Johnston_Well Abandonment_20240212 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY: i
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werle
Y 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on Iris/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2354 wells abandoned:one r
7b.Approximate volume of water remaining in well(s): 0 89 al.
NC Well Contractor Certification Number pp g (g )
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ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
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2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
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Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 19 Neat Cement Grout I' 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: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite — 20 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 Gravity feed bentonite chips to 5' bgs
❑Geothermal(Heating(Cooling Return) ❑Other(explain under 7g)
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.Cer'[cation:
5842 NC Highway 42 Garner, NC 27529 2 r/Z
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Physical Address,City,and Zip Signature of Certified Well C •tar or Well Owner Date
Johnston 06DO1008B
By signing this,%rin, I hereby cert�that the well(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 Ieen provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.60158808 N -78.57439021 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
Aaac/rivellconstrrrclionrecord(s)ifavailable. For nadtiple injection ornon-watersupplywells
ONLY nvidr the same constructionlabandonnnent,you can submit one for nn.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW05 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (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: 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: 14.53 (ft.) Division of Water Resources,IUnderground Injection Control Program,
1636 Mail Service i enter,Raleigh,NC 27699-1636
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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 and copy of this form within 30 days of completion
of well abandonment to the cc rrt njltht_#epaI tno,. e county where
6L Inner casing/tubing length(if known): 5 (ft.) abandoned.
FEB 1 2 2024
6g.Screen length(if known): 15
Fomr GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016