Wake_Well Abandonment_20240814 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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
3225-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '65 (gal.)
AECOM Technical Services of North Carolina,InC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)iflmown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout R 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
❑Uri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
R Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of-materials uwd:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-30 IbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquiterTest ❑StormwaterDrainage Water-1.0 gallons f ti
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment Pdeitdure:
❑Geothermal(Closed Loop) ❑Tracer 11:.
Slowly added bentonite chips and ensured there was no bridging
❑Geothermal(Hearin Coolin Return) ❑Other(explain under 7 )
taking place. Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 06.20.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway # 6987 00-0-0000006458
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2605 South Saunders Street, Raleigh, North Carolina 27603 07.18.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 1702-37-9490 By signing this form, I 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
56.Latitude and longitude indegrees/minutes/secontls 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:
35.748123 N -78.649334 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 conctruc6onrecord(c)ifavatlable. For multiple injection or non-water.supply wells
ONLY with the same construction abandonment,you can submit one Jorm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 5.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter:
2.0 (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 1.01 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
N/A (ft.) I Oc.For Water Supply&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
6L Inner casing/tubing length or known): 5.0 01.) abandoned.
6g.Screen length(if known): 10.0 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016