Carteret_Well Abandonment_20221031

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D.T. Chalmers 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wens 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
4146A wells abandoned.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(%): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name RECEIVE
7c.Type of disinfectant used:
2.Well Construction Permit H: NA 0 C r 3 1 2022
List all appbaable well construarian permits(I.r.CAC.Courm,State,fhrfance,ere J;,known
7d.Amount of disinfectant used:
3.Well use(check well use): OrinuQUan r..n,-A bidt(J L)nh
Water Supply Well: 7e.Sealing materials used(check all that apply): DWQIBOG
OAgricultural OMunicipaVPublic ❑ Neat Cement Grout a Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
[]Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ORecovery
Injection Well: 7E For each material selected above,provide amount of materials used:
OAquifer Recharge OGroundwister Remediation Bentonite Pellets —19 Ibs
❑Aquifer Storage and Recovery OSalinity Barrier
Concrete —51bs
OAquifer Test OStormwaler Drainage
OExperimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer Well abandoned in place with hydrated bentonite
OGcothermal(Healing/Cooling Return) OOther(explain under 7 )
pellets to within one foot of surface and topped
4.Date well(s)abandoned: 10/6/2021 with concrete to existing grade.
52.Well location:
NCDEQ-Wesley's Grocery NA
Facility/Owner Name Facility IDa(.fapph.iible) g.Certification:
317 Cedar St., Beaufort 28516 10/28/2022
Physical Address,City,and Zip Situation:of Certified Well Contractor or Well Owner Date
Carteret NA By signing 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 2C.0200 Well Constrncrion Standards
and that a copy of this record has been provided to the well owner.
51%.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 9.Site diagram or additional well details:
34.721055 N -76.663027 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)a/available Pormuldple injection ornon-water.supple wells
ONLY with the same conslrvclinn obondunrm m,ymr eon....hmlt one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 (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: 8.25 (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: 6.1 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
he.Outer casing length(if known): NA (ft.) 10c.For Water Supply&loiection 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): 3 (R.) 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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LEGEND
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® Abandoned Monitoring t
Well (Type II) I
Water Lines
Sewer Lines
❑ Approximate Location `
of Former USTs
❑ Parcel Boundary , Source:Esri. Maxar. eoEy a star Geographics.CNES/Airbus IDS,
USDA,USGS,A IGN, a d'the GIS User Communi
NOTES:
1.Tank locations were obtained from previous reports
prepared by other consultants and are approximate. 20 10 0 20 40
2.Utility data were obtained from the Town of Beaufort,NC Feet
and are approximate.
v GJKT Tnu:
FIGURE
WESLEY'S GROCERY
CATLIN 31BEAUFORT, NCET SITE MAP
Engineers and Scientists
NO. MTE EGLLE IXUWN BVILNECNEO By
16838 221161 OCT 2022 ASSHOWN MU/BJA