Bertie_Well Abandonment_20230706 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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I.Well Contractor Information: WELL ABANDONMENT DETAILS
q.
Steve Hudson 7a.For Geoprobe/DPT or Closed-L lop 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
wells abandoned:
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable ivell construction permits(i.e.UIC,County,State, Variance,etc.)iflmotvn
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Itidustrial/Commercial s. R t tial Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
Oltrigation tr., .,s n ElSpecialty Grout ElGravel
Non-Water Supply Well:" q ❑Bentonite Slurry N Other(explain under 7g)
LQ.
eMonitoring � � Q .., � ecovery .
Injection Well: U11.1
' 7E For each material selected above,provide amount of materials used:
E]Aquifer Recharge lnvt-p6,^i;t4�'� ��" a❑�roundwaterRemediation BentOnite 9 IbS
sat,' t �
❑Aquifer Storage and Recover' ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Topsoil 501bs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment:procedure:
❑Geothermal(Closed Loop) ❑Tracer Hydrated beritonite to —6 inches below
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
land surface. Topsoil used to bring opening to
a.Date well(s)abandoned: e/15/23 grade. Concrete pad and metal removed. -
5a.Well location:- PVC left in place.
Eli Cofield Jr. Heirs NA
Facility/Owner Name Facility ID#(if applicable) S.Certification: -,C.-/ C���/
1814 US HVVY 17, Merry. Hill, NC 27957 6/29123
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie County 6.843852597
By signing this form, 1 hereby certify that the well(s).was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.01,00 or 2C.0200 Well Construction 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 field,one lat11ong is sufficient) 9.Site diagram or additional well details:
36.026521 N -76.807380 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 ivell construction record(s)ifavailable._For multiple injection ornon-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
`n'. 10a.•For All Wells: Submit this form within 30 days of completion of well-.
6a:Well ID#: D V V—2 abandonment to the following:
Division of Water Resources;Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
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:
9.46 Division of Water Resources,Underground Injection Control Program,
(ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
24 10c.For Water Suaaly&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 to the county health department of the county where
6f.Inner casing/tubing length(if known): 25 ({t,) abandoned.
6g.Screen length(if known): 5
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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