Bertie_Well Abandonment_20230706 (4)

WELL ABANDONMENT RECORD For Internal Use 0NLY:
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-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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 well construction permits(i.e.UIC County,State,Variance,etc.)if.tnown
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 El Neat Cement Grout a Bentonite Chips or Pellets
LNon-Water
rmal(Heating/Cooling Supply) - ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
rial/Commerc j! ' it�@sjdGrttial Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
ion ❑ Specialty Grout ❑Gravel
Supply:Well:JUL np C 2 d2 ❑Bentonite Slurry Pg.Other(explain under 7g)
L':.r.
oring J - ❑Recovery
Injection Well: 7f.'For each material selected above,provide amount of materials used:
❑Aquifer Recharge F]Groundwater Remediation Bentonite 16.67 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage TOpS011 501bs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothernml(Closed Loop) ❑Tracer Hydrated bentonite 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: 6/15/23 grade. All concrete and metal removed.
5a.Well-location: PVC was left in place.
Eli Cofield Jr. Heirs NA
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 I SA 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:
(ifwell field;one ladlong 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 WELLS)BEING ABANDONED. SUBMITTAL:INSTRUCTIONS
Attach well construction records)ifavaildble..For multiple injection ornon-rvatersupply wells
ONLY with the same construcdonlabandonment,you can submit one forrim.
n A,n r 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 'V I V V-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 13 (ft.)
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• 4'04 (g) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA NA 10c.For Water Supply&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.
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6g.Screen length(if known): 1.0
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016