Martin_Well Abandonment_20230912 (2)

WELL L L ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James Lawrence 7a.For Geoprobe/DPT or Closed-tYlo Ip Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) Well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2193 wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water i ematniug in well(s):—(gal.)
SGI FOR WATER SUPPLY WELLS ONLY: i
Company Name �tt
7c-Type of disinfectant used: 1
2.Well Construction Permit##: ;
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.)iflo:own
7d.Amount of disinfectant used:
3.Well" ! (check well use):
Water supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Publie ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑'Dry Clay
❑lndustriZommereial ❑Residential Water Supply(shared) N Concrete Grout ❑Drill Cuttings
❑Itri ation ❑Specialty Grout ❑Gravel
Ron-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
IDMonitoring . ❑Recovery '
Injection Well:• 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 10lbs concrete
❑Aquifer Storage and Recovery OSalinity Barrier
l7Aquiler Test ❑Stotmwater Drainage
❑Expeeimental Technology El Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Gtxithelmal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled with concrete to top of casing and covered
with 3" of concrete
Q.Date well 8/15/2023s)abandoned:
Sa.Well location: E —�-�=�-�
James Lawrence ° 2
Facility/Owner Name_ FacilityID#(ifapplicable) in 8 rtif .eationf. tt Irair,�;ie Mr, s� t!r•
107 Elmwood Ave,Williarnston, NC 27892
Physical Address,City,and Zip" a ure of Certified Well Contractor or Well Owner Date
i
Martln By signing this form. I hereby.cert fy 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
and that a copy of this record has been provided to the well owner.
sb.Latitude and longitude in degrees/minutes/seconds or dec6mal degrees:
(ifivelt field;one lat/longis.sufficient) 9.Site diagram or additional well details:
•35.84430 N 77.06845 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 WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atiac*uwell'consinictionrecord(s)lfavallable. For multiple injection or non-watersupplywells
ONLY with the same construction/abandonment,you can submit one farm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID!#• MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 A) 1617 Mail Service Center,Raleigh;NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 3•5 (in.) above, also submit-one copy of this form•within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: 15 ( ) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft,) 10c.For Water Suably&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
3 of well abandonment to the'county; health department of the county where
6E Inner casing/tubing length(if known): (gip•) abandoned.
6g.Screen length(if known): 17 (ft.)
Form GW-3G North Carolina.Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016 -