Wilson_Well Abandonment_20231229

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
HENRY NEMARGUT 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-rater supply wells ONLY with the .same
construction abandonment,you can submit one form.
3426-A
7b.Approximate volume of water remaining in w ell(s): 2 gal (;;al)
NC Well Contractor Certification Number
HENRY NEMARGUT ENGINEERING SERVICES FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: �i /L r°"1
2.Well Construction Permit#:List all applicable well permits(i.e.Coun(v,State,Variance,Injection,etc)tfknown 7d.Amount of disinfectant used: DEC 2 9 2073
3.Well use(check well use): M1fiX71.A:i2D 7r,,« r�tJFJ
Water Supply Well: 7e.Sealing materials used(check all that apply): DWQ•31
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout O Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery_
Injection Well: 7f.For each material,elected Am%e.provide amount of materials used:
❑AquiterRecharge ❑GroundwaterRemediation 0.5 bags of bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite pellets were poured into the well to top of casing,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
saturated with H2O then capped with cement.
a. Dale mmell(,)abandoned: 12/13/23
:a.AV ell location:
Woodhaven Wilson 2, LLC N/A
FacilityiOwner Name Facility ID#(ifapplicable) g•Certification:
3601 Raleigh Road Parkway West-Wilson, NC 27896 Henry Nemargut 12/17/2023
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wilson By signing this form, l hereby certify,that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 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:
35.74518 -77.96596 You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. hbr multiple i nlecuon or non-water supply
wells ONLY with 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#: Unknown abandonment to the following:
Division of Water Resources,Information Processing Unit,
6h. rural m,cu depth: 17.5 (e.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
211 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: lin.l abandonment to the following:
Division of Water Resources,lluderground Injection Control Program,
6d.Water level below ground surface: 5'87 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 10c. For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): Unknown (ft ) where abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Enviromncnt and Natural Resources—Division of Water Resources Revised August 2013

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