Durham_Well Abandonment_20231122 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 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 GW-30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned: I
� I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorox pool shock
7c.Type of disinfectant used: p
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: 6 OZ
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) PResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irti ation ❑ 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 ❑GroundwaterRemediation Clay Placed from 38' to 3' Poured in top of well
❑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(HeatinglC..ling Return ❑Other(explain under 7g) 6 oz of pool shock'followed by 8 bags of
Bentonite clay to 3.feet below land surface
4.Date well(s)abandoned: 11-10-23 Water was added while clay was poured
5a.Well location: into well for hydration of clay chips
EB Capital Partners, LLC na
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5502 Old Chapel Hill Road �� 1-10-23
Physical Address,City,and Zip Signature of Certified Well Co for or Well Owner Date
Durham 0709098651
By signing this form,I 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,;ne laUlong is;efficient) 9.Site diagram or additional well details:
35 56 45.84 N 78 59t 49.65n 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.
' i' v
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-1vatersupply wells ((��,I c� qq (n)ONLY Wilt the sa`mt�e'constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 da� N obfnp9bt?-0Q z$well
6a.Well ID#: V V_1 abandonment to the following:
Uri,l'
Division of Water Resources,Information Processin .W'g a
66.Total well depth: 38 (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: 5 (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: 28 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (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
6E Inner casing/tubing length(if known): 28 abandoned.
6g.Screen length(if known): NSA
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016