Bladen_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
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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 d is needed. Indicate TOTAL NUMBER of
3324-A wells abandoned:
' 2.12,1.18,0.44
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): (gal.)
Applied Resource Management,'P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
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
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Su pl Well: _ —-p-Bentonite­Slurry— �L D-Other-(explain-under 7g)—
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 30, 25, 15 pounds bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 5 pounds neat cement
❑Experimental Technology El Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Disinfected well, remove 3' of casing to 1' below
grade,seal well with bentonite chips and cement.
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4.Date well 11/29/22
s)abandoned: a l It �f
5a.Well location:
Sandy Ridge RV Resort N/A DEC 1
Facility/Owner Name Facility IDff(ifapplicable) 8.Certification: InfONI 91DT1 PrZl.^.:�,mwing Unit
4720 US 701 N, Elizabethtown, NC
gL4je�/— �' 'F`�""""11/29/22
Physical Address,City,and Zip Signatur f Certifi d Well Contrac r or Well Owner Date
Bladen 133200865711 '
By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 38' 56" N 78 32' 12" 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 i
SUBMITTAL INSTRUCTIONS
Attach wellconstructionrecord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-1 A, B and C abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20, 14, 9 (ft.) 1617 Mail Service Ceuter,Raleigh,NC 27699-1617
10b.For Infection Wells: In addiiion 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:
6.72, 6.60,6.24 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): NA (ft) 10c.For Water Supply&Infection 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
6L Inner casing/tubing length(if known): 18, 12, 7 (ft) abandoned.
6g.Screen length(if known): 2 (ft.) I1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016