Bertie_Well Abandonment_20230706 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steve Hudson
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 30i 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)il(known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑MunicipaYNblic ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
chudustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings.
Ohrigation ❑ Specialty Grout ❑Gravel.
Non-Water Supply Well: ❑Bentonite Slurry- X_Other(explain under 7g)
MMonitonng ORecovery
Injection Well: 7f.'For each material selected above,provide amount of materials used:
❑AquiferRecharge ❑GroundwaterRemediation Bentonite 25:Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aqui£erTest ❑StormwaterDrainage Topsoil 37.5lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment.procedure:
❑Geothermal(Closed Loop) ❑Tracer Hydrated bentonite to.-6 inches below
❑Geothermal(Heating/Cooling Rctum) ❑Other(e�plairl ..a
grrddr'
`L_ -r'` land surface. Topsoil used to bring opening to
4.Date well(s)abandoned: 6/15/23 0 E; ZQ23 grade.
Sa.Well location; �s.;st L' PVC was left in place.
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Eli Gofield.Jr, Heirs ►nN;K4
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1814 US HWY 17, Merry.Hill, NC 27957 � 6/29/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie County 6843852597
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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field;one lat/loog 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 well construction record(s)ifavailable..F&multiple injection or non-iJaiermpply wells
ONLY with the same conatruction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a;Well ID#:
IVI W_1. abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 (ft.) 1617 Mail Service Center,Raleigh;NC 27699-1617
lllb.For Iniection 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: 7.59 (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 Suoaly&Iniection 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 (ft.) abandoned.
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016
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