Bertie_Well Abandonment_20240119 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY: j
1.Well Contractor Information: WELL ABANDONMENT DETAILS"
Justin Radford 7a.For Geoprobe/DPT or Closed-I qlp Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: i i
NC Well Contractor Certification Number 7b.Approximate volume of waterremaining in well(s): 0'�� (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A ;!
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoivn
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 ❑Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ( ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery �!
Injection Well: 7E For each material selected above:,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 20 Ibs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 Ibs Concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) r^^•'`�'
U ..
a.Date well(s)abandoned: 01/04/2024
5a.Well location: Ir,l
1111v1
Perrytown Service Center 00-0-0000022792
Facility/Owner Name Facility ID#(if applicable) 8.Certification: A
526 Sand Hill Road, Colerain, NC O j; 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Berne 3801-1432-6555 B signing this orm, I het certi that the tvelJ s was were abandoned in
Y S S .f Y .�', �� (were)
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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 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 i
Attach well construction records)ifavailable. For multiple ityectionornon-irater supply wells
ONLY with the same constructionlabandonment,you can submit one form.
I►A`/t, 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 'V'V V—27 abandonment to the following: j
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14.26 (ft) 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: 2 fin.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: 8.26 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
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6e.Outer casing length(if known): n/a —(ft.) 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
611 Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i, Revised 2-22-2016
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