Wayne_Well Abandonment_20241115

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 1
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 GV4 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): 0'1� (gal.)
AECOM Technical Services of North Carolina,lnc. FOR WATER SUPPLY WELLS,ONLY:
Company Name N/A
7a Type of disinfectant used:
N/A
Well Construction Permit#: N/A
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.)iftmown
7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout- - 11 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grouts Rs . .,+tL_r '',hi'inytlay
❑IndustriallCommercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
[]irrigation ❑Specialty Grout NOV < CO2C Gravel
Non-Water Supply Well: ❑ Bentonite Slu ❑(.)ther(explain under 7g)
RMonitoring ❑Recovery "" Ir '
injection Well: 7E For each material scleccil AW"e,Obvide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Portland Cement- 101bs Bentonite-.5 lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Water-1.0 gallons,.
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Installed tremmie pipe,Slowly added Portland mix and ensured
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
that no bridging is taking place.Slowly pulled tremmie pipe up.
4.Date well(s)abandoned: 1 1.5.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway#8230 N/A
Facility/Owner Name Facility iD#(if applicable) 8.Certification: i
400 East Ash Street, Goldsboro, NC 27530 f '' "`
� ��". 11.5.2024
Physical Address,City,and Zip Signature of Certified Well Contractor;r Well Owner Date
Wayne N/A By signing this form, T hereby certify that the well(s)was(were)abandoned in
County Parcel identification No.(PIN) accordance with I5A 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 lattlong is sufficient) 9.Site diagram or additional well details:
35.38364 N 77.99014 `,l, 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
Attachwellconstructionrecord(s)ifavailable.Por multiple injection ornon-watersupplywells
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#' MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Tniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 3/4 (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' 5.96 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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N/A 10c.For Water Supply&Tniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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
611 Inner casing/tubing length(if known): 2.0 (ft.) abandoned,
6g.Screen length(if known): 10.0 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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