Bertie_Well Abandonment_20240119 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILSI
Justin Radford 7a.For Geoprobe/DPT or Closed-Io Ip 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
3270-A wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water e i aining in well(s): 2.91 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 1
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown I
7d.Amount of disinfectant used: i.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply).
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout I X Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ,I ❑ 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)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above;provide amount of materials used:
i
❑Aquifer Recharge ❑GroundwaterRemediation 40 Ibs of Bentonite is
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 Ibs Concrete
❑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) Pour
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r; : � 9 %,
4.Date well 01/04/2024 AN s)abandoned: I, �G74
5a.Well location:
Perrytown Service Center 00-0-0000022792 ; t: r•'=
Facility/Owner Name Facility ID#(ifapplicable) S.Certification: j
526 Sand Hill Road, Colerain, NC !; 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or WeII Owner Date
Bertie 3801-1432-6555 B signing this otin, I hereby certi I that the wells ivas ivere abandoned in
Y S S .r Y fY �� � �
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beeA,provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1,
(ifwell field,one fat/long is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 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 wellconstructionrecord(s)ifavailable. For multiple byection or non-watersupply wells
ONLY tivit/t 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#: M W-4 abandonment to the following:
Division of Water Resource s,'Information Processing Unit,
28.22 1617 Mail Service Center;Raleigh,NC 27699-1617
66.Total well depth: (ft.) .
10b.For Inieetion Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
10.34 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center;Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Inieetion 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
6E Inner casing/tubing length(if known): 24 (ft.) abandoned.
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6g.Screen length(if known): 5 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016