New Hanover_Well Abandonment_ (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
i
D.T. CHALMERS, JR. 7a.Number ofwells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on liMier property) For multiple injection or non-water supply wells ONLY with the same
constrruetionlabandonment,you can submit one form.
4146A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State,Variance,injection,etc.)lfknown 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 El Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 101bs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomtwater Drainage
❑Experimental Technology ❑Subsidence Control
El Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well material removed and baekfilled with hydrated
bentonite pellets to existing grade. " -°
4.Date well(s)abandoned: 6/14/2022 MN
5a.Well Location: R07900-003-009-000,R07900-003-010-000, 2
R07900-0D3-010-001,R07900-003-010-002,
CRIBB POLLY GREENE and R07900-003-01 1-000 ;"
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Facility/Owner Name Facility ID#(if applicable) 8•Certification: �+ mt�ij"sOt
6221,6223,6229 CAROLINA BEACH RD,WILMINGTON, NC 28412 June 15.2022
Physical Address,City,and Zip Signature of Certified Well Contractor or ell Owner Date
NEW HANOVER 3133-33-4659 By signing thisforin I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C Well Construction Standards and
that a copy ofthis record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.112036 N _77 897825 �, You may use the back ofthis 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)ifavailable. For multiple injection or non-water supply
well ONLYwilh the same construction abandonment,you can submit one fonn 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-02 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 16 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 3.25(in.) 10a above,also submit one copy ofthis form within 30 days of completion
of well abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 10c.For Water Supply&r Iniection Wells: In addition to sending the form
to the address(es)above,also submit one copy ofthis form within 30 days of
completion of well abandonment to the county health department of the
6f.Inner casing/tubing length(if known): 12(ft.) county where abandoned.
6g.Screen length(if known): 4(ft.)
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Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Aug st 2013