Onslow_Well Abandonment_20231215 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 7a.For Geoprobe/DPT or Closedi 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-30 is needed. Indicate TOTAL NUMBER of
3344—A wells abandoned:0-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 '00_(gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
�`z..•a�� •� :.
2.Well Construction Permit#: WM0801185
List all applicable well construction permits(i.e.UIC.Counn,State.Variance,etc.)iflatown
7d.Amount of disinfectant used: DE
3.Well use(check well use): it I i1criz—,
Water Supply Well: 7e.Sealing materials used(check all that apply): ►�,{:V❑Agricultural ❑Municipal/Public IN Neat Cement Grout a Bentonite Chips or P'c5ts
❑Gcothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
r
❑Industrial/Conmiercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply=Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
IMMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite — 20 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement ~ 25 Ibs
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite - gravity feed from 15 to 5 ft bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Neat Cement- pour from 5 ft bgs to ground surface
4.Date well(s)abandoned:
11/28/2023
5a.Well location:
C&D Motors
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2227 Lejeune Blvd Jacksonville ,F 12.4.2023
Physical Address,City,and Zip Signature of Certified Well C o tractor or Well Owner Date
Onslow 018866
By signing this form, I herebv certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C 10100 or 2C.0200►Yell Construction Standards
and that a copy q/'this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
364329.46 N 2492428.52 �� _ 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
Alrach well comstt•uction record(+)ifnvailable. For multiple injection at,non-warersepply ivells
ONLY with the.sanre cotalruction/abanrlonrmcnt,von can submit one.(rrnt.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (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: 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: 8.96 (ft.) Division of Water Resourcesi Underground Injection Control Program,
1636 Mail Service Fenter,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft.) 10c.For Water Supply oc 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): 5 (ft.) abandoned.
I
6g.Screen length(if known): 10 (ft.)
Forrr GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016