Nash_Well Abandonment_20220808

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 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
3344-A wells abandoned:o-
1 7b.Approximate volume of water remaining in well(s): 0.50 al
NC Well Contractor Certification Number PP g (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Namc
2.Well Construction Permit#:
W M 050146 7 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State, I iiriance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check'all that apply):
❑Agricultural ❑Municipal/Public e Neat Cement Grout C 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
❑Itri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
CMonitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite - 20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement -35 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description ofithe abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed bentonite chips to 5'
bgs
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 8/2/2022
+v
5a.Well location: V tz
Rocky Mount ARD CGP, LLC N/A A UC 0 s 2022
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1450 Benvenue Rd, Rocky Mount nfcrAJ&ti ,Pr`c`�s�"g Une L 2 z
Physical Address,City,and Zip Signature of Certified WelVontractor or Well Owner Date
Nash
By signing this firm, 1 herebi,certili that the well(s) w•as (mere) abandoned in
County Parcel Identification No.(PIN) accordance with 15A ArCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
and that it copy ufthis record has Mien provided to the well owner.
(ifwell field,one[at/long is sufficient) 9.Site diagram or additional well details:
-77.80678655 N 35.97923931 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
Attachwellconctructiatrecord(s)ifavailable. Formultipleinjec•tionornoio-rratersupptvwells
ONLY ivith the same construction/abandonnteni,you can submit oneJornt.
MW03 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4.25 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 21.95 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
t
6e.Outer casing length(if known): (ft.) loc.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
6f.Inner casing/tubing length(if known): 1 0.0 (ft) abandoned.
6g.Screen length(if known): 15.0 (ft.)
Forni GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016