Bladen_Well Abandonment_20221028

' I
WELL ABANDONMENT RECORD -Fe;-Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIII.,
George R. Bridger
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on histherproperty) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2393A wells abandoned:
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
7c.Type of disinfectant used:
2.Well Construction Permit#:
Irst all applicable well construction permits#e.WC.County,State.Variance,etc)iirknown
7d.Amount oCdisimfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 1'Neat Cement Grout ❑Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) FResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commeroial OResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01trigation ❑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 ❑GroundwaterRemediation 25 Ibs portland 3 gallons water
[JAquifer Storage and Recovery ❑Salinity Barrier 1 Ibs bentonite
OAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
OGeothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
OGeothermal (Heating/Cooling Return) ❑Other(explain under 7 ) Tremie grouted
9/29/2022
4.Date well(s).abandoned- ? �`''v d ' •` "
l 5a.Well location:
Franklin White `�
Facility/Owner Name Facility IDN(if applicable) 8.Certification:
a 59i8 NC 242, Bladenboro; 28320 r "" v�� � hf.Gs�sN:''Mtn
�'n 10/04/2022
Physical Address,City,and Zip Si f Certified Wcll Contra r or Wj Owner Date
Bladen 1
ing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 1C.0200{yell Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude is degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 34 29 N -78 40 13 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 WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attacb well construction record(s)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this fort within 30 days of completion of well
6a.Well ID#:NA abandonment-to the following:
36 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
1 1/4 10b.For Iniection 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:
14 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (fL) 1636 Mail Service Center,Raleigh,NC 27699=1636 g"
f`)
31 . ( 10c.For Water Supply&IniecNon W Ils. In addition to sendin the form"to the
6e.Outer casing'lengtb=(iC known): 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 cashig/tubing length(if known): na (am) abandoned.
6g.Screen length(if known):5 (.ft-)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016