Beaufort_Well Abandonment_20231228 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
l� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or III owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
I I wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
f�< CC.� FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: H H
2.Well Construction Permit#:
List all applicable well consmiction permits(i.e.UIC,CosntR State,Variance,etc.)ifknown
7d.Amount of disinfectant used: 141
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ri;'Kat Cement Grout ❑ Bentonite Chips or Pellets
❑G��e++othermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I ❑ Dry Clay
Nfndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete GrouRECE1,"VED
`'9 ill Cuttings
❑irri ation ❑ Specialty Grou avel
Non-Water Supply Well: ❑Bentonite Slurry s 2023 ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each vc ov► a amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation �^� M V" /�S�
❑Aquifer Storage and Recovery ❑Salinity Barrier J
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) I ' O1AL i
[[�� e
4.Date well(s)abandoned:_ A' D`2
`}t Wt�' ot I t t✓
5a.Well location:
C
tj-r BUS
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
]530 A&I (twv 3065 QZU6A I,/I i /;Q- IF- 9-�
Physical MIT.City, d Zip( Signature of-Irtifig Well Contractor or Well Owner Date
far signing this rnr, 1 hereby certify that the ivell(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance frith 1 SA 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 beer provided to the well owner.
(if well field,one lat/long is sufficient // d �/ 9.Site diagram or additional well details:
n 33 5b N �O c D J(� ��, 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 IN`iTRUCTTONS
Attach well constntction record(.)ifavailable.Formulliple v jection ortion-watersupply wells
ONLY with the same consttxction•abrmdonment,)•otr can submit one forms.
�� � 10a. For All Wells: Submit this form within 30 days of completion of well
ID 6a.Well # abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: '.r (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: (in•) above. also submit one copy of tliis form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (D) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
addresses)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(f known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcest Revised 2-22-2016
r

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
' I ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
t:15� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or w 1 owner personalty abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well ++``Well Contractor Certification Number 7b.Approximate volume of water remaining in wetl(s): (gal.)
` E'[ A FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: i' i-
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown l
7d.Amount of disinfectant used: I L1191
3.Well use(check well use):
Water Supply Well: 7e.Sea ring materials used(check all that apply
❑Agricultural ❑Municipal/Public &4at Cement Grout W13entonit,Chips or Pellets
❑Geo ermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
�ndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ 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 ❑Groundwater Remediation ©—K+' ��tJ�w i e
❑Aquifer Storage and Recovery ❑Salinity Barrier tJ f' J
❑Aquifer Test ❑Stormwater Drainage of� `'Z5
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ! l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) C "'tvvT U ri '
d.Date well(s)abandoned: �1
GUJ t �'�!rl 4 i e
Sa.'4Velllocation: ('T , t_LLCtr ,EIVLD
tll.'A C
Facility/Owner Name Facility IDb(if applicable) 8.Certification: DEC 8 2023
Nv�\/ ik won PLOC skm�t Ij-;3
Physical Ad ss,City,and Zip Signature o ertified ell Contractor or Well Ou Date
AAv signing this form, I hereby cert(�that the ivell(s) was(here)abandoned in
ounty Parcel Identification No.(PIN) accordance with 15A 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 ire//owner,
(if well field,one latllong is sufficient) 9.Site diagram or additional welt details:
L�-3 ` W You may use the back of this page to provide additional well site details or well
N
/ abandonment details, You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAI,INSTRUCTiONS
Attache•eticanspxrtinnrernrd(s)ifaruilable.For ma/tipleirjectionor non-mver supply wells
O YLY with the same consrrrrcrionhhabandonmenr,you can submit one Jorm. 10a. For All Wells: Submit:this form within 30 days.of completion of well
6a.Well ID#: Is-Ii'�•� Vi c abandonment to the following:
r�
Division of Water Resources,Information Processing Unit,
6b.Total well depth: rqaS7 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1 .
U 10b.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: -1 (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: '
is
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Sunniv&Iniecti I n Wells: In addition to sending the form to the
address(es)above,also submit onelcopy 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.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I'