Burke_Well Abandonment_20231228

WELL ABANDONMENT RECORD For Internal Use ONLY-
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Justice 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 1 GW,30 is needed. Indicate TOTAL NUMBER of
2150 wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s):60 (gal.)
Justice Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name Clori ne
• 62238 7c.Type of disinfectant used:-
2.Well Construction Permit#:
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc)ifknown 8 OZ
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 ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) In Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑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: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2,000 Ibs pea gravel
❑Aquifer Storage and Recovery ❑Salinity Barrier 11-80 Ibs cement gravel MIX
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Chlorine ,pea gravel,eement
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) _
Ls EL ���
12/11/23 DEC 2 Q 2n2�
4.Date well(s)abandoned:
5a.Well location:
Autumn & Nathan Bell DWQM�•J-W:i
Facility/Owner Name Facility lb#(if applicable) 8.Certi cation:
2420 Corn Wallis Trail 12/11/23
Physical Address,City,and Zip Signature of Certified Well ntrac or o 11 Owner Date
Burk
By signing this form,I hereby certrfy that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
_35043.9 81. 5358.5.__ You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attac tT—additional pages if necessary:
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachwellconstructionrecord(s)ifavailable.For multiple injection ornon-water supply wells
ONLY ivith the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 120 (ft.) 1617 Mail Service Center,.Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter:6 (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:80 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):100 (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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
Gg.Screen length(if known): VL)
Form GW-30 North Carolina Department of finvironmental Quality-Division of Water Resources Revised 2-22-2016
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