Beaufort_Well Abandonment_20220826

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
George Bridger 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 constmction/depth,only 1 GW-30 is needed Indicate TOTAL NUMBER of
2393-A wells abandoned:3
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Bridger Drilling Enterprises, Inc. FOR WATER SUPPLY WELLS ONLY:
CompanyName lc.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable xell construction permits(Le.WC,County,State.Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural ❑Municipal/Public ❑Neat Cement Grout I e 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
❑hri 'on ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 10 lb bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Sttmnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop). ❑Tracer Remove pvc pipe from well, replace chips by pouring
❑Geothermal(Heating/Coolmg Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 8/18/22
a. —�
Sa Well location: Ora .
Former Jotem's Service Center 1 r;i
�3
Facility/Owner Name Facility IDH(ifapplicable) 8.Certification: fit:{lyl:il j(
2290 N. Carolina 99, Belhaven � �, 8/19122
Physical Address,City,and Zip Si ofCcaed Well Contract or Well Owner Date
Beaufort By signing this form,I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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 lattlong is sufficient) 9.Site diagram or additional well details:
35.31.27 N -76.39.35 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)##*available.For multiple injection or non-watersupply wells
ONLY with the same constructioeabandonment,you can submit one form
10a.For All Wells: Submit this 1.'orm within 30 days of completion of well
6a.-Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth.
10.8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
-
10b.-For Injection Wells: In addition to sending the form to-the address in 10a
6c:Borehole diameter: (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: 3 (ft.) Division of Water Resources,Underground Injection Control Program,
- 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(jf lmotr n): (fL) 10c.For Water Supply&Injection 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(f known): ( ) abandoned
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I