Brunswick_Well Abandonment_20220923 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 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 I GW-30 is needed. Indicate TOTAL NUMBER of
4330-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists 7,
TA' pt•' ,,, FOR WATER SUPPLY WELLS ONLY:
Company Name 2022 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,C qV*% ''fgt%JJ maAw-e)err,#bwjvhJr.
t,; y 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
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry N Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material,elected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets --29 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage TOpS011 -51bS
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Pad removed and well abandoned in place with
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
hydrated bentonite pellets to with 6 inches of
4.Date well(s)abandoned: 9/21/2022
surface and topped with topsoil to existing grade.
5a.Well location:
NCDEQ-Connie's MHP NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
C \l �V
902 Village Rd., Leland, 28451 9/21/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Brunswick 029LA008
By signing this form, I hereby terrify 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 lat/long is sufficient) 9.Site diagram or additional well details:
34.247376 N -78.023339 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)d available. For multiple injection or non-water supply wells
ONLY with the same consbvcttun o-andonment,you can.submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.well ID#: M W-3 R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total is ell depth: 18 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c. Borehole diameter: (ill.)
8.25 above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.N�ater IeN el below ground surface: 1 1.81 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA ({t) 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
6f.Inner casing/tubing length(if known): 8 abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WSW-1 MW-3 ®,r/
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NE MW-1 R ® MW-1 ® 15,000-GVQL.
LEGEND �� (CNL) usr
Monitoring Well `
® (Type II)
Abandoned Monitoring
® Well (Type II) A'
® Destroyed Non-Potable
Water Supply Well
1
Inactive Non-Potable
Water Supply Well wE
Approximate Location
of Former UST System
- Approximate Location
'�-• of Suspected UST
Parcel Boundary
Sou ee: - i..Maxar, rthstar Geographies,and the GIS ser Community
NOTES:
1. Well locations and historical site features were obtained from 60 30 0 60 120
previous reports prepared by other consultants and are approximate.
2. CNL=Could Not Locate Feet
PROJECT ill_c
CONNIE'S MOBILE FIGURE
ATLIN HOME PARK SITE MAP
902 VILLAGE RD
CLELAND, NC
Engineers and Scientists
INCIDENT NO I JOB NO DATE SCALE DRAWN BVICHECKED By
3160 220200 SEPT 2022 AS SHOWN KMC/BJA