Craven_Well Abandonment_20231024 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas J. Benthal I, 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
4508-B wells abandoned:N^
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.12_(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 1.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)jknown
7d.Amount of disinfectant used: NA
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
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx. 24.5 Ibs Bentonite Chips
❑Aquifer 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
Poured bentonite chips in well using a 1.5"diameter tremie pipe
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
at a rate of about 2 Ibs. per minute using a funneling device and
a.Date well(s)abandoned: 10/03/2023 hydrated bentonite with potable_water;_placed concrete grout
Jra.Well location: C.•� .-' Y _.,,6
in top of wellhead and in we l vault'to:grou�ic,,,,9u ce:
Adam Paul Boulia Incident No. 8309
Facility/Owner Name Facility ID#(if applicable) 8.Certifica' (11•1 93 2023
101 Short Street It,i ;;' '�'^ I ? = • is 210104/2023
Physical Address,City,and Zip Signature e e Contractor or-.Well Ow ei' " �s Date
Craven 6-067-056
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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has bein provided to the well owner.
(if well field one lat/long is sufficient) 9.Site diagram or additional well details:
34.871356 N -76.901228 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 construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-4 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
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Not Known (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: II
6d.Water level below ground surface 10.03 TOC (fk) 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 Sunaly&Iniection'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): NA (ft.) abandoned.
6g.Screen length(if known): 15.00 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
i
Thomas J. Benthall, Jr. 7a.For Geoprobe/DPT or Closed 1-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I G I-30 is needed. Indicate TOTAL NUMBER of
4508-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): 1.09 (gal.)
Eastern Carolina Environmental Services, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: NA
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if/mown
7d.Amount of disinfectant used:i NA
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout I e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑bri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
AMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx. 21.1 Ibs Bentonite Chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage approx. 12.5 lbs. ( Concrete Grout
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the,abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I
❑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 Ibs. per minute using a funneling device and
4.Date wells abandoned: 10/03/2023 i
(> hydrated bentonite with potable water; placed concrete grout
5a.Well location: in top of wellhead and in well l'vault1wgroo.h,'Slirface�
Adam Paul Boulia Incident No. 8309 '
Of:T Facility/Owner Name Facility ID#(if applicable) 8.Certification: .r 2023
101 Short Street1Q/04/2023
Physical Address,City,and Zip Signature of ed Well tmctor or Well dwner-: Date
Craven 6-067-056 1
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.01I00,or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has ben provided to the well owner.
(if well field one lat/long is sufficient) 9.Site diagram or additional well details:
34.871208 N -76.900672 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
Attach well construction records)ifavadable.Formultiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-5 abandonment to the following: 'I
Division of Water Resources,Information Processing Unit,
14.50 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Not Known (in) above,also submit one copy of this;form within 30 days of completion of well
abandonment to the following:
7.71 TOC Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 4.50 (ft) 10c.For Water Supply&Iniection 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
611 Inner casing/tubing length(if known): NA (ft.) abandoned.
00
6g.Screen length(if known): 10. (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

EAST MAIN STREET (US HIGHWAY 70)
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