Craven_Well Abandonment_20231024

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas J. Benthall, Jr. 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
4508-B wells abandoned:NA
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'53 (gal.)
Eastern Carolina Environmental Services, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.)ijknown NA
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 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑hidustrial/Commercial El Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
No_n-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx. 24.5 Ibs Bentonite Chips
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage approx. 12.5 Ibs. Concrete Grout
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Poured bentonite chips in well using a 1.5"diameter tremie pipe
at a rate of about 2 lbs.per minute using a funneling device and
4.Date well(s)abandoned: 10/03/2023 hydrated bentonite with potable water; placed concrete grout
5a.Well location: in top of wellhead and in well'yaultto:groundsarface
Adam Paul Boulia Incident No. 8309 m
Facility/Owner Name Facility ID#(if applicable) 8.Certific '
101 Short Street j �I: f 2Q23
10/04/2023
Physical Address,City,and Zip Signs a of ed Well ContraaUr ui'We116V e'r'
Craven 6-067-056 IG
By signing this form, I hereby certify 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
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record haseen provided to the well owner.
(ifwell field one lat/long is sufficient) t
9.Site diagram or additional well details:
34.871174 N -76.900721 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
Attach well constructionrecord(s)favailable.For multiple injection or non-watersupply 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 ID#: MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 17.00 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
1
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Not Known (in) above,also submit one copy of tliis form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface:
7.43 TOC (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 2.00 (ft.) 10c.For Water Supply&Iniectlon 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
6f.Inner casing/tubing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): 15.00 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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