Bertie_Well Abandonment_20240119 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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-30 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: {
NC Well Contractor Certification Number 7b.Approximate volume of water ie i aining in well(s): 12.80 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
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Company Name • 7c.Type of disinfectant used: {
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.)iflawwn
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 El Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) El 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)
XMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 250 Ibs of Bentonite'
❑Aquifer Storage and Recovery ❑Salinity Barrier 50 Ibs Concrete
❑Aquifer Test ❑Stormwater Drainage {
❑Experimental Technology ❑Subsidence Control r
7g.Provide a brief description of the abandonment procedure:
❑Geothernal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour iI
4.Date well(s)abandoned: 01/04/2024
5a.Well location: ! '
Perrytown Service Center 00-0-0000022792
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Facility/Owner Name Facility IDlt(ifapplicable) 8.Certification: ;dL. -',DG
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bettie 3801-1432-6555 By signing this form, I hereby cert �that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.010Q or 2C.0200 Well Construction Standards
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56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been p vided to the well owner.
(ifwell field,one lavlong is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 W You may use the back of this page tol,provide additional well site details or well
abandotment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL'INSTRUCTIONS II
Allach well construction record(s)ifavailable. For multiple injection ornon-watersupplywells {
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
RW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25.47 (ft.) 1617 Mail Service Center;Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
i6 alrove,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (n.)
abandonment to the following:
6d.Water level below ground surface: 8.32 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,l Raleigh,NC 27699-1636
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6e.Outer casing length(if known): n/a (ft.) 10c.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 i health department of the county where
6E Inner casing/tubing length(if known): 3 (ft.) abandoned.
6g.Screen length(if known): 25.5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j I Revised 2-22-2016
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