Johnston_Well Abandonment_ (6)

WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Virgil Wilson 7a.For Geoprobe/DPTor 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-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:NIA I
4473 i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.77 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable use//construction permits(i.e.UIC,Couniv,Slate, Variance,ea•.)il'known N/A
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) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
e Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.43 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Added bentonite pellets to well, removed surface
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
completion, cut well below grade, and restored
4.Date well(s)abandoned: 5-9-22 surface cover to match surrounding area.
5a.Well location:
Kinder Morgan Terminal 3 N/A I-
Facility/Owner Name Facility ID#(ifapplicable) 87Cer cation•
4383 Buffalo Road, Selma 27576 JUN p 72
Physical Address.City,and Zip Signature Certified Well Contractor or Vpwner aan .n 1?.g Urt)1
Johnston 260502-77-7402 By signing this form. /hereby certify that the tWOPQNere)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 IaUlong is sufficient) 9.Site diagram or additional well'
;details:
35.553157 N -78.301548 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
Auac•h well c•onslruction rec•ord(s)i furailable. Far multiple injection or non-wafer supp[v wells
ONLY frith the same construction abandonment,you can submit ane farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: PZ-1 abandonment to the following:
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Division of water Resources,Information Processing Unit,
6b.Total well depth: 15.2 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: 4.15 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): N/A (ft) 10c.For Water Supply&Iniectio'n 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
6E Inner casing/tubing length(if known): 3 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016