Burke_Well Abandonment_20230915

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J Ot,n C_ ct.,hcrplI 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
t R� wells abandoned:.
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NC Well Contractor Certification Number $ �l t-1 7b.Approximate volume of water remaining in well(s): (gal.)
M&W Drilling, LLC SEP 1 � 20?3 FOR WATER SUPPLY WELLS ONLY:
Company Name in.¢a;: we en Arty 7c.Type of disinfectant used:
,
Not Applicable DWo g Lfla
2.Well Construction Permit#: ` L78
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if 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 U Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry,_ - _ _O Other_(explain under_7g)_ __ . _ ___
U Monitoring DRecovery
Injection Well: 7f For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation —4.5 gallons neat cement .
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test StormwaterDrainage —5 lbs concrete
❑
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Neat cement emplaced,to —1 foot from the surface
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
via tremie pipe and topped with concrete to the
4.Date well(s)abandoned: 23 August 2023
surface
5a.Well location:
Cummins-Meritor
Facility/Owner Name Facility Mt/(if applicable) 8.Certifica' n: '
105 Wamsutta Mill Rd., Morganton, 28655 q/8/ 3
Physical Address,City,and Zip Si a of Certified Well Contractor or Well Owner Date
Burke 1793578109
By signing this form.I hereby certi.fr 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.
5b.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:
35.7462758339082 N -81.7087459082685 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- _.-- ` "- _ - - __'—
Atlach well construction record(s)if available.For Multiple injection or non-water supply wells ,
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well m#: MW-3 abandonment to the following
Division of Water Resources;Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 29 (ft)
10b.For Injection 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:
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6d.Water level below ground surface: —'16 ( ) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Supply&Injection 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
61.Inner casing/tubing length(if known): (ft-) abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016