Onslow_Well Abandonment_20231215 (5)

WELL ABANDONMENT RECORD I 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 construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:One I
NC Well Contractor Certification Number 7b.Approximate volume of wateIr remaining in well(s): 0'80 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: *�"b�`'S.,_v J 5 '}
2.Well Construction Permit#: WM0801 185
List all applicable well construction permits(i.e.UIC County.State, Variance,etc)ftnown DEC 1
7d.Amount of disinfectant used:
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3.Well use(check well use):
U�V�tsi•��L.�7
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic C Neat Cement Grout I e Bcntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 1 ❑ 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)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite — 20 lbs
❑Aquiter Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑StormwaterDrainage Neat Cement — 25 Ibs
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❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite - gravity feed from 15 to 5 ft bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder 7g)
Neat Cement- pour from 5 ft bgs to ground surface
4.Date well(s)abandoned: 11/28/2023
5a.Well location:
C&D Motors
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2227 Lejeune Blvd Jacksonville 12.4.2023
4
Physical Address,City,and Zip Signatu're-bTICcrtified Well CoYmctoror Well Owner Date
OC)SIOW 018866 By sighing this,%orm, I hereby cjert,J&that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 IVell Construction Standards
and that a copy q(this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 9.Site diagram or additional well details:
364274:22-- N 2492532.8.8 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 ivell construction record(e)ifavailable. Fornmltiple injection anon-water supply wells
ONLY with the.sane concn•uction/abandonmehnt,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (fit.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
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: 9.95 (ft.) Division of Water Resource`s,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit ohe'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 (ft.) abandoned.
i
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016

WELL AJ5A1V V U1V 1V1L+•1V•1• H U()" I 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 Iris/her property) well construction/depth,only 1 Gw 30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:0- I-
7b.A l remaining in wells: 0.90
NC Well Contractor Certification Number Approximate volume of wate! g (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
WM0801185 7e.Type of disinfectant used:
r-
2.Well Construction Permit#: 'r. )•-•
List all applicable well construction permits(i.e. U/C,Countr•.State. Variance,etc.)iflarown
7d.Amount of disinfectant used: DEC C 11 t '�02.1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
G.V va ���
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bcntonitc Chips or P�ellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply.Well:_ ❑ Bcntonitc Slurry ❑ Other(cxplairrundcr 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite - 20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement 25 lbS
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite - gravity feed from 15 to 5 ft bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Neat Cement-pour from 5 ft bgs to ground surface
4.Date well(s)abandoned: 11/28/2023
Sa.Well location:
C&D Motors
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
2227 Lejeune Blvd Jacksonville 12.4.2023
Physical Address,City,and Zip Signature ofCcrtificd Well Contra'Eqr or Well Owner Date
Onslow 018866 By signing this,fornn, 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 6Vell Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
364.1.3.7..35_____ N.2492450.59 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
Almchrvellcartcuuctionrecord(.c)ijrrvailuble. For•rttudtipleinjectiono•non-rratet•suppivweitc
ONLY with the same constrtiction/abandonntcnt,van can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1.5 (ft.) 1617 Mail Servic i Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 8.25 (in.) above, also submit one copy of;this form within 30 days of completion of well
abandonment to the following:
i
9.31 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniec+lion 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 (ft.) abandoned. ;
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resou Ices Revised 2-22-2016