Sampson_Well Abandonment_20230912

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONNLENT DETAILS
Jeovany Gutierrez Bautista 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
4125A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 90
A.C. Schultes of Carolina, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflorown 1 lb.
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 C Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grt.; I' t ,�1,DrX Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 6 Kam— 0. J�T nn 1 Cuttings
❑Irri ation ❑ Specialty Grout Gravel
Non-Water Supply Well: ❑ Bentonite SlurrySEP 1 2
202 Other(explain under 7g)
❑Monitoring ❑Recovery
ntz Injection Well: 7f.For each malerriial si ee4�abrt i ffl4tit�ount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4 CY y f J+
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of,the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Chlorinate well to bottom
Pumped slurry mix from bottom up
4.Date well(s)abandoned: 8/22/2023 I'
I'
5a.Well location: I,
Butterball Feed Mill
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5604 Hwy 24, Turkey, NC
Physical Address,City,and Zip rgnat erti ctor or Well Owner ),ate
Sampson
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel By
No.(PIN) accordance with 154 NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.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 IaVlong is sufficient) 9.Site diagram or additional well details:
34.985343 N 78.223041 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 Attach well construction record(s)ifavailable.For multiple ityection ornon-watersupply wells SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonmem,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: #2 abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
66.Total well depth: 238 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
tic.Borehole diameter: 14 (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: 60 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ce`ntier,Raleigh,NC 27699-1636
6e.Outer.casing length(if known): (ft,) 10c.For Water Sunnily&Iniectiori 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): (ft.) abandoned.
i
6g.Screen length(if known): 40 (ft.)
Form GW-30
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016