Brunswick_Well Abandonment_ (19)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAiCS
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.UIC,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 ( ! 6 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 IS Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of.materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets —63 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete ^5 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of:the abandonment procedure:
❑Geothermal(Closed Loop) [-]TracerStick up shield removed and upper 2 foot of casing.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) �r.—e
�7/14/2022 C,
�» ta9 ?=� Abandoned renamingwell in place with hydrated
4.Datewell(s)abandoned: CJ 9,021— bentonite pellets to within 6 inches of the surface.
JUL
5a.Well location: Topped with concrete to existing grade.
NCDEQ-Lucy Grant Unknoy I lw
�"''
Facility/Owner Name Faeil' �u��t ap llC�6 e) 8.Certification: �• L�/ ( /.
1Yut SG�C/
1370 Stanbury Rd. SW, Supply 28465 7/15/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Brunswick Unknown
By signing this form, I hereby cet•tify that the the/l(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a cop),of this record has been provided to the well owner.
5b.Latitude and.longitude in degrees/minutes/seconds or decimal degrees: I
(ifwell field,one Iat/long is sufficient) 9.Site diagram or additional well details:
33.945369 N -78.285084 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach Nell construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY ivith the same construction%ahandoninent,you can submit one form. '
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: I B-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Totatwell depth: 47 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
8.25 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
`- abandonment to the following:
6d.Water level below ground surface: 13.49 (ft.) Division of Water Resources,'Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): NA. (ft) 10c.For Water Suoaly&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 county where
6L Inner casing/tubing length(if known): 42 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016