Wake_Well Abandonment_20231122 (3)

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;.WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Austin Fowler 7a.For Geoprobe/DPT or Closed-Ldop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only l GW i M is needed. Indicate TOTAL NUMBER of
wells abandoned:
4366-A
NC Well Contractor Certification Number 7b.Approximate volume of water lremaining in well(s): 384 (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS'ONLY:
Company Name Chlorine Powder
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction pennits(i.e.UIC,County,State, Variance,etc.)iflovown 12 oZ
7d.Amount of disinfectant used:' -
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustriaUCommercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials.used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete 770lbS {
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage �JU V 2
❑Experimental Technology ❑Subsidence Control r
7g.Provide a brief description of the abandonment procedure: ;�-,,
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) i.
Pump and tubing removed from from well. Casing
was left in place.Well was filled to —5 feet below land
a.Date well(s)abandoned: 10/31/2023 surface with grout. Grout was introduced by pumping
5a.Well location: Into the well.
Apex Humie Olive LLC NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification: -
2236 Old US 1 Highway, Apex, NC 27502
�i 11/6/2023
Physical Address,City,and Zip Signature of Certified Well Contractor of Well Owner Date
Wake County 0720998487 i
By signing this form, I hereby certfy that the ivell(s) ivas (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:
35.699065 N -78.898932 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 ivell consnvctio»record(s)ifavailable. For mndliple my'eclion oreon-watersupply wells•
ONLY with the same constntctionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: WSW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 300 (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: 8.25 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: i
6d.Water level below ground surface: 38.68 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Suauly&Iniecti n Wells: In addition to sending the form to the
address(es)above,also submit one bopy 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): Unknown (ft.) abandoned.
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6g.Screen length(if known): Unknown (ft)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016