Wake_Well Abandonment_ (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
D.T. Chalmers 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 I GW-3b is needed. Indicate TOTAL NUMBER of
wells abandoned:
4146-A
NC Well Contractor Certification Number � --N 7b.Approximate volume of water remaining in well(s): (gal.)
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CATLIN Engineers and Scientists A1N O 9 2023 FOR WATER SUPPLY WELLS 0 i NILY:
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Company Name lfti .31t.7c.Typeofdisinfectantused:
r.ts;
2.Well Construction Permit#: NA "" t,�j�,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmown
7d.Amount of disinfectant used:
3.Well use(check well use):
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Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry e Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets — 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage TOPSOII ^' S Ibs
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
pellets to within to top of well. Vault pulled and filled
a.Date well(s)abandoned: 11/23/2022 with nearby crushed concrete to within 1 foot of surface
Sa.Well location: and topped with topsoil.to existing grade.
NCDEQ-Former Star Flite 52 Property NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification: �� " -V
1904 St. Albans Dr., Raleigh, 27609 Z� 12/29/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake NA
By signing this form, 1 hereby certify that the ivell(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 beets provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.834 N -78.606 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 ityection or non-water supply wells i,
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#:
MW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.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' NM (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center',Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA ( ) 10c.For Water Suonly&Infection Wells:ft 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
611 Inner casing/tubing length(if known): 10 (ft.) abandoned.
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6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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