Brunswick_Well Abandonment_20231101 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAIILS
Joseph L. Zuncich 7a.For Geoprobe/DPT or ClosedlLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 6W-36 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, P.C. FOR WATER SUPPLY WELLSIONLY:
Company Name
7c.Type of disinfectant used: 1
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)tfknown
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 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
❑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 90 pounds bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier l
❑Aquifer Test ❑Stormwater Drainage i
❑Experimental Technology ❑Subsidence Control 1
[]Geothermal(Closed Loop) []Tracer7g.Provide a brief description of the abandonment procedure:
❑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 to round surface.
5a.Well location:
Jones Holding NC LLC N/A
Facility/Owner Name Facility lD#(if applicable) 8.Certification: NOV J 2023
3917 Committee Dr, Southport, NC 28461 G �^ -� �....
City,Ph sical Address, J
Y and Signa of Ce ed Well Contractor or ell Owner — Date
Brunswick 207818318681 By signing this form, 1 hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has beer
(if well field,one lat/long is sufficient) 9.Site diagram or additional well detprovided to the well owner.
ails:
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
Attaelt well consinociton record(s)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same constructionlabandomnent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: PZ-1 B abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 1617 Mail Service Center,Raleigh,NC 27699-1617
5 7/8 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: above,also submit one copy of this form within 30 days of completion of well
(in.)
abandonment to the following: i
6d.Water level below ground surface: 20.49 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centl r;Raleigh,NC 27699-1636
6e.Outer casing length(if(mown): NA (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
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 of Environmental Quality-Division of Water Resources !• Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY:
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 I 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): NIA al.)
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 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
❑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 I
❑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 and concrete
a.bate well(s)abandoned: 10/18/23 ,pad. Remove 3' of well casing
Seal well with bentonite'to ground surface.
5a.Well location: _ — Y i
I '•c+.R„.�.rr*r E,. �r 'fit/' �:..,�,�
Jones Holding NC LLC N/A NOV J 12023
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
3917 Committee Dr, Southport, NC 28461 -,,0/20/23
Physical Address,City,and Zip Sign a of C led Well Contractor oi,Well Owne '1 �U~Date
Brunswick 207818318681 By signing this form, I hereby certo that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.(10.0 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well Iditails:
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 avel/constnrctionrecord(s)ifavailable.Formultiple 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-1A 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
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (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: 10.54 (ft.) Division of Water Resources,underground Injection Control Program,
1636 Mail Service Ceenter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Sunaly&Infection 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): 15 (ft.) abandoned.
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6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Enviromnental Quality-Division of Water Resources i Revised 2-22-2016