Carteret_Well Abandonment_20231024

WELL ABANDONMENT RECORD ForinternalUseONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 7a.For Geoprobe/DPT or Closed I-Lloop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:ONE
NC Well Contractor CertiFcation Number 7b.Approximate volume of water remaining in well(s): 0'4 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name 1 i
7c.Type of disinfectant used: i
2.Well Construction Permit#: 'A'V/A
List all applicable well construction permits(i.e.U/C,County.State, Variance,etc.)ifknown
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 a Bcntonitc Chips or Pellets
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bcntonitc Slurry ❑ Other(explain under 7g)
®Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite -10 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Remove well screen point and pour bentonite to groundsurface
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
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10/10/2023 Cover groundsurface with drill cuttings
4.Date well(s)abandoned: y' J k j� -� r�- M
5a.Well location: n( T �!J ^
Taylors Creek Group LLC N/A 023
Facility/Owner Name Facility lDlt(if applicable) rtiriication: lniC ^:i n ia!;;•�,h ;r�I�f.`�
326 Front Street, Beaufort 28516 1`0/10/2023
Physical Address,City,and Zip Signature of Certified Wei ontra or or Well Owner Date
Carteret 730617100154&730617100136 ,
By signing this fortis, 1 hereby,certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 [yell Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this reco•I has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.717201 N -76.666634 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
Aaacltweticonstntctionrecord(s)ifrtvailable. Fw-natilipleisjectionornon-iv(iict•stippl),wells
ONLY with the same consit•uction/abandonnient,you can submit one ftrt•ni.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 5.0 (ft.) 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: 3.25 (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: 2.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail i ervice Center,Raleigh,NC 27699-1636
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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 sdbrilit one copy of this form within 30 days of completion
of well abandonment t the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 5.0
Fort GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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