Robeson_Well Abandonment_20240301

,. WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 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
4630C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):_(gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc)ij known
7d.Amount of disinfectant used:
3.Well use(check well use):
Nk ater Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand CementPWui.. , y`,. Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) El Concrete Grout E,.La L i �/ 1„.Lkrill Cuttings
❑hri ation ❑ Specialty Grout MAN 0 , 2�?A ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry CY ❑Other(explain under 7g)
EMonitoring ❑Recovery .
Injection Well: 7t. I or each niaT�t t� I'd a.0�e,prilvtde amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite l•i 10 I b s
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete 16.67 I b s
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heatin Cooling Return) ❑Other(explain under 7g) Well was abandoned easing hydrated bentonite to
approximately 6 inches below land surface.
4.Date well(s)abandoned: 2/15/2024 Concrete was used to cap PVC and bring opening
,a."ell location: to grade. All materials left in place.
Frank E Thompson NA -
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
220 West Main Street, Rowland, NC 28383 441� 2/20/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Robeson 921817305300
By signing this form, /hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.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:
34.538219 N -79.294581 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 wellconstructionrecord(s)ifavailahle. For multiple injection or non-water supply wells
O,VLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.well ID#: M W-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
61).Tutal\Nell depth: 14 (tt) 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: 3.48 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (it) 10c.For Water Suooly&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): 4 abandoned.
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

CO
•
8,000-GAL.
GASOLINE
UST
FORMER 2,000-GAL. 4,000- GAL.
KEROSENE UST MW-01 GASOLINE
USTS
DISPENSER
ISLAND
LEGEND
® Abandoned Monitoring
a
Well (Type II)
0 Approximate Location `
of Former AST
Approximate Location •
of UST System
0 Parcel Boundary M'4//V
Source Esn, Maxar, Earthstar Geographics, and the"GIS User Community
NOTE: Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 20 10 0 20 40
Feet
PROJECT TITLE FIGURE
THE CORNER STORE
ATLIN 220 W MAIN ST SITE MAP
ROWLAND, NC 2
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BYICHECKED BY
29037 223193 MARCH 2O24 AS SHOWN KMC/SJO