Bertie_Well Abandonment_20230706 (5)

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-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:
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 known
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 Grout9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout El Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply: elk L_ ° ❑ Bentonite Slurry-.. 11 Other(explain under 7g) .
MMonitoring ecov ery
Injection Well: ' - - 7f.'For each material selected above,provide amount of materials used:
OAquiferRecharge r,,,, CYtlisi8ibaterRemediation Bentonite 16.67Ibs
El Aquifer Storage an�W veery-,%Qj3 Cj❑Salinity Barrier
El Aquifer Test ❑StortnwaterDrainage Topsoil 50lbS
❑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 Return) ❑Other(explain under 7g)
land surface. Topsoil used to bring opening to
4.Date weu(s)abandoned: 6/15/23 grade. 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: �,C.-/ C���`'
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.p100 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 lattlong 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 SUBMII'PAL:INSTRUCTIONS
Attach ivell construction record(s)ifavailable. For multiple injection ornon4aiersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a.-For All Wells: Submit this form within 30 days of.completion of well-
6a.Well ID#: M W_3 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
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: 7.03 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC.276994636
NA 10c.For Water Sum&&Infection Wells:.In addition to sending the form to the
6e.Outer casing length(if known): 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
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016