Brunswick_Well Abandonment_20230706 (10)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Bill Mabie 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Cormactor 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 re maining in well(s): 0.0 (gal.)
WSP USA Environment and Infrastructure, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Typeofdisinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State, Variant e,etc.)ifbtown
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 19 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial 011gsidential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri tion it G "j ❑ Specialty Grout ❑Gravel
Non-Water Supply 11 a Bentonite Slurry ❑Other(explain under 7g)
eMonitoring t overy
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge 1n(o0Y'4;:"1 --":�zGiQ'1u64AterRemediation 48 Ibs of Portland Type lilt 5 gallons of water
❑Aquifer Storage and RecoveryDV 4Qi5 NSalinity 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 I/II was combined with Bentonite Chips and
❑Geothermal (Heating/Cooling Return ❑Other(explain under 7 —
mixed into a slurry that was both free poured and tremied
4.Date well(s)abandoned: 5/23/23 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-Ha6ahMn StpNtund Site i Haney"I Int—tonal Inc. N/A
Facili /Owner Name Facie ID#(if applicable) 8.(ertification:William.Ma DIcitally signed by
ty Facility ( aPP ) Nilliam.Mabie
Date636 John L. Riegel Road, Riegelwood, NC 28456 b1e 13-4221-04 .26
ts:a221-0aroo' 6/26/2023
Physical Address,City,and/ir Signature of Certified Well Contractor or Well Owner Date
Brunswick County N/A
By signing this form, /hereby terrify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 latflong 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
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the some 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-4A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 16.1 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
1Ob.For Injection Wells: In addition to sending the form to the address in IOa
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.Water level below ground surface: Dry (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NIA (ft.) 10c.For Water Supply&Injection 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): 6 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016