Carteret_Well Abandonment_20220817 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas J. Benthall, Jr. 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
4508-B
wells abandoned:NA
�
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Eastern Carolina Environmental Services, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name NA
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.U1C,County,State,variance,etc)tfknown NA
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 1 ❑ Drill Cuttings
❑Irri ation r=, . r ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: i�_ VrL`� V w ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recov
Injection Well: i, - 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge p'J~ l❑Groundwater Wegnediation approx. 15.7 Ibs(0.2354 cu ft.) Bentonite Chips
❑A uifer Storage and Recove
q g ry Barrier
❑Aquifer Test (rnvt( D'I�iSt ter Drainage approx. 12.5 Ibs. Concrete Grout
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Tagged well depth;Poured bentonite chips in well from bottom to the top
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
using a 1.5"diameter tremie pipe at a rate of about 2 Ibs.per minute using a
4.Date well(s)abandoned: 7/21/2022 funneling device and hydrated bentonite with potable water;placed concrete
5a.Well location: grout in well vault around wellhead(well filled with soil to 10.8 ft.below TOC)
Town of Emerald Isle Incident No. 16270
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
7500 Emerald Drive 7/22/2022
Physical Address,City,and Zip Signature o ontractor or Well Owner Date
Carteret 539306390689000
By signing this form, /hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been;provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laUlong is sufficient) 9.Site diagram or additional well details:
34.66708 N -77.02739 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For 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
6a.Well ID#: MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20.00 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
Not Known 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:
NA(partially filled w/soil)(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 10.00 (ft) 10c.For Water Water Su��ly&Infection Wells:Infection 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
611 Inner casing/tubing length(if known): NA (ft) abandoned.
6g.Screen length(if known): 10.00 (ft.)
I
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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