Johnston_Well Abandonment_20230428 (8)

WELL ABANDONMENT 1 RECO" For internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher !°I 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning' of or°hiyhjvn e ) well construction/depth,only 1 G W-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:"'^
3225-A APR 2 b 2023
NC Well ContractorCertification Number itl{OfA",F•ZifrJ� `ter. „
7b.Approximate volume of water remaining in well(s): 1' 1 (gal.)
AECOM Gt�,+ , Uri FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.a.UiC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Hcating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Cornmercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Portland-22.56lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainagc Water-1.25 gallons
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothemtal(Closed Loop) ❑Tracer Tremie grouted with a portland mix.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 03.28.2023
5a.Well location:
Kinder Morgan SE Terminals LLC N/A
Facility/Oa-ner Name Facility rD9(if applicable) 8.Certification: ?
4086 Buffalo Road,Selma,27576 f;t'' `~ `4'� 4.25.2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Johnston 260502-86-5063 By signing this fibrin, I hereby certify that the well(s) was(were) abandoned in
County Parcel Tdentification 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 welt field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.55084 78.30013 You may use the back of this page to provide additional well site details or well
N w abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well crnrsinrciton record(v)ifavatlable. For multiple injection or non-water supply welts
ONLY with the some constructionnbanrlonment,yorr can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#: M W-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 12.0 (ft)
10b.For iniection Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter• 2.0 (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• 3.97 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): NA (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
6E Inner casing/tubing length(if known):2.0 (ft) abandoned.
6g.Screen length(if known): 10.0 (ft.) f
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016