Johnston_Well Abandonment_20240212 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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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/(ter property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2354 wells abandoned:one I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.72 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifknoum
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 IN Neat Cement Grout C Bentonite Chips or Pellets
❑Geothenmal(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: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite ~ 25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Neat Cement ~30 lbs.
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer i
❑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
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5a.Well location:
Triple B#32 - Mast, LLC NA '
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5842 NC Highway 42 Garner, NC 27529Q 2- /S z y
Physical Address,City,and Zip Signature of Certified Well Con for I r Well Owner Date
Johnston 06DO1008B By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C i0100 or 2C.0200 Well 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:
(if well field,one IaUlong is sufficient) 9.Site diagram or additional well details:
35.60142539 N -78.57479442 �� 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 ivcll construction recor (s)if available.For multiple injection or non-watersupply wells
ONLY with the scone construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW04 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 Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 14.48 (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 Suaaly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit pne copy,of.tlusJ9 'Win 30 days of completion
of well abandonment to the;'edu y(�ie"l dui�t t'o the county where
6f.Inner casing/tubing length(if known): (ft.)
10 abandoned. �•
FEU 1 2 2024
6g.Screen length(if known): 15 (ft.) WO IAR✓ uklil P=46*iRg UW
DWOM00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016