Harnett_Well Abandonment_20230127

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.\N ell(ontractor Information: WELL ABANDONMENT DETAILS
Corey D. F utral 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:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:_
2.Well Construction Permit tt: NA
List all applicable well construction permits(i.e.(AC,County,State,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry e Other(explain under 7g)
RMonitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets - 25 Ibs
[]Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑StormwaterDrainage Topsoil - 7.5 Ibs
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Hydrated bentonite to 0.5' BLS. Concrete and outer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
metal casing removed. Topsoil useda bb , rade.
4.Date well(s)abandoned: 01/23/2023 '� �, e t1
5a.Well location: BAN 2 7 2023
NCDEQ-Bass Country Store NA
8.Certification: �iu;A.S:i3D Pru 3ewxj Ur4
Facility/Owner Name Facility m#(if applicable) V DVIOMO i
8440 NC 27 East, Coats, NC 1/27/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Harnett 1610-80-8353 By signing this fonn, 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.
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:
35.399057 -78.601229 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)ijavailable.For multiple injection or non-water supply wells
ONLY with the same construction ahandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#: M W-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
61).Total well depth: 18 (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:
6d.Water level below ground surface: 12.03 (ft) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
be.Outer casing length(if known): NA (ft.) 10c.For Water Suouly&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
6E Inner casing/tubing length(if known): 3 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

�tiwy N
SST
MW-6
® MW.7 MW3
' WSW-B
MW-4
® WS,W-1
x
MW-1
MW-9 /
® MW-01
MW-2
� MW8
® MW-5
LEGEND
Recovery Well !
� Y
® Monitoring Well
(Type II)
IP
® Abandoned Monitoring
Well (Type II)
P Inactive Potable
0 Water Supply Well
000 O
x Abandoned Potable "' 44
Water Supply Well 00, I
Communication Lines UZi
Electric Lines
Approximate Location F
of Former UST System
® Parcel Boundary
(Incident#6361)
Parcel Boundary
(Incident#3357)
Source: Esri, Maxar,Earthstar Geographies,and the I
NOTE: Well and tank locations were obtained from previous 50 25 0 50 100
reports preapred by other consultants and are approximate.
Feet
PROJECT TITLE FIGURE
BASS COUNTRY STORE
ATLIN 8440 NC 27 EAST SITE MAP
CCOATS, NC 1
Engineers and Scientists
INCIDENT NO I JOB NO DATE SCALE DRAWN BY/CHECKED BY
6361 221267 JAN 2023 AS SHOWN KMCBJA