Richmond_Well Abandonment_20230602 (2)

WELL ABANDONMENT RECORD For lntemalUseONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Morey D. 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 SCIeCItI$1S FOR WATER SUPPLY WELLS ONLY: .,
Company Name
NA 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC;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 e-Bentonite Chips or Pellets
❑Residential Water Su 1 sin le ❑ Sand Cement Grout;—° 1
❑Geothermal(Heating/Cooling Supply) pp y.( g ) ..z :, _; :E7- ry Clay
Oindustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill-6uttings-
❑Irrigation O'Specialty Grout JU]ti .G232 Gravel
Non-Water Supply Well: ❑Bentonite Slurry" IN Other(explain under 7g)
RMonitoring ❑Recovery lJr,,t
Injection Well: 7f.For each material selected`a`liove,prii.Vide amount of materials used:
❑Aquifer Recharge. ❑GroundwaterRemediation Bentonite 37.5lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 16.5 IbS
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop). ❑Tracer
❑Geothermal(He ating/Cooling Return) OOther(explain under 7g) All well material abandoned In place with) hydrated -
bentonite pellets to within — 1 foot of surface and
4.Date well(s)abandoned 5/24/23 topped with concrete.to existing grade_.
5a.Well location:
NCDEQ-Starflite Food Store 272: NA
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1416 Fayetteville Road, Rockingham, NC• -5/25/2023...
Physical Address,City,and Zip = : Signature of Certified Well Contractor or Well Owner. Date
Richmond 747310357941 -
By signing this form, I hereby,certify that the ivell(s),wits(were) abandoned in
County Parcel Identification No.(PIN) ac'cot•dance with 15A NCAC 02C.0100 or 2C.0200 Well- onstriction Standards .
and that a copy of this record has been provided to the well owner. .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well afield,one lat/long is sufficient) - .. 9.Site diagram or additional well details: ..
34.945485 N -79.754974" `I 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 yell construction records)ifavailable..For multiple itliection or not-water supply wells
ONLY with the sane construction/aband6nment,you can submit one form.
-'10a:.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-1 abandonment to the following:
Division of Water Resources,Information Processing
g Unit,...
20 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
-8.25 above, also.submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in:)
abandonment to the following:
6d.Water level below ground surface: 3,19 (ft) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
NA::: 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment the county department of the county where
5 abandoned.
6f.Inner casing/tubing length(if known): A)
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources. Revised 2-22-2016

. .
WELL`xLLL�'�' ABANDONMENT 1 RECORD For Internal Use ONLY:
1.Well Contractor information: WELL ABANDONMENT.DETAILS ..
Corey p. FUtral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner persoaally'abandoning well.on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4300-8 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate:volutne of water remaining in well(s): (gal.)
Catlin Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
NA 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,.elc).ifknown
7d.Amount.of disinfectant used:
3.Well use(check well use):
Water Supply Well:. 7e.Sealing materials used(check all that apply):
❑Agri,ultural ❑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 Groutbitll Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Benton ite Slurry J U N 2 2,0239 Other(explain under 7g)
IRMonitoring ❑Recovery
Injection Well: q 7f.For each m%rial-selected above,providg amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
Bentonite "� -
:�...,:..._, 251bs ..
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test". ❑Stormwater Drainage
Concrete: .' 25 Ibs
❑Experimental Technology ❑Subsidence Control
❑Geothermal Closed Loop) 7g•Provide a brief description:of the abandonment procedure:
( , ❑Tracer,
❑Geothemtai(Heating/Cooling Return) ❑other(explain under 7g) All well material abandoned in place with hydrated'
bentonite pellets.to within — 1 foot of surface and
a.Date well(s)aban[loned: 5/24/23 topped with concrete.to existing grade.: .
5a.Well location:
NCDEQ=Starflite Food Store 272 NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification: . .
1416 Fayetteville Road, Rockingham, NC 5/25/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner- Date
Richmond 747310357941
Bji signing this form, I hereby certify that the ivell(s) wds,(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 or 2C.0200 Well Cohstr•uction Standards
and that a copy of this record has been pippided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well detailsi
34.945485 N _79.7549. 74 W' 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)ifavailable..Fqr multiple injection or non-watersupply wells
:ONLY with the same construction/abandonment,you can subnut one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-2 _ abandonment to the following::'
Division of Water Resources;Information Processing Unit, .
6b.Total well depth: 13 (ft.) 1617 Mail Service Center,IkAeigh,'NC 27699-1617
0b For Iniection Wells: addition to sending form to the address in 10a
1 1 In dog the.
8.25 above,-also.submit.one copy of this form within 30 days of completion of"well
6c.Borehole diameter: (in.)
abandonment-to the following:
6d:Water level below ground surface: (ft.)
3.55 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
6f.;Inner casing/tubing length(if known): 3 abandoned.
6g.Screen length(if known): 1
Form GW-30 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016 ...