Martin_Well Abandonment_20230912

WELL ABANDONMENT RECO" For Internal Use ONLY: �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Stuart Spruill 7a.For Geoprobe/DPT or Closed-Loo 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 i9 needed. Indicate TOTAL NUMBER of
2193 wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
i,
- SGI FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit 0:
List all applicable well construction permits(i.e.(11C.County.Stare,I'ariance,etc.)i/'known
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 ❑ Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay _
❑Industrial/Commercial, OResidential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
MIMonitoring ❑Recovery
Injection Well: 7E For each material selected'aboveJprovide amount of materials used:.,.
❑Aquifer Recharge ❑Groundwater Remediation 31bs bentonite chips I,
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 5 Ibs concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Place bentonite to 3ft from LS filled from-3ft.to top of manhole
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Ar
08/28/2023 X—I- V Vwn Vw.a
4.Date well(s)abandoned: c�.
Sa.Well location: S E P 1 2 2023
Mable Thomas
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: ,Infrl'1v98�tCf1 ?>"c ''g UR°
DI 101,0 o
410 State Street Williamston, NC 27893 08/29/2023
Physical Address,City,and Zip Signature of Certified Well Colliractor or Well Owner Date -
Martin By signing this form, l hereby cerrU that the tvell(s) was(iver•e)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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loug is sufficient 9.Site diagram or additional well details:
-35:824838 --_ `N 7T:069443 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
Aiiach well consiructiaii rec•ord(,t)ifarailable.liormultiple ii jection or non-water supply hells
- ONLY frith die saine c•onstruc uon abandoi nlew,you can submit one form.
10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#• M W 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
14 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total.well depth: (ft.)
10b. For lniection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter: (in.)
3.5 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: 3.5 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service 'Center,Raleigh,NC 27699-1636
lOc.For Water Sunaly&lniection iWells: In addition to sending the form to the
Ge.Outer casing length(if known): (R) 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): 2 (ft.) abandoned.
6g.Screen length(if known): 12
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcl s! Revised 2-22-201 G
- - j