t,Welt.Contractbrinfor uiatioa: W F LL A WN 136NHRN6 DETAGLS l
I
Stefan Smith 7a•�Tumlicre► )r�•Ilsbeidigabandonlr0i 1
LVe7fCat�rie+orham<`(orirclt.o�rrsr rSoiiallYiti��tdnino'uc61.on9u ur-prupcnyj For intrtttple. 111pelf1mr iW aare>okrti'rI sIippj- wffs ONLY with the saws
- c�ortimrotrturr�5mY7MiN��rif:;:rrrrtiu�•srrtvrlrf�rurefrrrrn, -
3576A
71r..Apnmi6nate volume a.rwatrr maitabiang w Nvdl{s)<i (gat.)
NC Well CanlrauarCcttifiatlita«N>;ntkcr - �
SAEDACCo FOIt.�!"r1IRSE1F1'[,Y�Vt[.[.SUhQ.Y:,
I .
UdnV ny'.Nanit lc.T�pc of d6infutant'-used::None'
2.Wat Coustntction Permit#:
LLUiWirrrnkt M'iwIlp-rmitc(Li OWW.v,.State;1'aNiLntic.L¢irriur.ctc;l-IJdirowu p
7d.Amount ofdislnfictaut usi-d:.
;
3:Welt use(c 1;01trcll tile)
:
Water Snppi��Vcll; 7c.Sealing-lh itcdalsLuRd(ehc0;Al!dhiit,apply):
!]AFiicnitttrat pl4ptinicipalrPittitic Gd'Ni~ttCerticiit-Gtvrit" q Bcntoaitc:Ghipstirt'cll¢ts.
C1Gcotiremntl(Hcatinr,JCoolina$ttlsply) Llltcsitlentinl%VatcrSupply(singlgl D�ad Cent�rtt Grout ❑DiF Clay
❑Indo5trialfCbmrucrcial ❑Ittsidetitiat Water Supply(shaved) ❑CanctrteGrout D bA.Cutlin'
Ditti• tiou --O'Spccialty.Groot 3-Graval
Non AVater%ppl}:%W1: Cl Betitotvte Sintiy I D Other(explain uudcr 7gj,
ffi149tinUoriirL 17Ra:oi�en' I
Injection 7f For each material selected aborty l m•ide ainonotof,materials used.
ip
❑Aqui(e�Recftar},tic t7Giiiuixti}ntcrRenied'Z.uitioti Neat Cem..:941b -,Wtr:7gal. I, Sand Cem.:lb ,Wtr:gal.
'nr�tjtiiferSttiriigc atsi.Reeai'ery 17Sallnidy'Darner .
❑Agttife�Test ❑Sloinni'aterDrsiruge.
Bentonite.:31b ,Wtr:gal. f
17@xpgtiutental Techuofogv nStibsideiit ,Cuninil 7 FiniYdc a hiief i
9.. dcscrTtionofthcaboadnnmcntpnicivfuar:
b3cotitemffit(closcd.Loop) Wracer
Pulled well surface casingl,and broke at screen interval,
' ClGeothemtal(H�ttinttrCoaiin Return_} �10thcr•(c. lain under 7s) I. ;
pressure.grouted.•bore using, Portland cement and bentonite
d.'Datewd[{a).abandoncd 10-17-23 grout.
Sa.�VeflC Eticutiou: �,.,� jz..4 ^�rj �:..'j: .
ExxonMobil _ A`0" ' 2Q23.
[acOdj'rOntxrNuirc F itity IPe tWtip liwtilc) $•CErtitiiitdiaryt IVV VV
26/2023
1515 River Road SE Leland, 28479 s _ter . ,n� ?
;qt r,` �0
Pkvdcal Addmss.City;aW Zip S• iac�,:•Cofino Wai CkrmnctOr Or Well &-Y—" D31e
1
Brunswick 13y signing this farm, I here-by certify 4ltqi Aie u'e)l(sJ wax(trere);abandaaed.in
County frarcct idcet3tci tilnnNo:(P(plj xtctutYhttice ivah,I'A'M^wiG iizi ,01Qt9;urIC.6Z00 iMell Guris'lrucllatt Slcin+krrtfs
11 flrctl ti cop)r offIxis recor4i ht w beets,provi3lerf to her i4ft Owner.,.:
5U,Latitude and lnngitadc iri dcgriccslirtinuteslscmtids or dtcWll degrres:. . .
