Robeson_Well Abandonment_20240119 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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
4548 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wat j emaining in well(s): 1.15 (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,State,Variance,etc.)if known
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 ! e Bentonite Clips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slung ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 26 Ibs of Bentonit&
❑Aquifer Storage and Recovery ❑Salinity Barrier �:
❑Aquifer Test ❑StormwaterDrainage
10 Ibs of concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
El Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
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4.Date well(s)abandoned: 09/28/2023 JAN 1 9 '2G24
5a.Well location:
Johns Citgo Service 00-0-0000021055 U i tl ivR....r•^•
Facility/Owner Name Facility M#(if applicable) S.Cer.1iticatio..
211 N Main Street, Red Springs, NC { 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contmctorbr a Date
Robeson 9348-583-9600
By signing this form,I hereby wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C�:0100 or 2C.0200 Well Construction Standards
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
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(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.49664 N 79.105445 `1, 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 WELMS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
well construction record(s)ifavailable.For multiple injection or non-water supply wells,
ONLYwith 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#: G M W-4 abandonment to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18.30 (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:
11 .23 Division of Water Resources,;Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service'Ceniter,Raleigh,NC 27699-1636
n/a 10c.For Water Sunuly&Iniectio i Wells: In addition to sending the form to the
6e.Outer casing length(if lmown): (ft.) 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): 10 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30.. North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016