Wake_Well Abandonment_20230419 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT.DETAiLS
Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute
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
wells abandoned:
4330-B
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. APR !
List all applicable well construction permits(i.e:UIC,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 ❑Municipal/Public ❑Neat Cement Grout 19 Behtonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout El Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 9 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 -37.5 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete -20 lbs
❑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. Topped with
4.Date well(s)abandoned: 4/6/2023 concrete to existing grade.
5a.Well location:
WSP NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: �C�J L� '
3900 Electronics Dr., Raleigh, NC 27609 4/10/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake NA
By signing this forrn, 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 been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.833980 N -78.605569 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
Alitrchu•ellconsirnctionrecoi•d(s)ifuvailable.Pot•multipleinjectionor»on-waierstipplvwells
ONLY with the scone construction/abandonment,you can subttdt one forrn.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-33 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (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:
6d.Water level below ground surface: 18.02 (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 Sunnly&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
6L Inner casing/tubing length(if known): 10 (ft.) abandoned.
6g.Screen length(if known): 25 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

NEI,y
L HOPE CHURC N
"'- H RD
Iyl
M W-34
(CNL
± MW-8
i
CNL MW-25 4
r CNL)
M -7
MW-5 4 f.
MW� r
5 • q ,
AS- MW-3 1 M W-4
• MW,1 MW-
Mw=16D ® RW-1 MW-11 MW-9 (CNL)
(CNL) ■ MW-10 RW-3 MW-31U
MW:1 'MW-2 &)CNL)- ■ Mw- ® CNL)
(CNL) • ■ 'RW-2
MW-20 MW-13 M± M -33
• MW-29 ® MW o #
0 0 MW-30 MW'17
• W 2
LEGEND �w Y
®MW-21
® Monitoring Well
(Type II) ®MW 2
® Abandoned Monitoring
Well (Type 11)
O Monitoring Well ® MW-24
(Type III) '
OAbandoned Monitoring
Well (Type III)
O Abandoned Air
Sparge Well
Abandoned
■ Recovery Well
Q Parcel Boundary r
Approximate Location
of Former Tank Basin
Es Ma ar o r es, d•the-Gi- 4serCommunity
NOTES:
1. Well and tank locations were obtained from previous reports 80 40 0 80 160
prepared by other consultants and are approximate.
2. CNL=Could Not Locate Feet
PROJECT TITLE
FORMER STAR FLITE FIGURE
ATLIN 52 PROPERTY SITE MAP
1904 ST ALBANS DR
1 Engineers and Scientists RALEIGH, NC
INCIDENT NO I JOB NO DATE SCALE DRAWN BY/CHECKED BY
6896 220333 APRIL 2023 AS SHOWN KMC/SJO