Wake_Well Abandonment_20230109 (5)

WELL ABANDONMENT RECORD For[ntemal Use ONLY: C
l
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. FUtral 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-30 his needed. Indicate TOTAL NUMBER of
4300-B wells abandoned: I
* 7b A roximate volume of water re l ainin in wells al.
NC Well Contractor Certification Number �,�4 4:� `a• PP I I g O• (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name ^
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
� • f. �>^'r' th, i
List all applicable well construction permits(i.e.UIC,County,State,Variance,,els.J-i5-iaivn
7d.Amount of disinfectant used:
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑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) 0 Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry a Other(explain under 7g)
eMonitoring . ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets — 75 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 5 Ibs
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer 7g.provide a brief description of the abandonment procedure:
Well abandoned in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) []Other(explain under 7g)
pellets to within 6 inches of surface and topped
4.Date well(s)abandoned: .12/6/22 with concrete to existing grade.
5a.Well location:
NCDEQ-Former Star Flite 52 Property NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1904 St. Albans Dr., Raleigh, 27609 � 12/29/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 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 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:
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 records)ifavailable.For multiple injection or non-watersupply 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#: MW-28 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 43 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.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:
36.21 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) i
1636 Mail Service Centei,Raleigh,NC 276994636
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
611 Inner casing/tubing length(if known): 13 (ft.) abandoned.
I
6g.Screen length(if known): 30 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i

i
WELL ABANDONMENT RECORD For Intemal.Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Corey D. Futral 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-30 is needed. Indicate TOTAL NUMBER of
4300-B wells abandoned: i
NC well Contractor Certification Number ;', .f, ` ° j7b.Approximate volume of water remaining in well(s): (gal.)
�' ;
CATLIN Engineers and Scientists ca FOR WATER SUPPLY WELLS OONLY:
Company Name JAN " 7c.Type of disinfectant used: I
2.Well Construction Permit#: NA tr,:n::a ^t ?r^ •- rs -1 i P-,1
List all applicable urell construction:permits(i.e.UIC,County,Stare liar, ce et.).to rioum
'`'` `c' 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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry IN Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets _ 75 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete 5 Ibs
❑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) Well abandoned in place with hydrated Bentonite
pellets to within 6 inches of surface and topped
4.Date well(s)abandoned: 12/20/22 with concrete to existing grade.
5a.Well location:
NCDEQ-Former Star Flite 52 Property NA L
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: c
1904 St.Albans Dr., Raleigh, 27609 12/29/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake NA
By signing this form, I 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 been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell 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 records)ifavailable. For multiple ityection ornon-,vatersupply 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#: MW-29 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (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: 8.25 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
1
6d.Water level below ground surface: 32.63 (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&Iniection 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
6E Inner casing/tubing length(if known): 10 (ft) abandoned.
6g.Screen length_(if known): 30
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016