Pamlico_Well Abandonment_20220826

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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
3225—A wells abandoned:
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): <1.0 gal (gal)
AECOM Technical Services of North Carolina, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7a Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,Slate,Parlance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S 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
DIrrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
INIMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation 20 lbs
❑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 Slowly Pour Bentonite Chips Down Borehole till it gets to the surface
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
adding water to hydrate bentonite.
' 4.Date well(s)abandoned: 8'11.22 `�, ?� q
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Sa.Well location:
7-Eleven/Speedway 47027-8262 0-034515
Facility/Owner Name Facility 1D#(if applicable) 8.Certification:
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10816 NC Hwy 55 east Grantsboro NC p� ov �8 E2,22
Physical Address,City,and Zip Sign °ua yet of Certified Well Contractor or Well Owner Date
Pamlico 654153108000 By signing this form,1 hereby certfy that the well(s)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.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 9.Site diagram or additional well details:
35.140212 N -76.841400 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
Auachwelicnasiruclionrecord(s)ifavailable.For multiple injection ornon-water.supply wells
ONLY with the same construchoniabandonment,you can submit one form.
IOa. For All Wells: Submit this farm within 30 days of completion of well
6a.Well M#: T-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 7.0 (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: 2.75 (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• 3.81 00 Division of Water Resources,Underground injection Control Program,
1636 Mail:Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft) 10c.For Water Sunnly&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(if known): 2.0 (ft) abandoned.
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6g.Screen length(if known): 5.0 (ft.)
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Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resource I Revised 2-22-2016