Brunswick_Well Abandonment_20230706 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Bill Mabie 7a.For Gtoprobe/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
3137-A wells abandoned:wA
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.0 (gal.)
WSP USA Environment and Infrastructure, Inc. FOR%% %I ER SUPPLY WELLS ONLY:
Cody Name 7c.T.pe of disinfectant used:
2.Well Construction Permit#: NIA
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)l(known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Staling materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout 11 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01m,gation '"' � '' .�! ❑ Specialty Grout ❑Gravel
Non-Water Supply 'll; 1. In Bentonite Slurry ❑Other(explain under 7g)
eMonitoring covery
Injection Well: - 7f For each material selected above,provide Amount of materials used:
❑Aquifer Recharge GjytpjAterRemediation 48 Ibs of Portland Type lill 5 gallons of water
❑Aquifer Storage andlli$ect 6,'*,Vja�, Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 50 Ibs of Bentonite Chips
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Portland Type 1/11 was combined with Bentonite Chips and
❑Geothermal (Heating/Cooling Return) ❑Other(explain under 7g) —
mixed into a slurry that was both free poured and tremied
a.Date well(s)abandoned: 5/22/23 into the well until the slurry mix displaced all groundwater
5a.Well location: in the well and the slurry was seen exiting the well.
LCP-Hortr hw SuperturW Site Homy"I ieri,et-1 w. N/A
William.M Digitally signed by
Facility/Owner Name Facility ID#(ifapplicable) 8.('ertificali0n: William.Mabie
Date636 John L. Riegel Road, Riegelwood, NC 28456 abie 11:10. 023.070'
9 9 11:1 o:a7-0a�oo� _
Physical Address,City,and Zip Signature ofCertified Well Contractor or Well Owner Date
Brunswick County N/A By signing this form, 1 hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34* 21' 33" N 78* 12' 33" 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
Atiachwellconstructionrecord(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same constructionlabandonmem,you can submit one form.
10m. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-10AR abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20.3 (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: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.,Pater level below ground surface: 15 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): N/A (ft.) 10c.For Water Sumoly&Infection 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
6L Inner casing/tubing length(if known): 1 0.3 (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
Fonn GW-30 North Carolina Department ofFinviroranental Quality-Division of Water Resources Revised 2-22-2016