Bertie_Well Abandonment_20240119 (8)

WELL ABANDONMENT RECORD
For Internal Use ONLY: �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 7a.For Geoprobe/DPT or Closed-Lol p 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
i Q
NC Well Contractor Certification Number 7b.Approximate volume of water re j aiuing in well(s): 0'78 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc)iflarown
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 N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 6 ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring El Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 Ibs of Bentonite;
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 Ibs Concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of tli'e abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) •❑Other(explain under 7g) 7 y " --
4.Date well(s)abandoned: 01/04/2024 9 2024
5a.Well location: I, In,;;;;,;�
Perrytown Service Center 00-0-0000022792
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
i
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 By signing this form, I hereby certify that the ivell(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one hit/long is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 `,l, 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 nndliplehjectionornon-water supply wells
ONLY ivilh the same construction/abandonntent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
M W-5 abandonment to the following:
'
I'
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14.40 (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: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
9.61 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.) loc.For Water Supply&Infection 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): 5 (ft.) abandoned.
;y
6g.Screen length(if known): 10 (ft.) i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i -
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 7a.For Geoprobe/DPT or Closed-Loop p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on histher property) well construction/depth,only I GW-30 pis needed. Indicate TOTAL NUMBER of
3270—A wells abandoned: II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.00—(gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: i�
2.Well Construction Permit#: N/A ;I
List all applicable well construction permits(i.e.UIC,County,Slate,variance,etc.)ifknotivn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
i
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heatiug/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 Ibs of Bentonite i.
❑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 Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) `
!i .r.• ' Li
4.Date well(s)abandoned: 01/04/2024 JAN
9 2024
5a.Well location: c
Perrytown Service Center 00-0-0000022792 a,Y '�,�W -
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 By signing this form, I hereby certify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 a•2C.0200 Well Construction Standards
and that a copy of this record)nas been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one iaUlong is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 W You may use the back of this page t6 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 ornon-water supply wells
ONLY with the same construction/abandomnent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14.97 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 above,also submit one copy of this form within 30 days of completion of well
(in.) abandonment to the following:
8,82 Division of Water Resources,Umle(ground Injection Control Program,
6d.Water level below ground surface: (ft.) i
1636 Mail Service Center Raleigh,NC 27699-1636
6e.Outer casing length(if known):
n/a (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
6E Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 10
Form GW730 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016