Anson_Well Abandonment_20220805

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 I GW-30 is needed. Indicate TOTAL NUMBER of
4330-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.1/1C,County,State, Variance,etc.)trknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S 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
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry all Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets —50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete --51bs
❑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 surface. Topped with
4.Date well(s)abandoned: 7/1/2022 concrete to existing grade.
5a.Well location:
NCDEO-Former Deese Service Station Unknown
Facility/Owner Name Facility lD#(ifapplicable) 8.Certification:
L�.
1413 E Caswell St., Wadesboro, 29596 c 8/2/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Anson NA
By signing this form, 1 hereby certify that the weH(s An
Parcel Identi fication No (PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 gner.
7and that a copy ofthis record has been provided to the we
4;�P
Sb.Latitude and longitude in degrees/minutes/seconds or Decimal Degrees: ,�t f r.
(ifwell field,one tat/long is sufficient) 9.Site diagram or additional well details: H(J(2 t, c5 2022
34.963449 -80.051524 W You may use the back of this page to provide additional well site details or well
N
abandonment details. You may also attach addition�i'�6�ilIF+i 4"R'f$W6G". UrA
DW
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavatlable.For multiple injection or non-water supply wells
ONLY with the.came construction abandonment,,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M 1N-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 8.25 (ill.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.%N titer level below ground surface: 17.71 (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 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 county where
6E Inner casing/tubing length(if known): 15' (ft.) abandoned.
6g.Screen length(if known): 15' (ft.)
Form GW-10 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
r 'A
X
-� INV
3
MW-1
#Poo
CASWELL ST
l -
LEGEND
® Monitoring Well r
(Type II)
Approximate Location
of Former UST Basin
Parcel Boundary
rthstar
NOTE: Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate.
30 15 0 30 60
Feet
PROJECT DEESE TITLE FIGURE
ATLIN SERVICE STATION SITE MAP
1413 E. CASWELL STREET
CWADESBORO, NC
Engineers and Scientists
INCIDENT NO JOB NO DATE SCALE DRAWN BY!CHECKED BY
295961 221159 AUG 2022 AS SHOWN KMC/BJA