Robeson_Well Abandonment_20230818 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. �/V e rl ey 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
3344—A wells abandoned:c^a 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'1$ (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoun
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 a Neat Cement Grout C Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring El Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite — 25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Neat Cement^35 lbs.
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Gravity feed bentonite chips from 20' to 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' has to ground surface
4.Date well(s)abandoned: 08/09/2023
5a.Well location:
Lumtrerton(150 Jackmn)W W,U.C.a Delaware limiletl Ga�ility company
NA AUf
Facility/Owner Name Facility 1D#(ifapplicable) 8.Certification: — JI k8tri _ �P^i
150 Jackson Court Lumberton, NC 28358 023
Physical Address,City,and Zip Signature ofCertitied Well Contractor r Well Owner Date
Robeson 939384512500
By signing this,{orm, /hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0l00 or 2C.0200 Well Construction Standards
and that a copy ofthis retard has been provided to the ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details:
34.6680376 N -79.00484568 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 trellconsintctionrecord(s)ifavailable. Fornmltiple injection ornon-untersupplya'ells
ONLY with the same construction/abandonment,you can submit one jbrm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 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: 6 (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: 6.67 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
NA (ft.) 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
611 Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (ftJ
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016