Carteret_Well Abandonment_20230327 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.�N ell 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:
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#: NA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifbrown
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 III 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 Supply Well: ❑Bentonite Slurry N Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets ^ 12.5 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 12.5 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other lam under-7g).. Bentonite used to fill to �4" below land surface.
:..`'Bentonite was hydrated to create seal and concrete was
4.Date well(s)abandoned: 03/03/2023 MAR 2 7 2023 9 opening
used to brio the o enin to grade.
5a.Well location: C.;
NCDEQ - Newport, NC 00-0-09RQQ�51.20
FacilityiOwncrNamc Facility ID#(ifapplicable) 8.Certification:
5338 US HWY 70 West, Newport, NC 28557 3/14/23
Physical Address.Cite.amd hp Signature of Certified Well Contractor or Well Owner Date
Carteret 6356.06.48.7344000
By signing this form, I hereby certify that the wells) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 1C.0200 WeU 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:
34.742423 -76.820116 `` 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-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#• M W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total rvell depth: 13 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (irr) 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: 2.30 (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&Injection 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
6f.Inner casing/tubing length(if known): 3 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Forth GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016