Johnston_Well Abandonment_20240212 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 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
2354 wells abandoned:one
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.65 (gal)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
I
CompanyName 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U1C,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 C Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout j ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I ❑ Drill Cuttings
i
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite — 25 lbs..
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement —30 lbs.
❑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) Gravity feed bentonite chips to 5' bgs
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 01/26/2024
5a.Well location:
Triple B #32 - Mast, LLC NA
Facility/Owner Name Facility lD#(if applicable) 8.C tification:
5842 NC Highway 42 Garner, NC 27529 Z s z
il
Physical Address,City,and Zip Signature of Certified We Co ractor'or Well Owner Date
Johnston 06DO1008B i
By signing this form, 1 hereby certify that the well(s) was (were) abandoned ill
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C 10100 or 2C.0200 IVell Construction Standards
and that a copy of this record has'een provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rfwell field,one lat/lon is sufficient)
( g 9.Site diagram or additional well details:
35.60159717 N -78.57463635 �` 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 cmrsu•nction record(s)ifavailable. For multiple injection or non-walersapply wells
ONLY with the same construction/abandonment,voa can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface:
14.87 (ft.) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
NA (ft.) 10c.For Water Supply&Injection 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 c ty ea tdepartment of the county where
6f.Inner casing/tubing length(if known): 10 (f.) abandoned. 8 'P j:� V L(
15 FEB 1 2 20Z4 ••+
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water ResourcI s ��' Revised 2-22-2016