Richmond_Well Abandonment_20240205 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 7a.For Geoprobe/DPT or Closed-L!otip Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:one 1
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name None
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A '
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflorown None
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 a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ 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 ❑Groundwater Remediation Neat Cement Grout 6 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
Bentonoite 20 Pounds
❑Aquifer Test ❑StormwaterDrainage
❑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) Grout well in place.
Remove manhole and concrete pad.
4.Date well(s)abandoned: 1-22 8t 1-23-24
5a.Well location:
CSX Transportation-Hamlet Yard
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
803 NC Hwy 177, Hamlet, NC 28345 FCD 0 2024 1-24-24
Physical Address,City,and Zip Signature of Certifiedlwej F,g gRcj9r,,,6-WeI1,Qtvnerj UFA Date
Richmond I�t:rc.:
By signing this forin, I hereby certfry 11tar the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well 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:
34.894380 N -79.689101 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 records)ijavailable.For multiple hyection or non-water supply wells
ONLY with the same construcnoWabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-19 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 48.5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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:
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6d.Water level below ground surface:
30 (ft.) Division of Water Resources,Underground Injection Control Program,
,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): None (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one c6py 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): 38.5 (ft) abandoned.
6g.Screen length(if known): 10 (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
Jeffrey Grant 7a.For Geoprobe/DPT or Closed- fop 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
4328-B wells abandoned:one
NC Well Contractor Certification Number 7b.Approximate volume of waterIrei aining in well(s): IC (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLSIONLY:
Company Name Norae
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown !'Non e
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 S Neat Cement Grout IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ 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 ❑Groundwater Remediation Neat Cement Grout 70 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
BentOnOlte 350 Pounds
❑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) Grout well in place.
Remove manhole and concrete pad.
4.Date well(s)abandoned: 1-22 & 1-23-24
5a.Well location:
ii,�_r.• b�.4
CSX Transportation-Hamlet Yard
Facility/Owner Name Facility ID#(if applicable) 8.Certification: FED 0 5 2024
803 NC Hwy 177, Hamlet, NC 28345 In;-M: 11;i i 1.� - :;;. �1;: 1-24-24
Physical Address,City,and Zip Signature of Certified Well Contractor or if owrW Date
Richmond
By signing this form, I hereby certify that the the//(s) was(Were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.894380 N -79.689101 `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 WELLS)BEING ABANDONED
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
SUBMITTAL INSTRUCTIONS
ONLY with the sane constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-20 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 55 (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: (in.)
above,also submit one copy of this,,form within 30 days of completion of well
i •
abandonment to the following: r
i
6d.Water level below ground surface:
30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
None (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
6E Inner casing/tubing length(if known): 38.5 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016