Bertie_Well Abandonment_20240119 (12)

WELL ABANDONMENT RECORD For Internal Use ONLY: p
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
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 1 GW-36 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: I i
NC Well Contractor Certification Number 7b.Approximate volume of waterI reimaining in well(s): .67 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS IONLY:
Company Name
7c.Type of disinfectant used: �
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifb-no,vn
7d.Amount of disinfectant used:1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal(Public ❑Neat Cement Grout R Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ; ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 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 oft,he abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
P Z 01/04/2024
4.Date well(s)abandoned:
5a.Well location: JA'q Z024
Perrytown Service Center 00-0-0000022792 In;,r„�r.i .,r,,,
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
a oc
526 Sand Hill Road, Colerain, NC ; c�'
01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 By signing this fon», I hereby certify that the ivell(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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:
(if well field,one hit/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 alsojattach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-waler 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#: MW-23 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth:
13.31 (ft.) 1617 Mail Service Ce il nter,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 firm within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 9.1 7 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cent i r,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): n/a (ft) loc.For Water Supply&iniection4ells: 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): 2 (ft.) abandoned.
6g.Screen length(if known): 13 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I' op Geothermal Wells having the same
Justin Radford
7a.For Geoprobe/DPT or Closed-Lc
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW j30 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water ire i aining in well(s): 0.62 (gal.)
Geological Resources, Inc. FOR WATER SUPPLYWELLSIONLY:
Company Name 7c.Type of disinfectant used: f
2.Well Construction Permit#: N/A II
List all applicable ivell construction permits(i.e.UIC County,State,variance,etc.)ifknown
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 GroutA 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 ❑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:
❑Aquifer Recharge ❑GroundwaterRemediation 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 the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) "
4.Date well(s)abandoned:
01/04/2024 VP_ ,
e�
Sa.Well location: I �� 1 9 1024
Perrytown Service Center 00-0-0000022792
Facility/Owner Name Facility ID#(if applicable) 8.Certification: i� ��^es,?�Um j'j
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, 1 hereby certify that the tvell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0160 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: I!
(ifwell field,one lat/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 well construction record(s)ifavailable.For multiple byection or non-watersupply wells
ONLY with the same constructia✓abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-25 abandonment to the following:
I
Division of Water Resources;Information Processing Unit,
6b.Total well depth: 14.05 (ft) '1617 Mail Service Cer"ter,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:
I ,
6d.Water level below ground surface: 10.26 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft) 10c.For Water Supply&Infection W Ills: 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 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I 1 Revised 2-22-2016