Wilson_Well Abandonment_20230428 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.\1 ell Contractor Information: WELL ABANDONMENT DETAILS
Corey F u tra I 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 I 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:
Company Name t
7c.Type of disinfectant used: ,...
2.Well Construction Permit#: 2 S 2023
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.)if town APR R
?d.Amount of disinfectant used:
3.Well use(check well use):
N1 ater Supply Well: 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
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry a Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected abot e,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 16.67lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑AquiferTest ❑StormwaterDrainage Topsoil 751bs
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer All well material removed and backfilled with
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
hydrated bentonite pellets to within 8 inches of surface
4.Date well(s)abandoned: 4/11/2023 and topped with topsoil to existing grade.
5a.Well location:
NCDEQ-Quick Stop Mart 00-0-000005563
Facility/Owner Name Facility ID#(if applicable) 8.Certification: Z> --/
300 East Herring Avenue, Wilson, NC ��J^{I 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 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:
(ifwell field one Iat/long is sufficient) 9.Site diagram or additional well details:
35.727683 N -77.904247 N 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)rfavailable. For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can suhmit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6s.Well ID#: M W-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total sell 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.NN ater leN el below ground surface: 6.52 (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 Sootily&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 abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): 2 ({t•) 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

N
550-GAL.
GASOLINE
LISTS
i
RANG PEE
NER FORMER
DISPENSER
ISLAND
MW-1 R
MW-2
MW-3
10,000-GAL.
GASOLINE UST
® MW-04
4
a
ti
LEGEND
® Active Monitoring
Well (Type 11)
Temporary Monitoring
Well (Type 1)
t,
Approximate Location of i
Telephone Conduit Vault �u G'
�4�;�
Approximate Location +
of Former UST Systems
Parcel Boundary
TMW-01ii { w
Source Esri, Maxar. Earthsta-Geo'graph cs and the GIS lJJser Comm uniityA,
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 20 10 0 20 40
Feet
PROJECT TITLE
FIGURE
QUICK STOP MART
ATLIN 300 HERRING AVE E SITE MAP
CWILSON, NC 1
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BVICHECKED BY
3658 221049 APRIL 2023 AS SHOWN KMC/SJO