Hoke_Well Abandonment_ (16)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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 GW130 is needed. Indicate TOTAL NUMBER of
4548 A wells abandoned:
NC well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): 0.93 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.U/C,County,State, Variance,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 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grow ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 5 Ibs of Concrete 23.9 Ibs of Bentonite
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour one
4.Date well(s)abandoned: 09/26/2022 Nov 1 8 2022
5a.Well location:
Food Stop #1 00-0-0000026072
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
513 West Prospect Avenue, Raeford, NC 9/29/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Doke 6943-4050-1071 By signing this form, 1 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 Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.9839694 N 79.2325333 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)ifavailable. For multiple injection or non-water supply wells
ONLY with the sane construction/abandonment,you can submit oneform.
I�II 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14.99 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Unknown (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: 9.26 (ft.) Division of Water Resources)Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
n/a loc.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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): 5 (ft.) abandoned.
i
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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