Brunswick_Well Abandonment_20231101 (5)

WELL ABANDONMENT RECORD For Intern I Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joseph L. Zuneich 7a.For Geoprobe/DPT or Closed L lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW 130 is needed. Indicate TOTAL NUMBER of
3324-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water f remaining in well(s): N/A (gal.)
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Applied Resource Management, P.C. FOR WATER SUPPLY WELLS,'ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
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List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.)ii/mown
7d.Amount of disinfectant used: I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout I I 9 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: 7f.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
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❑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) 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
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 28461g�!a, NOV t ((�� .,10720/23
Physical Address,City,and Zip Si cure of ertified Well Contractor or Well Owner 2`'��ate
Brunswick 207818318681
By signing this form, I hereby certrfylthat e,3uel((� iL'as: ej;e�iabandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or k b2 l Constr ut tion 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
33 58' 16" N 78 5' 41" 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 record(s)ifavailable.rormttliiple 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-1 C abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 67 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Injection 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: I
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6d.Water level below ground surface: 21.82 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Suouly&IniectiotiWells: 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 1health department of the county where
611 Inner casing/tubing length(if known): 62 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016