Nash_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Wen Contractor Information: WELL ABANDONMENT DETAILS
Michael Young 7a.For Ceeprobe/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
2370—A wells abandoned:
NC Well Comsea ter Certification Number 7b.Approximate volume of water remaining In well(s): 0 (gaL)
Fishburne Dulling Inc. FOR WATER SUPPLY WELLS ONLY: L
Company Nana
NCD045646924 7c.Type ofdmnfectantused: --i • ' n_
2.Well Construction Pd ert M 4 —, 4,
List all applicable well Cmvirntion perntln(i.e.UIC Cow9e Slate. Variance.etc.)ifbmxn c' j r'
7d.Amount of dhdnfeenmt used: IV
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check a6 that apply): ..l r�%;,r J ' o(.tr,;f
❑Agricultural ElMunicipaf/Public S Neat Cement Grout ❑ Bentonite Chips or Pellets
OCrec thermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout O Dry Clay
❑IndusMal/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
ClIntigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
eMoniloring ORocovery
Injection Well: 7f.For each material selected above,provide amount or materials used:
❑Aquifer Recharge OGroundwater Remediation 5.0 gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
OGeothermel(Closed Loop) OTracer Tremie grouted from the bottom of the well to the surface
❑Geothermal(Heating/Cooling Return)
OOthcr(ex lain umder 7 )
4.Date well(s)abandoned: 1 1-03-2022
Sa.wen loutlon:
Kaba Ilco Corp.
Faciity/Owcer Name Facility IDM(if applicable) 8.Certification:
400 Jeffreys Rd., Rocky Mount, NC 12-05-2022
Physical Address,City.and Zip SWadfire ofCeNfied Well Caatrumr or OOwner Data
Nash By signing this form,1 hereby c that the well(s) war(wrre)abandoned in
County Parcel Idemification 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field am:tatil.it is sufficient) 9.Site diagram or additional well details:
35.990087 N -77.787895 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
Atmchaelleansbactionrecord(s)ifavai/able. Formaltipleinjectioaorron-w tersupplyweils
ONLY with the same conaaucdm✓abandonmenl,you can submit one(arm.
10a. For All Wells: Submit this farm within 30 days of completion of well
a.Well ID#. Y Y�A�—1 1 s abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 28 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.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:
6d.Water level below ground surface: NA (R.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (R.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
acki ess(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): NA (ft.) abandoned.
6g.Screen length(if known): 10 (IL)
Form GW-30 North Carolina Department of Environments]Quality-Division of Water Resources Revised 2.22-2016