(iraan CrtJ;ota.k�tllt+ug.ls ttlieia>0) `9.Site dlagrani or addldonal well dmills:
1''ou 64a tise Uec.Uact.ofhis p tage to pidi idd addthonal n12ll site derails or will
34.181774 , . .A. 77.988273 �V' :,16udotinetnitetuils. You«tti5 ttsoattach khciouslpa• sifiwcc'ssary:
CON,;,rRITC""6.V DF3TAIV. OF WFLL410 DEINir ABAN60NED. CLTBII(1T AL iNSTRLTQ'TlOdfS.
tttnch n0 cianrt udkiqa •Fur mulople brfeaidu fir tMirr.irent r stgph-
ri lls O irLl'uiili rlw srtnre rwrstrr riat'rs5riru ry raq+.jrtu can sir unit cure jfunrr FOa: Far All Weds: Suhm(t iltiS form within'30 days of ctitnplctian of.ur ll
6a.%Nell[DLt.Mw7 a#iaotimcnt to thb'Callativitrr:
Division of Water Rest urn.Infyr-inati in Lirnccsvinj.Unit,
GU:Total iv'cltdcpth: 12 16t'7 ruaiigeimcc Cent,O R c'4gh,NC- 2769946I7
0h.For'lnie�Qua tVrlltti In wkfitiott to.sending tha(orm to the,aftU ss,In 10'a
frG.Satehaic diirateht:2 abotti:also subiuil one i py of this form.e ilhui 30 cloys.QC corupteiion of well
(u:}' ubandotuncut to the.lIoilaii'i
Divrysbra of�Wmtcr Resunrie ,UudcrT r i unil Bnji•ctlou Cotidavl!*trogrmu.
6tl �Vatcrlcvcl.bclon gr+itett+l snrFace: 4 (fd:) i63G mail Sceiicc triter;Ralclo,NC 27699-106
I�
I(ic,Foe tV itcr S+rnnle• Bnier�n}}`misg� hr addition to sending the fotm.to
6c.Outer casing lenlob(if lnoii a): 4 (M) tt.le add.wss(esj abtige. also submit owe Opy of tW form ivilliitt 30 days of
Cornptetioti of hell abanduownt to(bL cirunty health'dc�adMid of the county
df.Inner C rsitel;JhcUiu Ccnyrth(if letavtn): (ft.)
ivhrro abandoned•
6g Sert't n length(tf ktiotrn):10 (�.)
Form GW.;30 Nonli Cowilm Depannrnt df EnOwnmeni aN Nattu311(esomTes-Dieistonof Water Rtsoum:- Rc%,6cd Angusv 20t3
i
I.

61
WELL ABANDONMENT RECORD For.IrdenwlUMONLY;,
This form can lie usi d,&r single or mdllipte Wells'
1.�VCI[.Catittactur liifotmatititi !E1.L ABANDONh1ENT DETAIL.S1
l
Stefan Smith. 7a Numhcrar�rcllslieitignbnndauled: 1
Wc1kCfl�rietorTame(ort►�llo�racr �ari�Ily;rLa�aGninoti«llon9risrl>;rpropcnyj N rNr{lrtple 111fcrtic0r iu r+tn�rer(crI sIrp ,. we& ONLY wtrh Mv, sawe
carYrrrrc_rti+vr'ratdir��rrriAt�'ra�_-;lrut rym,sralvfirl�vlaftrrvn
3576A
NC\ircgCvtdr�ctgrCcrtit> itiauIYuo�6si 7b.Anprififinke vol lnin cl�/fiteTtYlila119W1;ImN-elj(4 i6)
SAEDACCO FOR WATER-SUPPLYWWLISONLY;.
Con anyNatri>i 7c.TypetifdWarcetanitked:None
L FVd Coastructlon-Pertait 4:
Lim idl rtjlllft�blL ueilperlrtlir:lir,C�trth,S+ate;d'uitiutie,liirctiur,rlc f tfduurrn I
7a-Amount of disinfectant ttW:-
3:�Vdl uar(taeCln•i'ti.rosej: - �,
�{'atE¢r Stt `li.3VcU: Vic.Scahn ttt ttC�als uscd.(cpCCle allshiit apply):
nn � g
AA iirtlhlrt6 [1Talnnici l/Pttblic, NartCcntcatGYigt. I Q HctlroartcChili§6rl'cllcts-
l7UcotheM11(HCatinNCo[tlina$apply) []Etssi atiltl Woter$uppl)(sIpggic) �7 Saud CententGmut �; ❑pry Clay
DludaSiriaUC�immCn ial 1711csidetahtt Witcr Supply:(slim-cd) E3 UncmtdGrout i 17 6611;Wongs
❑Gti lion d Spaciafty,Grout0 Gcnel
— - -
NOR Voter Supply WCfl; 0 ntonite S I q1W 11 Gther(explain under 7g)
�MotiUoditg Ulkeedvety
Tn jccsian'�VcQ: 7f For.-each ntater'fal selected abot'G proside'antountaC,materials Used:
t7Aquifer,Recftare 17GtiiupditulerRctuedirltian Neat Cem.:941b ,Wtr:7ga1. ; Sand Cem.:lb ,Wtr:gal:
DeAtjteife>Staragcstitti•f2eco�'eii� L1SuliniCy©airier- . � .
