Brunswick_Well Abandonment_20230706 (17)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Bill Ma bie 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. Indicate TOTAL NUMBER of
3137-A wells abandoned:wA
NC Well Cormactor Certification Number 7b.Approximate volume of water remaining in well($): 0.0 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.)iftnown
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ^"f" r—'pf e ft Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri tion �`'—�r Lz I' k �—y ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ,(�, N Bentonite Slurry ❑Other(explain under 7g)
eMonitoring IJ L 0 e Z91'ery
Injection Well: UrA 7f.For each material wlected above.pr)cide amount of materials used:
❑Aquifer Recharge D 0rC��a��oundwater Remediation
pv�a�at� 48 Ibs of Portland Type I/II 5 gallons of water
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 50 Ibs of Bentonite Chip:_
❑Experimental Technology OSubsidence Control 7g.Pros ide 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 7 —
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 nux displaced all groundwater
52.Well location: in the well and the slurry was seen exiting the well.
t.CP Sipe t.W sae,H—Y-11 learnt-1 Irk. N/A —
WilliamN Willially n.Manedby
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: 1Nilliam.Mabie
636 John L. Riegel Road, Riegelwood, NC 28456 abie Date:2023.07.05
11:31.49-04'00'
Physical Address,City,and Zip Signature ofCertified Well Connector 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 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34" 21' 33n N 78* 12' 33" 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 same construction abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well WN: MW-17 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.9 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.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 forth within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 1.3 (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.) 10c.For Water Supply&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
6E Inner casing/tubing length(if known): 7'9 (ft) abandoned.
6g.Screen length(if known): 5 (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016