Jones_Well Abandonment_20231113 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT.DETAILS
William J. Miller
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
2927A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):. (gal:)
CATLIN. Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well constriction permits(i.e.UIC,County,State,Partance,e'tc.)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 El Neat Cement Grout ® Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
OIndustrial/Commercial ❑Residential Water Supply(shared) ❑,Concrete Grout ❑ Drill Cuttings
NIrri anon ❑.Specialty Grout = ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ' ❑ Other(explain under 7g)'
❑Monitoring ; []Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater"Remediation 10:13ags of Bentonite i, 500'Ibs of•_Bentonite
El 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 Retum)'. . ❑Other(explain under 7g) Well was filled Wlth bentOrllte chips t0 within 1 foot
of the surface T-
i..;.
11/01/2023
4.Date well(s)abandoned: t9'
5a.Well location: 3
Sunland:Builders -
Facility/OwnerName Facility lD#(ifapplicable) 8.Certification: [,',•,•'iy.,•'
Belgrade.Swahsboro Rd., Maysville; NC28555 11/7/2023
Physical Address,City,and Zip Signature of Certified Well Contractor oi•Well Owner Date
JONES
By signing this form, 1 hereby certify that the ivell(s) was (were) abandoned in
County Parcel'Identification No.(PIN) accordance ivith 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the tivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field;one.lathong is sufficient) 9.Site diagram or additional well details:
34.88300 N -77.23022 N 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&BEING ABANDONED .. SUBMITTAL INSTRUCTIONS
Attach tivell cotistruction record(s)ifavailable.Fo multiple injection or non-tii,alersirpply wells
ONLY with the same bonstructionlabandonment,yori can submit one form.
10a: For All Wells: Submit this form within 30 days of completion of well .:
6a.Well ID#: Supply_We11-2 abandonment to the following:
Division.of Water Resources;Information Processing Unit,
6b,Total will depth: 80.20 (ft.) 1617 Mail Service Center,Raleigh;NC 27699-1617
10.b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) above; also submit one copy of this form within,30 days of completion of well
abandonment to the following: 1
Gd.Water level below ground surface: 17.22 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
Ge.Outer'casing length(if known): (ft.) 10c.For Water Supply&Iniection 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
611 Inner casing/tubing length(if known): A) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016