Brunswick_Well Abandonment_20231101 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joseph L. Zuncich 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 I30 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 (gal.)
Applied Resource Management, F.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.)i,/known
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 IN 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)
CMonitoring ❑Recovery'
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 20 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 3' of well casing.
a.Date well(s)abandoned: 10/18/23 Seal well with bentonite chips to ground surface
Sa.Well location: and hydrate.
�
Jones Holding NC LLC N/A
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: i �m c b s } .•�
3917 Committe Dr, Southport, NC 28461 j NOV 1 2023 10/20/23
Physical Address,City,and Zip Si a of tified Well Contmctdrifr-Wpril;Qivger],.,.,,I_,; Dite i
Brunswick 207818318681
By signing this form, I hereby certify that I we11(sf was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.01'00.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 latllong 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
Aftach well construction record(s)ifavailable.For multiple injection or non-u'atersupply wells
ONLY with the same construction/abandonment,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: FZ-2B abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
5 7/8 10b.For Infection Wells: In additi�n�to sending the form to the address in 10a
6c.Borehole diameter: (in,) above, also submit one copy of thisl,form within 30 days of completion of well
abandonment to the following: f
14.57 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft) ,
1636 Mail Service Ce'te'r,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) loc.For Water Sumnly&Injection Wells: hi 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): 30 (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

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-Ltiop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW i 3Q is needed. Indicate TOTAL NUMBER of
3324-A wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of waterreinaining in well(s): N/A (gal.)
Applied Resource Management, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name I
7e.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown f
7d.Amount of disinfectant used: I ;
3.Well use(check well use): I
I'
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout l X Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I ❑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: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 75 pounds bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control 7g,provide a brief description of theabandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g) Measure well depth and water level. Remove
standpipe, concrete pad and 3' of well casing.
a.Date well(s)abandoned: 10/18/23 Seal well with bentonite,chips-to;gro. n surface
5a.Well location: and hydrate.
Jones Holding NC LLC N/A _ j
2023
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
3917 Committee Dr, Southport, NC 28461 t r :C.;_: 10Y0/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Brunswick 207818318681
By signing this form, I hereby certyy that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.TO or 2C.0200 Well Construction Standards
and that a copy of this record has begn provided to the ivell owner.
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
33 58' 11" N 78 5' 57" W You may use the back of this page io 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
Atlach well construction record(s)ifavallable.For multiple injection or non-water supply wells
ONLYwith 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-2A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.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:
6d.Water level below ground surface: 12.02 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Celnter,Raleigh,NC 27699-1636
NA 10c.For Water Sunnly&Iniectionl Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county rhealth department of the county where
6E Inner casing/tubing length(if known): 15 (ft) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016