Pender_Well Abandonment_20220616

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sanford Sweeting 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-30 is needed. Indicate TOTAL NUMBER of
2082-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 41 (gal.)
ARM FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: MITI-I
2.Well Construction Permit#:
List al/applicable well construction permits 0.e.UIC,t:ounp',State,Variance,etc.)ifknown
7d.Amount of disinfectant used: 1 LB
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout X Bentonite Chips or Pellets
gGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) DO Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry C Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 12 Bag's Bentonite Chips
[]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
❑Geothermal(Heatin Cooling Return) ❑Other(explain under 7g) Measured well depth at 88'
Poured 12 bags of chips in well
a.Date weu(s)abanaonea: 06/7/2022 Brought it up to 1' below grad �t•
in."'ell location:
Rhonda O'Jampa
Facility/Owner Name Facility 1D!#(ifapplicable) S.Certification:
110 Broadview Lane Hampstead 28443 �' a / �' L' �. ;06/Q7/ . ;
Physical Address,City,and Zip Signature6Kcrtified Well Contractor or We06wner Date
Pender 3293-62-3932-0000 gy signing this form, I hereby certifi,that the ivell(s) was (were) abandoned in
County Parcel Identification No (PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34°21'19954" N 77°41'13260" �� 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)ifm ai/able. For multiple injection arson-u atersupply wells
ONLY with the same construction abandonmem,you can submit nne form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
61b.Total well depth: 88 (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: 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: 25 (11.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NSA (ft.) 10c.For Water Suonly&Infection 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
61. Inner casing/tubing length(if known): NSA (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016