Person_Well Abandonment_20240610 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: t�'F:LL ABANDONMENT DETAILS
Gary Sim cox 7s.For Geoprobe/DPT or Closed-Loop Geothermal V1 ells 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
2 944-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.2 (gal.)
S&M E, Inc. 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.)ifbnown
7d.Amount of disinfectant used:
3.Well use(check"ell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout a 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 ' `h L�j �✓ Cuttings
01trigation ❑ Specialty Grout ❑ r('ravel
Non-Water Supph "ell: ❑Bentonite Slurry JUN 1 V n 4243 Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each msl�S�it�l�Il4W A Veppauv4ejWunt of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 30 l b S DWQ "a
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑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 under7 ) Filled well casing with Bentonite chips to
surface and hydratE�d.
a.Date wens)abandoned: 05/29/24
Sa.NN'ell location:
Huffman Oil Company —
Facility/Owner Name Iacilm ID#(ifapplicable) A.Certification:
9353 NC-157 Hurdle Mills, NC 27541 'z_a4— 05/31/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Person By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/bng is sufficient) 9.Site diagram or additional well details:
36° 16' 25.23" N 79° 02' 47.57" 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 well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10s. For All Wells: Submit this form within 30 days of completion of well
69.Well ID#: MW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18.0 (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: 2 (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: 1 7.31 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suooly&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
61.Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): A)
Form GW-30 North Carolina Department of Environtmental Quality-Division of Water Resources Revised 2-22-2016