Robeson_Well Abandonment_20220817

I.
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JOHNNY BURR T � 7a.Number of wells being abandlned: 1
Well Contractor Name(or well owner personally abandonin ell�on°I°s/hpf r—B'ri.< nr nruhiple injection or non-water supply wells ONLY with the same
P y �. S pa ���l .,
construction/abandonment,you can.rubnrit one form.
A - 3098 15.0
NC Well Contractor Certification Number
A i�r, 1 r7 202z 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC U n fOR WATER SUPPLY WELLS ONLY:
Company Name �'''' 7c.Typeofdisinfectantused: ,GRANULAR CHLORINE
2.Well Construction Permit#: 1 OUNCE
List all applicable well construction permits(i.e.County,Suite, Variance,etc.)ifknown 7d.Amount of disinfectant used:,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check,iall that apply):
❑Agricultural OMunicipal/Public O Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) O Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout O Gravel
Non-Water Supply Well: O Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation 19.0 GALLONS
OAquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test OStormwater Drainage
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) OOther(explain under 7g)
4.Date well(s)abandoned:
06/23/22
5a.Well location: `
MCDONALD RESIDENCE
Facility/Owner Name Facility ID#(if applicable) $•Certification:
753 WATSON FARM ROAD SHANNON 28386 � 07/21/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
ROBESON By signing this form. 1 hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
34° 52' 11.03" 790 07' 59.11" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. I-or multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells' Submit this form within 30 days of completion of well
W W-1 abandonment to the following:
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
29.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter- 4'0 -(in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 6'0 (ft.) 1636 Mail Service,Center,Raleigh,NC 27699-1636
G
10c. For Water Supply & Infection Wells: In addition to sending the form to
6c.Outer casing length(if known): (ft.) 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 abandoned.
6f.Inner casing/tubing length(if known):
6g.Screen length(if known):
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of WaterQuality Revised March 2013