Bladen_Well Abandonment_20221205

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joseph L. Zuncich 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 GW 301 is needed. Indicate TOTAL NUMBER of
3324-A wells abandoned:
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): 1.94,1'02,.40(gal)
Applied Resource Management, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name H T H
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)ifknown 1/8 pound
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 a 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
-Non-Water-Supply-Well:— - -- .- — — - -—- -- _El_gentonite"Slu L-7-Other-(explain-under 7
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRetnediation 30,25,15 pounds bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 5 pounds neat concrete
❑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) Disinfected wells,'remove 3' of casing to 1' below
grade, seal wells with bentonite chips and cement
4.Date well(s)abandoned: 11/29/22
5a.Well location;
Sandy Ridge RV Resort N/A r 2022
Facility/Owner Name Facility ID#(if applicable) S.Certification:
4720 US 701 N, Elizabethtown, NC
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Physical Address,City,and Zip SignatutfAf Certifred Well Contra4Kr or Well Owner Date
Bladen 133200865711
By signing this form, I hereby certify that the ivell(s) ivas(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constniction 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 IatAong is sufficient) 9.Site diagram or additional well`details:
34 38' 56" N 78 32' 13" W You may use the back of this pageito 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 records)ifavailable.For multiple injection or non-watersupply wells
ONLY with the some constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-2A, B, and C abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20, 14, 10 (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: 8.25 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I
6d.Water level below ground surface: 7.85,7.59,7.48(ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
NA (ft) 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
18 12 8 of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if!mown): (ft.) abandoned.
6g.Screen length(if known): 2 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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