Brunswick_Well Abandonment_20241101

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WELL ABANDONMENT RECORD For Internal Use ONLY: I
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1.Well Contractorn Information: WELL ABANDONMENT DETAILS IVI Scott M. Werley 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:Mr... I '
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
1
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,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 OMunicipal/Public IN Neat Cement Grout II Bentonite Chips or Pellets
. ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
_ ❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
IMonitoring 0 Recovery
Injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentontite-10 lbs
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Neat Cement 30 Ibs
❑Experimental Technology ❑Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I 1
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite gravity feed from 13-5 ft bgs
Neat cement pour from:5 ft bgs to surface
4.Date well(s)abandoned: 1 0/1 0/2024 1 T
5a.Well location: " ' W �'�- �
Proposed Wawa NA NOV ► 2024
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
I ,: .-..t:F u rt€/'7I2b24
Frontage Road NW, Shallotte, NC 28470 0111i:Cr2i-1
Physical Address,City,and Zip Signature of Certified ell Cont clot Well Owner Date
Brunswick 439613146891 and 439613146612
By signing this form, I hereby cerafv that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.000 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
33.987524 ' N -78.364548 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)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
h A 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 'V'W-1, 3, 4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 7 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1
2.74,3.73, 5.21 Division of Water Resources, nr Proler round In ection Control ram
6d.Water level below ground surface: (ft.) g I g
1636 Mail Service C nter,Raleigh,NC-27699-1636
6e.Outer casing length(if known): NA (ft,) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one dopy of this form within 30 days of completion
of well abandonment to the courity!health department of the county where
6E Inner casing/tubing length(if known): 3 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 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): 1 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name I
7c.Type of disinfectant used:
2.Well Construction Permit#: I '
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.)?I-known
7d.Amount of disinfectant used:
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout I M Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentontite-15lbs
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Neat Cement 30 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite gravity feed from 20-5 ft bgs
Neat cement pour from 5 ft bgs to surface
4.Date well(s)abandoned: 10/10/2024 `t :-� (>_ _
b�T-i. l 2 L
5a.Well location: I
Proposed Wawa NA NOV v ; 2G2, �
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Facility/Owner Name Facility ID#(if applicable) 8 er location: r
Frontage Road NW, Shallotte, NC 28470 c: :a10/ 7f224
Physical Address,City,and Zip Signature of Certified We C tractor on Well Owner Date
Brunswick 439613146891 and 439613146612
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
(if well field,one Iat/long is sufficient) 9.Site diagram or additional well details:
33.987524 i, 78.3645-48- 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 construction/abandonment,you can submit one form.
n n 10a. For All Wells: Submit this(form within 30 days of completion of well
1V1 6a.Well ID#• W-2 abandonment to the following: 1
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 20 (ft.)
10b.For injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 7 (in.) above, also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 3.73 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Supply&iniectionl 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): 3 (ft.) abandoned.
6g.Screen length(if known): 17 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016