Onslow_Well Abandonment_20231215 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 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 constniction/depth,only I GW;-30 is needed. Indicate TOTAL NUMBER of
3344—A wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water)remaining in well(s): 1 .25 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
WM0801185 7c.Type of disinfectant used: ^;� r,;
ti
2.Well Construction Permit#: �t,g
List all applicable cell construction permits(i.e. U/C,County,State, Variance,etc.)ftnown �E('
7d.Amount of disinfectant used:.' l.• .5 902)
3.Well use(check well use): tlif�rr3?i�
Water Supply Well: 7e.Sealing materials used(check all that apply): ;:�; f J� ' jr•<
❑Agricultural ❑Municipal/Public a Neat Cement Grout N Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) I]Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑G'roundwater Remediation Bentonite ~ 20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonmwaterDrainage Neat Cement — 25 Ibs
❑Experimental Technology El Subsidence Control
❑Geothennal(Closed Loop) ❑Tracer
7g.Provide a brief description of?the abandonment procedure:❑ n Geothenal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite - gravity, feed from 15 to 5 ft bgs
Neat Cement- pour fromJ5 ft bgs to ground surface
4.Date well(s)abandoned: 1 1/28/2023
i
5a.Well location:
C&D Motors
Facility/Owner Name Facility ID#(if applicable) S.Certification:
2227 Lejeune Blvd Jacksonville 12.4.2023
Physical Address,City,and Zip Signature of Certified Wontractor or Well Owner Date
Onslow 018866 By signing this form, 1 hereby certij�that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C!0100 or 2C.0200 Nell Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy q/'this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
364289.02 N 2492414.57 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 cotnslrnctkut recortl(v)ifavailrtble. Forttnuitipic injeciion o•mm-ivuter snppl),ivell.v
ONLY nvilb the same consh-uction%abandonnnent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in I0a
6c.Borehole diameter: 8.25 (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: 7.42 (ft.) Division of Water Resources,)Underground Injection Control Program,
1636 Mail Service I Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water SUPPIV&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): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016