Brunswick_Well Abandonment_ (2)

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 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 I GW i30 is needed. Indicate TOTAL NUMBER of
4330-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONL
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.)ijknown
7d.Amount of disinfectant used: !..a.,.rmratiai1 ipr0c^ 9 Urt;R
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal'Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ® Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 24 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete 5 Ibs
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Abandoned well in place with hydrated Bentonite
pellets and topped with concrete to existing grade.
4.Date well(s)abandoned: 5/18/2022
5a.Well location:
NCDEQ-Jennifer's Subdivision Unknown
Facility/Owner Name Facility ID#(if applicable) 8.Certification: �
( \J
3198 Mt. Misery Rd., Leland 28451 5/19/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Brunswick NA
By signing this form, I hereby certify that the tnell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200(Yell 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: I !
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.304278 N -78.076703 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well ceatsiractiott records)ifm,ailable.For multiple ityccrion or non-watersupply 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#• F-4R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 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: 8.25 (in.) above, also submit one copy of this fomt within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 10.90 (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&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
611 Inner casing/tubing length(if known): 3 (ft.) abandoned.
i
6g.Screen length(if known): 12 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016