WQ0001664_Report_20230502 (2)

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Joseph L. Zuncich
Well Contractor Name (or well owner personally abandoning well on his/her property)
3324-A
ti(- Well Contractor Certification Number
For internal t: se 014LY
WEI.I. ABANB0N,%lENT nQTAII S
Its. For Gcoprobe/DPT or Closed -Loop Geothermal Wells having the some
well construction/depth, only l GW-30 is needed Indicate TOTAL NUMBER of
wells abandoned
7b. Approximate volume of water remaining In %yell(s): 1.91 (gal.)
Applied Resource Management, P.C. I FOR N1 ATER SUPPLY WELLS ONLY
Company Name
7c. Type of disinfectant used:
2. Well Construction Permit ii: N/A
List all applicable nr/t can imcnontxrmus (i.e. U1C. Cutinn Sime !'uriancv. etc.) tfkno"'rr
7d. Amount of disinfectant used:
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (l-leatmg/Cooling Supply)
❑ Industrial/Commercial
Non -Water Supply %Nell:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aqudcr Tcsl
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (HeatingtCooling Return
4. Dale well(s) abandoned:
5/1 /2023
❑Municipal Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater Remcdiation
❑Salinity Barrier
❑Storm%vuter Drainage
❑Subsidence Control
❑Trucer
5a. %fell location:
lronClad Ventures Corporation
Faeilh).Owner Name Fac:lir}'.0a (ifapplicable)
2368 Country Club Drive, Hampstead, NC 28443
Physical Addreai, City, and Zip
Pender
County
4203-77-4185-0000
Parcel ldemiticai= No. (PIN I
5h. Latitude and longitude in degrees/minutes/seconds or decimal degrees;
fifwell Aeld, one latllong is sufficient)
34 23' 16" 1 77 38' 47"
11'
7e. Scaling materials used (check all that apply):
❑ Meat Cement Grr.ut a Bentonite Chips or Pellei .
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7C For each material selected above, provide amount or materials used:
Bentonite chips
30 Ibs
7g. Provide a brief description or the abandonment procedure:
Measure well depth and water level. Remove
concrete pad, steel standpipe, and cut well casing
15" below ground surface. Add 1/8 lb chlorine and
seal well above casing with Bentonite.
S. Certification:
Q8d' � � 5/2/2023
S ttue o0l2ertified %Veil Contractor or Well Owner Date
By signing this fornt. 1 hereby certify that the trell(s) was (were) abandoned in
accordance with 15A hCAC 02C.0100 or 2C ,0200 11'eH Construction Standards
and that a copy, of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary
CONS'I'RUC'r10N DETA[I S OF WF.LIASt BEING ARANDONED SUBMITTAL INSTRIT'T10NS
.tuachwellcnrrrtrucrinnrrcorrL(.rJrjar�iluhle!•armi+lriplrinjrcllunarnon-warcrr+t;-r.,rtlls
0M.1'"Ith the same con trualan ah,rcrdonmeni. you can submit one form.
6a. Well Ina• Unknown
6b. Total well depth: 15.5 (rt.)
6c. Borehole diameter: Unknown (In )
6d. Water level below ground surface: 3'46 A)
iun. For Ali "ells: S'.bmil this form %vithin 30 days of completion of well
abandonment to the vl lowing:
Division of M:uler Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lob. For [nlection Wells: In addition to sending the form to the address to 10a
above, also submit one copy of this form within 30 days of completion of %veil
abandonment to the follo%ving:
Division ol"liV ater Resources, Underground Injection Control Program,
1636 :%[uil Service Center, Raleigh, INC 27699-1636
6e. Outer casing length or known): Unknown (rL) 10c. For Water Sunnly & Injection Wells: In addition to sending the form to the
address(es) above- also submit one copy of this form within 30 days of complction
of well abandonni"; to the county health department of the county where
6f. Inner casing/lubing length (irknown): Unknown (ft.) abandoned.
6g. Screen length (if known): Unknown (ft.)
Form G%% -3u North Carolina Department otEn5immmental Quality - Division of Water Resources Revised 2-22-2016