Robeson_Well Abandonment_20230428

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 same
Well Contractor Name(or well owner personally abandoning well�itNlwr ) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
�`�P` 4- wells abandoned:
4330-B �- �;
NC Well Contractor Certification Number p ' l"pprozimate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientist t1 2 b ?023 FOR WATER SUPPLY WELLS ONLY:
nFs APrsr-
Company Name ry�„ r Type of disinfectant used:_
2.Well Construction Permit#: N/A DWQ*S�+ss
List all applicable well construction permits(i.e.11IC,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 Ill 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)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets -50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete —51bs
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief De.criptinn of)he 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
a.Date well(s)abandoned: 4/13/2023 with concrete to existing grade.
5s.Well location:
NCDEQ-Former Roberston Mobil 0-0-0000019044
Facility/Owner Name Facility ID#(if applicable) 8.Certification: L-
110 N. Main St., Red Springs, 28377 4/17/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Robeson N/A
By signing this form, I hereby certify that the wells) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA 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 well field one lat/long is sufficient) 9.Site diagram or additional well details:
34.8167262 N -79.1820295 K 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)tfavailable. 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#: MW-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (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.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NSA (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 abandonment to the county health department of the county where
611 Inner casing/tubing length(if known): 15 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WATER I N
r METER
/
/ FORMER
/ 4,000-GAL.
/ UST
LIGHT • ;
POLE MW-01 •
FORMER
••..i 550=GOAL.
usrs LEGEND
FORMER ® Monitoring Well
DISPENSER (Type II)
ISLAND
Electric Lines
Water Lines
•, POLE Gas Lines
Telephone Lines
FORMER 4,000-GAL.
GASOLINE U TS / Unknown Lines
UST Lines
Approximate Location
WATER 6--= of Excavation Limits
METER Approximate Location
4;. 0 of Former UST System
Q Parcel Boundary
Source Esri. Maxar. Ear-thstar Geographics. and the GIS User Community
30 15 0 30 60
Feet
PROJECT FORMER TITLE FIGURE
ATLINROBERTSON MOBIL SITE MAP
N MAIN ST& 3RD AVE
Engineers and Scientists RED SPRINGS, NC
INCIDENT NO. JOB NO. DATE SCALE I DRAWN BY/CHECKED BY
23233 221123 APRIL 2023 AS SHOWN KMC/BJA