L3Aquifet Tes! DStontm'atcr Drifiw .
Bentonite.:31b ,Wtr:gal.
7
❑E et#ntetil l Tielmnlo DStibsidettt Coidgll 7 Pro%ide a brRf`ileccription of the ali0iidnnmcat pe aecdarr:
17Grotflenttat(ClasCd.h;oop). L�Ttacetr '
tJGsothemtal(iieatinsiJ+CoalinxRetum) IOthcr(eaiilain uoder.7a)'
Pulled well surface casingl'and broke at screen interval.'
pressure.grouted bore using-Portland cement and'bentonite
r ,
4J)ate*cll{s),nbanddncd. 10-17-23 grout.
ExxonMobil 3
8.CcrtiRc::tcian� 1•
FaeilitylUivi>:v Mind- `Ca:iliN lDtr CCuppli��tilc)
1815 River Road SE Leland, 28479 �. _ `��"��='�`� 10/26/2023
Physical M&L5.City;and Zip .f i(+irc u difiJA%V411 Cn IIrt*r or W411.4hrn:i Date
Brunswick 7.Jo.vignhjg.ihls farnt,,I hale,,by certjylltai Owwellfy)u;ar(trere)ubmtd�onad'I'lr
Cnutii?' Aarccl idantiCdaiUnriNo:(PIN, riuc'ulYhrtit a 1r r!(+'1T+t e1 IG 0�C.0100.dr 2C.b.',00 IT Cuirfifit(effun Shinikmis
nrirllferrt u cnp),aJ?Iris.reeurif(rru baeia.Frot'i,'cr!!a"llro t+el1 onvea:
56,I-atifudeand tong tuffs in orideci ud ctcimcCs;
(if«ell t"atd otu 1 rt/lou>;isslrmcicrz} 9.S1Q1 diagragt or additional well dctrilCc:
You-ftI4 tse ttk,b&K:;pf uiis pag�.[a.Pi64it[e additiotunt rteD sfte.derifis or,Will.
34.182088 .. �r 77.988764 `�: :abaoiiotutteittdt:iails: V'0t t6y'alsoall3chas&litiautlpo s'ifmcissatS.
CONS?RITMON DETAILS OF WELLlS411L+JNG ABANDoNklj, SUBhr17TAi..IN9TRCTQ T10NS. {
:!rich .1'ar mulofple hlectidtf erMn=urtlW=Ppb. ,
F4Y'lL4.O APL1l'11'lrlr VW BVgR I?Jd C[thi i7fl�lrGt UJk','iGFf7ff. - -1044 For All-Wells- Sttbuitt tit« fame uithin'30 days.ofcoitiplction of well
sa.!1i'cll[U#•MWla. abutidotimcnt Who fallativit►g;
bi*bdanof%Vatcrltcstiurc ,lnfutmiition-Prtitesvng-Unit,
tibcTotul tt'ell d olt: 12 (tt.) fGt7 Ati ail Senice a catet,Raildi i.`It 27699-1617
f101t.Ege-lttleetiott tVclls; In additibdio setuiiug tlk farm to the addtrss lit l0a
6C.Bat,tiholc dtttneteg:2 (i'n.y' about;also Submit otie ci}py of This fotin.tcitltiit 30'days,of cotnptetion of till
abandonment td thu,fglldts'itta: I
I
t1t1.�VatCr tcFCt.bcftitt'btotttitG surfaCi 4 -- (ft;) ltitistaa of lYater Rt sontt is,lJttticr};rottad lnjectlmrCanitol.Ptrogratu,
ia9 flail Strike Center,Ralcigh,11C'Zi(M-1636
t.
Ga Outce casing ictegth(iff hnttt�n): 4 (fC;) 10,k rn'" . mpIx,&lnjMLlan a t1A; In addition to sending Me foint to
.die address(ds nbot'e. also-wbaii one Copy' of this,form tvitbin'3Q days of
eiarnptetiani of aril abandannu-n to the{caunty bcaf h deparitncitt of the county
Gr.inuer easitipt wbtnw t't:ni'th(ir Imawa):
tvlt;rC;tb.�ndoncd, '
fg,SCreca length(If knoau):10 (fd.)
i
EorntG1\'=3a. NonlitataflmDepznt�mafPmlrotnitcntattlNa<tual[lcsouxcs-Qli'[sionoCtYacerRflowR.� ltotitcd'AitFuvst01:+