Moore_Well Abandonment_20240617 (11)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nate 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 1 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.(/C,County,State,Variance,etc.)if 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 ❑Neat Cement Gror -Z entnite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grotlt i`l,�` iq6R y, 0lay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 4 Drill Cuttings
❑Irri ation ❑ Specialty Grout J U N 1 7 20 Gravel
Non-Water Supply Well: ❑ Bentonite Slu qf,47Ji1r.tt:?�� ,,,0_Dit�c,(explain under 7g)
SMonitoring ❑Recovery fy, si
Injection Well: 7C For each material selectedabove,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 60 I bs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete SIbS
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under 7 ) Abandoned in place using hydrated bentonite to
approximately 6 inches below land surface. Concrete
a.Date well(s)abandoned: 5/8/2024 used to cap PVC and the shield was filled in with
5a.Well location: native soils and rocks to bring opening to grade.
EPA NA
Facility/Owner\,ne Facility ID#(ifapplicable) 8.Certification:
Aberdeen, NC 28315 %zt� 41*1� 5i92024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Moore NA
By signing this form. 1 hereby certify that the we!!(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.1269202600 N -79.4181915000 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)ifavadahle Eor multiple injection or non-watersupply wells
ONLY 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#: ACGMW17 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 67 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.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:
6d.Water level below ground surface: 26.30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Supply&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
6E Inner casing/tubing length(if known): 47 (ft.) abandoned.
6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016