Beaufort_Well Abandonment_

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 construction/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:
Company Name lc.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well consnvction permits(L.a UIC,Cmmty,State,Yariance,etc.)ij/mown
7d.Amount of disinfectant used:
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
OIrrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7L 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 ❑Stormwater Drainage _
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Remove pvc pipe from well, placed chips by pouring
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 8/18/22
Sa.Well location AUG G
2022
Former Jotem's Service Center
Uml
Facility/Owner Name Facility IDt/(if applicable) 8.Certification:
2290 N_ Carolina 99, Belhaven 8/19/22
Physical Address,City,and Zip SifnatureoftartifiedWellContractor 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 I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.21.26 N -76.39.35 �, 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
Altachweliconstr=rctionrecord(s)ifavailable.Formulliplemjectionarnon-watersupplywells
ONLY with the same constructionlabandonment,you can submit oneform.
10a.For All Wells: Submit this foam 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: 10.7 (ft.) 1617 Marl Service Center,Raleigh,NC 276994617
10b.For Infection 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: 2.5 00 Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft-) 10c.For Water Supply&Injection Wfells: 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 casingltubing length(if known): (ft) abandoned
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016