Wilson_Well Abandonment_20240814 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. W e rl e y 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
3344-A wells abandoned:—)
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'0 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
Unknown 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
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 a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of ri ai `
❑Aquifer Recharge ❑Groundwater Remediation Bentonite — 20 lb$ t `� •`" i-- 3..
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement - 30 Ibs AUG 1 1- 2024
❑Experimental Technology ❑Subsidence Control !r•`.:.:::.: w�� , , r,
7g.Provide a brief description of the abandonment proced ei
❑Geothermal(Closed Loop) ❑Tracer Bentonite - gravity feed from 20- `ft�bg
❑Geothermal(Hearin Cooling Retum) ❑Other(explain under 7g)
Neat Cement- Pour from 5 ft bgs to surface
4.Date well(s)abandoned: 7/26/2024
5a.Well location:
Proposed Wawa (Forest Hills) N/A
Facility/Owner Name Facility ID#(if applicable) 8. rtification:
1600 Forest Hills Road, Wilson, NC 27893 7/30/2024
Physical Address,City,and Zip Signature of Certifie Well C tractor or Well Owner Date
Wilson 3711-18-1733.000 By signing this for hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 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:
35.720374 N 77.951841 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 WELLI SI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaach well construction records)i/available. For multiple injection ornon-watersuppty 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#: M W-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (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: 6.25 (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: 8.84 (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) 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
fit.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Fomi G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016