Sampson_Well Abandonment_20230406 (13)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
SR&R Environmental, Inc. 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
Patrick Beccaria wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 5 (gal.)
N C-4543 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if from
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 C Neat Cement Grout 19 Bentonit•
ip Chsorl'ellets
p
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill CuttingNNrp -...
❑lrri ation ❑ Specialty Grout ❑ Gravel U C1 2093`�
Non-Water Supply Well: El 11
Bentonite SlurryOthaBe la't unde5 7 ) C
®Monitoring ❑Recovery r•s,.-,• `�;{`'.;�':;1 r�f .`t
Injection Well: l :
j 7f.For each material selected above,provide amount of material's'vsed:
❑Aquifer Recharge ❑GroundwaterRemediation neat cement 6" plug
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 1/2 bag betonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Used betonite until top 6" for cement plug.
4.Date well(s)abandoned: 1/1 1/2023
5a.Well location:
The Finn Group LLC
Facility/Owner Name Facility ID#(if applicable) S.Certification:
5519 Plain View Highway 1/15/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Sampson 14010836401
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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has beer?provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 14'56.59tt N 78°33'22.85" 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.Formultiple injection m•non-watersupply wells
ONLY with the same construction/abandonment,you can submit one fonn.
lVl W-10 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
2„ 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter (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: 5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (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
6f.Inner casing/tubing length(if known): n/a (ft.) abandoned.
6g.Screen length(if known): n/a (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016