Brunswick_Well Abandonment_20231101 (3)

WELL ABANDONMENT RECORD I For Intent I Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joseph L. Zuncich
p 7a.For Geoprobe/DPT or Closed- oop 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: I
NC Well Contractor Certification Number 7b.Approximate volume of water!Jremaining in well(s): N/A (gal.)
Applied Resource Management, P.C. FOR WATER SUPPLY WELLS`ONLY:
Company Name
7c.Type of disinfectant used: I
2.Well Construction Permit#: N/A
List all applicable well construction permits(1.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
❑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)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 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 Measure well depth and water level. Remove
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
standpipe, concrete paid and 3' 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 � , � �: NuOV ; z023 10/20/23
Physical Address,City,and Zip Si tune of ertified Well Conl R6r 6KWeltQw'upr.-,_,;��_;, tii pate
Brunswick 207818318681 t '' �: ' i
By signing this form:, 1 hereby certify'that tyre well(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: i
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
33 58' 11" N 78 5' 57" �, 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.Tor 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#: PZ-2C abandonment to the following: I.
Division of Water Resou,ces,Information Processing Unit,
6b.Total well depth: 65 (ft.) 1617 Mail Service CcI ter,Raleigh,NC 27699-1617
10b.For Infection 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 fonn within 30 days of completion of well
abandonment to the following:
23.50 Division of Water Resources Underground Injection Control Program,
(f 6d.Water level below ground surface: t.) 1636 Mail Service Ce i nter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Supply&Iniection6ells: 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 coun ea h department of the county where
6f.Inner casing/tubing length(if known): 60 (ft) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016