Brunswick_Well Abandonment_ (15)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 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 1 GW,-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
4330-B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientist FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.111C,County,State, Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout 9 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 9 Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets —13 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete —5lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Abandoned well in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
pellets to within 6 inches of the surface. Topped.
a.Date well(s)abandoned: 7/14/2022 with concrete to existing gra .
5a.Well location: ��JI 19 2022
NCDEQ-Lucy Grant Unknown
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1370 Stanbury Rd. SW, Supply 28465 ,:,,�3Yr\�ll'�IP /�fi' 72b22
rt�r
Physical Address,City,and Zip Signature ofCenified Well Contractor or Well Owner Date
Brunswick Unknown
By signing this farm, I hereby certify that the well(s) was (here) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 IVell Construction Standards
f
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has provided to the well owner.b I
ee
(ifwell field,one lat(long is sufficient) 9.Site diagram or additional well details:
33.944825 N -78.258309 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
Attrichwelicoirsirrictionrecords)ifrn,ailable.Foirmsliipleityectionorcoon-rratersupplvwells
ONLY with the scone consuuction/abandonineni,you can subinit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: B-3 - abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For injection Wells: In addition to sending the form to the address in 10a .
6c.Borehole diameter: 8.25 (in.) above, also submit one copy of thus form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 5.36 (ft.) Division of Water Resources,+Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Sunaly&Injection Wells: In addition to sending the forth 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
6f.Inner casing/tubing length(if known): 2 abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016