Wilson_Well Abandonment_20220801

WELL ABANDONMENT RECORD Fee lmemal Use ONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 7&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on bolter property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4330-B wells abandoned.
NC Well Cononctor Cenificauon Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: E�` I�EAE�
Company Name 7c.Type of disinfectant used: /V- q\/pp qq
2.Well Construction Permit#:
L.rt Lill appb<uhle well,morrummm prrmm fr.e.(IIC.Couss ,Suisse, tbrrnmoe,etc)ifkrrown
7d.Amount of disinfectant used:
3.Well am(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgncultural ❑MunicipaVPublic ❑ Neat Cement Grout Ill Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
01tri tion ❑ Specialty Grout ❑ Gravel
Noo-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ORecovery
Injection Well: 7t.For each material selected above,provide amount of materials used:
[]Aquifer Recharge OGroundwaser Remediation Bentonite Pellets —25 lbs
[]Aquifer Storage and Recovery []Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage Sand —5 lbs
[]Expenmenml Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OCnnthermal(Closed L-oop) OTracm
[]Geothermal(Heating/Coolin Return) ❑Other(e lain under 7 ) Abandoned well in place after cutting casing below
existing grade. Used hydrated bentonite pellets to
4.Date well(s)abandoned: 7/22/2022 within 6 inches of surface and topped with sand
sa.Wen location: from around the site to existing grade.
NCDEQ-Glover's Grocery NA
Facility/Owner Name Facility IDN(if applicable) g.Certification: �
6408 Main St., Sims 27880 7/27/2p22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wilson NA By signing this form. /hereby certify that the wells) was (were) abandoned in
County Pared ldrmificaoon No.(PIN) accordance with 15A NC4C 01C.0100 or 2C.0100 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iadong is sufficient) 9.Site diagram or additional well details:
35.760106 N -78.060116 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well comtrucnon recordlsl rlmvduhle. For multiple rgection or non-wLiter nrp(v wells
ONL}'uyrh the same mnvn,rnon oham/omnrnr.you rommhmr1mre{rrm.
IOa. For All Rells: Submit this form within 30 days of completion of well
6a.Well IDN: MW-8 abandonment to the following'.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniectioo Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in) above, also submit one copy of this forth within 30 days of completion of well
abandonment to the following.
6d.W'aler level below ground surface: N M (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA Ifl) 10c.For Water Supply&Imecton N'ells: 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
LIE Inner casing/tubing length(it known): 4 (B) 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

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LEGEND �MW-1
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Vent Well
® Destroyed Monitoring MW-5
Well (Type II) /
® Abandoned Monitoring 1
Well (Type II)
OAbandoned Monitoring
Well (Type III) �.
Parcel Boundary
rc'e .Esn.Maxar Eajths rtGeographics. and the GIS User Community
NOTE. Well locations were obtained from previous reports
prepared by other consultants and are approximate. 40 20 0 40 so
Feet
raoACT mLE FIGURE
GLOVERS
6408 M^S NTDREERV SITE MAP
CATLIN
Engineers and Scientists waoEHT Ho ae No DATE KAu I DRAWN VICMELXED9r
17270 220199 JULY2022 AS SHOWN KMCISJO