Brunswick_Well Abandonment_20231101

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joseph L. Zuncich
p 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
3324-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A
Applied Resource Management, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,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 s Bentonite Chips or Pellets
i
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ 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 ❑Groundwater Remediation 130 pounds bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer i
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Measure well depth and water level. Remove
standpipe, concrete pad and T of well casing.
a.Date well(s)abandoned. 10/18/23 Seal well with bentonite chips to ground surface
5a.Well location:
and hydrate. t` , u,�
Jones Holding NC LLC N/A — �� : L_11s
Facility/Owner Name Facility ID#(if applicable) 8.Certification: NOV J 12023
3917 Committee Dr, Southport, NC 28461 a 10/20/23
-,.'.:-�<�..;r..,i_
Physical Address,City,and Zip Sig a ofC ied Well Contractor or Well�pwvef,; "� 15ete
Brunswick 207818305160
By signing this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.01 P01 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: I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
33 58' 2° N 78 5' 50" 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formuhiple 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 ID#: PZ-3C abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 63 (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: 5 7/8 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
22.32 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Cen�ter,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): NA (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
6f.Inner casing/tubing length(if known): 58 (ft.) abandoned. I
4
6g.Screen length(if known): 5 (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joseph L. Zuncich
p 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
3324-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water iemaining in well(s): N/A (gal.)
Applied Resource Management, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: �
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)tjknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑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) ❑ Concrete Grout ❑Drill Cuttings
DIrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well:- - - ❑ Bentonite Slurry- ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Retnediation 90 pounds bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑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) Measure well depth and water level. Remove
standpipe, concrete pad and T of well casing.
a.Date well(s)abandoned: 10/18/23 Seal well with bentonite chips to ground surface
5a.Well location:
and hydrate.
Jones Holding NC LLC N/A
Facility/Owner Name Facility ID#(if applicable)
8.Certification:
3917 Committee Dr, Southport, NC 28461 amcz� NOV v 1 2023 10/20/23
Physical Address,City,and Zip Sig gym of tified Well Contr.qritor or,Well Qwger Date
Brunswick 207818305160 l�{. t;
By signing this form, 1 hereby certify'th2Nlie�tvkl�(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:
(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details:
33 58' 2" N 78 5' 50n 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
ONLYwith 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#: PZ-3B abandonment to the following:
Division of Water Resources,Information Processing Unit,
61b.Total well depth: 35 (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: 5 7/8 (in) above, also submit one copy of this)form within 30 days of completion of well
abandonment to the following:
12.55 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): NA (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
6E Inner casing/tubing length(if known): 30 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department o£Environmental Quality-Division of Water Resources I Revised 2-22-2016