Scotland_Well Abandonment_20240529 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): �5'6 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.UIC.County,State, Variance,etc.)it-known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic a Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑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 undid') 2 '+ 2024
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation —43lbs Bentonite '
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage --61bs of Grout
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite was placed in one foot lifts and hydrated
until one foot from top of casing. Remaining space
a.Date well(s)abandoned: 3/20/2024 was capped with grout to surface grade, flush
5a.Well location: mount protective cover filled with grout.
Former Quick Stop#50 00-0-0000008086
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
11761 McColl Rd, Laurinburg, NC 28352 5/1/2024
Physical Address,City,and Zip Signature of Ceni d W Contractor or Well Owner Date
Scotland 01023701006
By signing This form. /hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.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:
34.73262441648223 -79.50122163171994 N 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 OP NN ELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructionrecord(s)i/anwlahlc l of nnduple injection ornon-water supply wells
ONLY with the same construction abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-1 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40.00 (f�) 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:
2" above,also submit one copy of this form within 30 days of completion of well
(in.)
abandonment to the following:
6d.NN ater loci below ground surface: 6.54 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Suonly&Infection 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): NA (ft.) abandoned.
6g.Screen length(if known): 30-40 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016