Nash_Well Abandonment_20230905 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 7a.For Geoprobe/DPT or Closed-L I p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW j30i is needed. Indicate TOTAL NUMBER of
wells abandoned:0-
3344-A
NC Well Contractor Certification Number 7b.Approximate volume of water;remaining in well(s): 2.1 1 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS'ONLY:
Company Name
2.Well Construction Permit#:
M WO7O 1277 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.VIC,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 Gr `, fe Bentonite Chips or Pellets
❑Geothernal(Heating/Cooling Supply) ❑Residential Water Supply(single) El Sand Cement G yui E C � —ED Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout SEP � 5 20230 Gravel
Non-Water Supply Well: ❑ Bentonite Sltt a ❑Qther(explain under 7g)
eMonitoring` ❑Recovery,
Injection Well: 711 For each material sole e$a- (Ie, 'rovide 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 El Subsidence Control
❑Geothennal(Closed Loop) []Tracer7g.Provide a brief description of the,i abandonment procedure:
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) Gravity feed bentonite chips from 20 to 5' bgs
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: OS/1 6/2023 i '
5a.Well location: '
Frontier Development, LLC NA
Facility/Owner Name Facility IDt/(if applicable) 8.Certi tcation:
North Wesleyan Boulevard at Bishop Road,Rocky Mount,NC 27804 8"2Z'z3
Physical Address,City,and Zip Signature of Certified WeII ,2f.ctor or Well Owner Date
Nash 386206484507 By signing this form, 1 hereby certi/y that the tvell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.010,0 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well'details:
36.02170449 N -77.76899983 W You may use the back of this page 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 n ell construction record(s)ifavailable.Fornurltiple injection ornon-watersupply wells
ONLY with the sane 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 WO 1 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: 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• 7.05 (ft) Division of Water Resources,Underground Injection Control Program, T
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Suuuly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this fonn within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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