Camden_Well Abandonment_20240903 (2)

WELL ABANDONMENT RECORD For Intent I Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 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
4629C wells abandoned:
7b.Approximate volume of water remaining in wells. Unknown_(gal.)
�'C Well Contractor Certification Number PP g O'
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.U/C,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 ❑Neat Cement GrouC '. q-Be ite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout `' `' [?Ff)E� lay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout j SE P L024 Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply )1 e11: ❑Bentonite Sltt4Tr 0'.*r --.*',=', A-'VnOACAgCkMk(explain under 7g)
CMonitoring ❑Recovery Wl%:;3(,=j
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Baekfill Soil
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
h„.Provide a brief description of the abandonment procedure
❑Geothermal(Closed Loop) ❑Tracer
Well was pulled out of ground during excavation
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
activities. Hole collapsed in on itself.
4.Date well(s)abandoned: 8/6/24 Hole/excavation pit was filled in with backfill soil.
5a.Well location:
Berry Brothers
Facility/Owner Namc Facility ID#(if applicable) 8.Certification: ! /�
600 NC Hwy 343 S, Camden, NC 27921 5 ' 8/21/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Camden
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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.30330274731958 N -76.11821394732583 µ 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)ifarmlable. For multiple injection or non-water supply 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-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9.0 (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 litr.) 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: Unknown (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 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
6f.Inner casing/tubing length(if known): 4.0 (ft) abandoned.
6g.Screen length(if known): 5.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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C',y DISPENSER N
AREA
MW-3
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MW-9
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MW-8
MW-1 - :
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MW-5 AFVR-2 ® NIW-7 - QP�MER
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LEGEND
® Monitoring Well
(Type II)
® Destroyed Monitoring
Well (Type II)
® Abandoned Monitoring
Well (Type II) '� MW-11
Monitoring Well
®
O E
(Deep) y
❑ Approximate Location
of Former UST Systems @MW-12
rj Parcel Boundary 14 '%
�
Sow'�rice: Esri, Maxar Earthstar Geograpncs and the"
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 60 30 0 60 120
Feet
PROJECT TITHE
BERRY BROTHERS FIGURE
ATLIN 600 NC HWY 343 S SITE MAP
CCAMDEN, NC
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BVICHECKED BY
6221 221036 AUG 2024 AS SHOWN KMC/SJO