Wilson_Well Abandonment_20220923

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
COREY D. FUTRAL 7a.Number ofwells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her prpp�ay) For multiple injection or non-water supply wells ONLY with the same
construction abandonment,you can submit one fornt.
4330E F'F�' - '_,
3 �...'•"1. ..a t`'
7b.Approximate volume of water remaining in well(s): N/A (ga
NC Well Contractor Certification Number l.)CATLIN Engineers and Scientists S r P FOR WATER SUPPLY WELLS ONLY:
Company Name :1 " 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,.State,I•anance,Injection.etc.)ifknown 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout N 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
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets -50 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stommwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All Well material pulled and boring baekfilled With
hydrated bentonite pellets to existing grade.
4.Date well(s)abandoned: 8/30/2022
5a.Well Location:
NCDOT ROW N/A /�
Facility/Owner Name Facility IDk(if applicable) 8•Certification: -f-(//
300 East Gold SO,Wilson, NC 27893 Seotember 21,2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WI LSON N/A By signing this form I hereby certift that the well(s)was(were)abandoned in
Count) Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C Well Construction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.727469 -77.90427 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELUSI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply
well ONLYwith the same construction ahamlonrment,you can submil one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMVV-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in
10a above,also submit one copy of this form within 30 days of completion
6c.Borehole diameter: 3(in.) of well abandonment to the following:
6d.Water level below ground surface: 15.5(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 10c.For Water Supply&Infection Wells: In addition to sending the form
to the address(es)above,also submit one copy ofthis form within 30 days of
completion of well abandonment to the county health department of the
6E Inner casing/tubing length(if known): 10.8 (ft.) county where abandoned.
6g.Screen length(if known): 5(ft.)
S:U1,MPROJEC-rS\NCDEQ-SLP PROJECTS(ALL)_CDF\221049_NCDEQ SLP QUICK STOP MART.GPI
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Emtronment and Natural Resources-Dimon of water Resources Revised August 2013

M1�
550-GAL.
GASOLINE
USTs
RR`NG PVEE �
NE FORMER
DISPENSER
IS�LA�ND MW-1 R
MW-2
ai
MW-3
10,000-GAL.
A •LINESUST �
a
® MW-04
r �
LEGEND . '
® Active Monitoring
Well (Type II)
Temporary Monitoring '
Well (Type 1)
Approximate Location of F
Telephone Conduit Vault F qST -'
Approximate Location 1 C��O�S•TI
of Former UST Systems
® Parcel Boundary , TMW-01
Source: Esrj. Maxar. Earthstar�Geograp es.and%the GIS U er Comm c itANAEL
NOTE: Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 20 10 0 20 40
Feet
PROJECI ���= FIGURE
QUICK STOP MART
ATLIN 300 HERRING AVE E SITE MAP
CWILSON, NC 1
Engineers and Scientists
I�C,72�I NO DATE SCALE DRAWN Bv!CHECKED BV
3658 221049 SEPT 2022 AS SHOWN KMC/SJO