Nash_Well Abandonment_20240119

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WELL ABANDONMENT RECORD For Internal Use ONLY:. •
1.Well Contractor Information: WELL ABANDONMENT DETAILS 1
Justin Radford 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 I GW-30 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.63 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: 1
2.Well Construction Permit#: N/Ali
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: II
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) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial DResidential Water Supply(shared) P Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lbs Concrete .
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) i' n '{ ;� ?(� r' `' P"^-.
4.Date well(s)abandoned: 08/8/2023 I J� 9 �l0gL4
5a.Well location: into irtz:ta1 p,.^
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New Dixie Mart #229 00-0-0000020652 n'= w"=�V:,,.; L''
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
5095 Dortches Blvd, Rocky Mount, NC (1 OA 6 Z3
Physical Address,City,and Zip Signatur f Certified ell Co actor ar ell Owner Date
Nash 335264
By signing this form, I hereby certify that the well(s)was (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:.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.012822 N 77.860330 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 well construction record(s)ifavailable.For multiple injection or non-water supply wells I`
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#: MVV-1 abandonment to the following: 1
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24.92 (ft.) 1617 Mail ServiceCenter,Raleigh,NC 27699-1617 ,
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (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: 8.76 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Servicei Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Injection 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 couhty health department of the county where
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6E Inner casing/tubing length(if known): 1 0 (ft.) abandoned.
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6g.Screen length(if known): 15 (ft) 1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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