New Hanover_Well Abandonment_ (2)

WELL ABANDONMENT RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D.T. CHALMERS, JR. 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on lilsdier property) For multiple injection or norm rater supply wells ONLY with the same
constnrctionlabandonment,you can submit one form.
4146A
7b.Approximate volume of water remaining in well(s): N/A (gal.)
NC Well Contractor Certification Number
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 ivell permits(i.e.County•State,Variance,Injection,etc.)ifknown 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 ❑MunicipaVPublic ❑Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) ❑Concrete Grout El Drill Cuttings
❑Irrigation ❑Specialty Grout El Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 10 Ibs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomlwater Drainage
❑Experimental Technology ❑Subsidence Control
❑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 backfilled With hydrated
bentonite pellets to eAsting grade.
4.Date well(s)abandoned: 6/14/2022 E�b
5a.Well Location: R07900-003-009-000,R07900-003-010-000, `'�"t " "" V L_`'.1
R07900-003-010-001,R07900.003-010-002, JUN 20��
CRIBB POLLY GREENE and R07900-003-01 1-000 A
Facility/Owner Name Facility IIN(ifapplicable) 8•Certification:
�iit'i:3±'D�l 6221,6223,6229 CAROLINA BEACH RD,WILMINGTON, NC 28412 llrtil=1 ��, 02
Physical Address,City,and Zip Signature of Certified Well Contractor or ell Owner Date
NEW HANOVER 3133-33-4659 By signing thisforin I hereby cerlift that the ivell(s)was(vere)abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C 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 lat/long is sufficient) 9.Site diagram or additional well details:
34.112259 N _77 898248 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
Attach well construction records)if available. For multiple injection or non-water supply
well ONLYwith the same construction abandonment,you can submit oneform 10a.For All Welts: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-04 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.) IOa 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: (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&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
6f.Inner casing/tubing length(if known): 12(ft.) county where abandoned.
6g.Screen length(if known): 4(ft.)
S:\GtNP?R0JECrS\222113 CRIBB'S HOBBY.GPJ
Adapted from NCDENR DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013