Brunswick_Well Abandonment_20230706 (15)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: HELL ABANDONMENT DETAILS
Bill Mabie 7L 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. Indicate TOTAL NUMBER of
3137-A wells abandoned:wA
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'0 (gal.)
WSP USA Environment and Infrastructure, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifkwwn
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 N Neat Cement Grout R 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 Supppw, t1 ■ Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ° "r '-E)Uvery
Injection Well: 1 I I n G ?023 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge lr ❑Groundwater Remediation 48 Ibs of Portland Type 1111 5 gallons of water
❑Aquifer Sto vetry.;: :,y, ; tity Barrier
'14 50 Ibs of Bentonite Chips
❑Aquifer Test Gi�,ft�r_'.:� ❑Stormwater Drainage _
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heatin Cootie Return ❑Other(explain under 7 Portland Type I/II was combined with Bentonite Chips and
mixed into a slurry that was both free poured and tremied
4.Date well(s)abandoned: 5/18/23 into the well until the slurry mix displaced all groundwater
sa.Well location: in the well and the slurry was seen exiting the well.
"44aftradnin SupeftW Sits,tbmywWlInt«nati—I- N/A
WI I I Ia m.Ma Wil Digitally signed by
Facility/Owner Name Facility ID#(if applicable) S.Certification: tIIam.Mam.Mabie
Riegel Road, Riegelwood, NC 28456 b1e Date:2023,07,
636 John L. Rie
9 9 11 1:30:20-oa'oo'
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Brunswick County N/A By signing this form, I hereby certify 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]at/long is sufficient) 9.Site diagram or additional well details:
34* 21' 33" N 78* 12' 33" N 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
Aitach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
109. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-P5 abandonment to the following:
Division of Water Resources,Information Processing tlnit,
6b.Total well depth: Could not measure(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: 1 (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: Could not measure(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 1 Or.For Water Sunnly&Iniectlon 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
6E Inner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form G W-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016