Johnston_Well Abandonment_20240306

WELL ABANDONMENT RECORD Forinternal Use ONLY,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 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 constiuction/depth,only I GW�30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned:
NC Well Contractor Certification Number 7b.Approichmate volume ofwateri remaining in well(s): O
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorox pool shock
7c Type of disinfectant used:
2.Well Construction Permit#: na
List all applicable well construction permits fLe.ULG Cauuo,State,Variance,eta)ii known
7d.Amount of disinfectant used: $ OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Great 1 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial []Residential Water Supply(shared) El Concrete Grout ❑Drill Cuttings
OIrrization ❑Specialty Grout ❑Gravel
Non-Water Supply Well: _ O Bentonite Slurry- _ __-❑_Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete Placed from 170' Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
L1AquiferTest ❑StormwaterDrainage to Land Surface
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g:Provide a brief description of the,abandonment procedure:
8 oz of chlorox pool shock poured in well followed by filling
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
2-22-24 concrete from bottom'to land surface �,�
i �N..� rl�t,
4.Date well(s)abandoned.
Sa.Well location:
20Z4
JR.Development LLC na
FacrlitylOwnerName Facility IDR(ifapplicablc) S.Certification Q�1dti/30G
SOL! um Court Eatmons Landing 2-26-24
Physical Address,City,and Zip Siftatun offltcrtificd Well Contractor or Well Owner Date
Johnston 270100-63-9944
By signing this form,I hereby certify ffiat the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) acc ikdance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the weU owner.
(ifwell field,one lat/long is sufficient) 0 9.Site,diagram or additional well details:
35 42' 30.85't N 78 18' 01,51 u 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED_- - -- SUIiiVII TTAi;INSTRUCTIONS "-
Attacliwrllconstructionrecord(s)ifavailable.Formultipleinjectionornon-watersupplywclls
ONLY with the same construction/abandonment,you can submit one form.
�11I IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1D#: �y—1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
bb.Total well depth: 170 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following,
i
6d.Water level below ground surface• 15 01L) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i6e.Outer casing length(if known): N/A —(ft.) 10c.For Water Suppiv&Injectio Wells: In additionto 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 coity;health department of rile county where
6£Inner casing/tubing length(if(mown): N/A (D.) abandoned.
t
6g.Screen length(if known): NIA (fL) I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016