Johnston_Well Abandonment_20230428 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 7a.For Geoprobe/DPT or Closed-L I p 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
3225-A wells abandoned:""
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.42 (gal.)
AECOM FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if/mown
7d.Amount of disinfectant used: N A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public N Neat Cement Grout ❑ 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
❑Uri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Portland-26.3lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquiterTest ❑StormwaterDrainage Water-1.45 gallons
❑Experimental Technology []Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(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 LIB
5a.Well location: APR 2 8 ZUZJ
i0nder Morgan SE Terminals LLC N/A
Illiol�►:slu� Pr.^o5&o:e,9 Urlx
Facility/Owner Name Facility M#(if applicable) 8.Certification:
4086 Buffalo Road,Selma,27576 �f- . f� 4.25.2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Dale
Johnston 260502-86-5063 By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PM accordance with ISA NCAC 02C.0100 or 2C.0260 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: 1 1
(if well field,one IaUlong is sufficient) 9.Site diagram or additional well details:
35.55060 N 78.29960 `,I, You may use the back of this page to provide additional well site details or well
abandonment details. You may also allach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recatd(s)ifavailable. Formultiple injection ornon-water rupplywells
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 V VA,-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14.0 (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: (in.)
2.0 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• 5.30 (tI) 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
6C Inner casing/tubing length(if known):4.0 M.) abandoned.
6g.Screen length(if known): 10.0 (ft)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016