Wilson_Well Abandonment_20230428

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey 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:
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Company Name t 1
7c.Type of disinfectant used:
2.Well Construction Permit#: APR
C
List all applicable well construction permits(i.e.1I1C,County,State,Variance,etc.)ifknown H f f1 O � 1
7d.Amount of disinfectant used:
3.Well use(check well use): ..nt*1 r r,-� . `m
Water Supply NN ell: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry N Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material.elected abut e.prom ide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 16.67lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 251bs_
❑Experimental Technology ❑Subsidence Control
7k.Prucide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) —
pellets to within 6 inches of surface and topped with
4.Date well(s)abandoned: 4/11/2023 concrete to existing grade.
58.Well location:
NCDEQ-Quick Stop Mart 00-0-000005563
Facility/Owner Name Facility lD#(if applicable) 8.(ertiticatiun:C�
300 East Herring Avenue, Wilson, NC lJv-J{ 4/18/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wilson 3722-51-2546.000 By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 1C.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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.727683 -77.904247 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-1 R abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 12 (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: 8.25 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Ny titer level below ground surface: 2.35 (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&Infection 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 abandorunent to the county health department of the county where
6E Inner casing/tubing length(if known): 2 (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016