Bertie_Well Abandonment_20230706 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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 I GW-30 is needed. hrdicate TOTAL NUMBER of
wells abandoned:
i
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
7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc)!f/atown
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 I N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
: ..
❑hrig El Gravel
ation ❑ Specialty. .. p ty Grout
Non-Water Supply.Well:
❑ Bentonite Slurry 19 Other(explain under 7g)
IlMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used.
OAquiferRecharge ❑Groundwater Remediation Bentonite 25Ib.S
El Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Topsoil 50lbs
O 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
a.Date weil(s)abandoned: 6/15/23 grade. All well materials removed..
5a.Well location:
Eli Cofield Jr. Heirs NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: .,C�Av
G `1814' US HWY 17, MerryHill; NC 279576/29123
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 I5A NCAC 02C.01100 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/long 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 ifneoessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED- . SUBMITTAL INSTRUCTIONS
Attach udell construction records)ifavailable..For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
. 10a. For All Wells: Submit this form within 30 days of completion of well.
6a.Well ID#: M V Vn'-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.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• 7.09 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 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 abandoned.
I
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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LEGEND
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® Monitoring Well
(Type II)
OMonitoring Well t.
(Type III)
® Abandoned Non-Potable ` a
Water Supply Well s
Approximate Location
of Former UST System
Parcel Boundary
MEN :ar'� Source: Esri, Maxar, Earthstar Geographics, and the I; U - ComnlL pity
NOTE:Well and tank locations were obtained from previous reports
prepared by other consultants and are approximate. 60 30 0 60 120
Feet
IROJECT "_E
COFIELD FIGURE
ATLIN SERVICE STATION SITE MAP
1814USHWY17N
CMERRY HILL, NC
Engineers and Scientists
INCIDENT N0. JOB NO. DATE SCALE DRAWN BY/CHECKED BY
16616 220297 JUNE 2023 AS SHOWN KMC/BJA