New Hanover_Well Abandonment_

WELL ABANDONMENT RECORD For Internal 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 ofwells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on bis/Irer property) For multiple injection ornon-watersapply wells ONLY with the sante
constnretion/abandonnnent,you can submit one form.
4146A
7b.Approximate volume of water remaining in well(s): N/A (gal.)
NC Well Contractor Certification Number
CATLIN Enqineers 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 ri.e.County,State,Variance,Injection,etc.)ifknorn 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 ❑MunicipaUPublic ❑Neat Cement Grout ®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)
■Monitoring ❑Recovery
Injection Well: 7f.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
❑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 4 !2 fdledo with-, h'ydratQd
bentonite pellets to existing grade. _
4.Date well(s)abandoned: 6/14/2022 JUN A 0 2022
5a.Well Location: R07900-003-009-000,R07900.003-010-000, iri;o,Ina-'en P:--:;^�s:ng. unk
CRIBB POLLY GREENE ndR07900003-011-000 900003010-002,
�,0,YG
-
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
6221,6223,6229 CAROLINA BEACH RD,WILMINGTON, NC 28412 June 15.2022
Physical Address,City,and Zip Signature of Certified Well Contractor or flell Owner Date
NEW HANOVER 3133-33-4659 By signing lhisforin I hereby certify that the ivell(s)Ivas(were)abandoned in
County Parcel Identification No.(PRq) 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:
You may use the back ofthis page to provide additional well site details or well
34.112198 N -77.898475 W
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i
Attach welt construction record(s)ifavailable. For nmlliple injection or non-xaler supply
well ONLYwith the same construction abandomneni,you can submit onefonn 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-05 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: 3.26(in.) IOa 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&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.)
S:\GKnPR0JECTS\222l l3_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