Craven_Well Abandonment_20231024 (2)

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): 6'1 1 (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.)if known
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 H 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
Oh-ri tion ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx. 72.7 lbs Bentonite Chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage approx. 12.5 lbs. Concrete Grout
❑Experimental Technology El Subsidence Control
DGeothermal(Closed Loop) OTracer _ r oured bentonite chips in well using a 1.5"diameter tremie pipe
Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(e 3in pnder.9`' . j i`. ..� g)
/: 2023 at a rate of about 2 lbs.per minute using a funneling device and
4.Date well(s)abandoned: 10/03/2023 hyc.r
�•r.� �iated bentonite with potable water; placed concrete grout
ci.,!�-i,•�rf..^ is-aa,..
5a.Well location: G `'�`�' in top of wellhead and in well vault to ground surface
Adam Paul Boulia Incident No. 8309
Facility/Owner Name Facility ID#(if applicable) 8.Cc tifrcat' n:
101 Short Street 10/04/2023
Physical Address,City,and Zip Signature e e Contractor or Well Owner 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
r
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has beeetaovided to the well owner.p
(if well field,one lat/long is sufficient) 9.Site diagram or additional well dils:
34.871202 N -76.900705 �, 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-water supply 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#: DCW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 50.00 (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: Not Known (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: 11.79 TOC (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
42.00 (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
40.00 of well abandonment to the county' health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 10.00 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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