WQ0022052_GW-30_20201027 (3)

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Brian James Bellis
Well Contractor Name (or well owner personally abandoning well on his/her property)
WithersRavenel, Inc.
NC Well Contractor Certification Number
NCWC-3510A
Company Name
2. Well Construction Permit #: NA
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
OMonitorine ❑Recovery
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
4. Date well(s) abandoned: 10-15-2020
5a. Well location:
Harbour Island Investors NA
Facility/Owner Name Facility ID# (if applicable)
Grandview Drive, Hampstead NC
Physical Address, City, and Zip
Pender 3293-40-8630-0000
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.376568 N-77.691299 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. Well ID#: MW-3
6b. Total well depth: 13.1 (2.9'S U) (ft.)
6c. Borehole diameter: 6 (in.)
6d. Water level below ground surface: 2.02
6e. Outer casing length (if known): NA (ft )
6f. Inner casing/tubing length (if known): 5.99
6g. Screen length (if known): 10 (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 .5 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: NA
7d. Amount of disinfectant used: NA
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout S Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
s Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite Chips -30 pounds
Conctrete Grout -10 pounds
7g. Provide a brief description of the abandonment procedure:
Pour and tamp bentonite chips from base of well to
ground surface. Fill stick up portion of well head with
concrete grout. Take photographs.
8. Certification:`
10-15-2020
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016