Martin_Well Abandonment_20240918 (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270 wells abandoned:NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.51 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(1.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 ❑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) s Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ORecovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 20
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Grout 15
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Pour as placement
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
4.Date well(s)abandoned. 04/17/2024 SEP 1 S 2024
5a.Well location:
Peele's Service Station 00-0-0000013895
Facility/Owner Name Facility ID#(ifapplicable) 8.Certitication:
2675 Old US Highway 64, Jamesville, NC 04/17/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Martin 6746-71-5500 By signing this form,I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/tong is sufficient) 9.Site diagram or additional well'details:
35.8222805 N 76.8156861 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 constructionlabandonment you can submit one form.
1�A,n, 10a. For All Wells: Submit this form within 30 days of completion of well
V'6a.Well ID#: ' V V—1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.00 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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: 11 .79 (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 (ft,) 10c.For Water Sumaly&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
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 10 (ft) f
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources II Revised 2-22-2016

Geological Resources,Inc:
SITE INFORMATION _
Site Name: Peele's Service Station Date:04/17/2024
Project Number:2516 Completed By:L.Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. License Number: 3270
Driller:Justin Radford
WELL,ABANDONMENT INFORMATION
Bentonite (Ibs):20
Boring ID: Mw-1 Grout(Ibs): 15
Total Depth Outer Casing
15.00 From (ft) To (ft) Length (ft)
0 0
Depth to Water Inner Casing
11 . 179 From (ft) To (ft) Length (ft)
0 5 5
Water Volume (gal) Screen
,0.51 From (ft) To (ft) Length (ft)
5 15.00 10
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Pre-Abandonment Post Abandonment