Durham_Well Abandonment_20231101 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Scott M.. Werley 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-k is needed. Indicate TOTAL NUMBER of
3344—A wells abandoned:
NC well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): O'5 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name i
WM0501585 7c.Type of disinfectant used:
2.Well Construction Permit#: r
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc)iflazown
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 ! e Bcntonite Chips or Pellets
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout i ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑ItTi ation ❑ Specialty Grout ! ❑ Gravel
Non-Water Supply Well: ❑ Bcntonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation bentonite -- 10 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) remove well screen, pouribentonite, and cover with cuttings
4.Date well(s)abandoned: 1 O/9/ZO23 u 119r7
5a.Well location: U - 023
IBM N/A
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: UViE 1G
4205 S Miami Blvd, Durham 27703 10/19/2023
Physical Address,City,and Zip Signature of Certified Well Contmcto r Well Owner Date
Durham 157755 & 157802
By signing this/brut, I hereby certify that the 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
.845752 W You may use the back of this page to provide additional well site details or well
35.899211 N -78
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.Fornaitiple injection ornon-ivrttersnpply wells
ONLY with the.same consttruction/abandonntent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-1 abandonment to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: 4.O (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 3.25 above, also submit one copy of this form within 30 days of completion of well
(►n.) abandonment to the following:
0.5 Division of Water Resources Underground Injection Control Program,
6d.Water level below ground surface. (ft.)
1636 Mail Service(Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): (ft.) loc.For Water Suaaly&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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
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6g.Screen length(if known): 4'0 (ft.) i
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016