New Hanover_Well Abandonment_20240306 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
f
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 GV1 30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:°°a 1
NC Well Contractor Certification Number 7b.Approximate volume of waterlremaining in well(s): 0.70 (gal.)
ECS Southeast, LLC 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)ijknown
7d.Amount of disinfectant.used:
3.Well use(check well use):
1 Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑MunicipaUPublic 19 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout r ❑ Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout I ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
®Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat cement -20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite �20 Ibs
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite - gravity feed from 12 to 5 ft bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Neat cement - pour from 5 ft bgs to surface
4.Date well(s)abandoned: 2/1 9/2024 .,.
1.d 1.
5a.Well location: T
Richard Yang 00-0-0000035295 I
Facility/Owner Name Facility ID#(if applicable) 8. rtifieation:
7617 Carolina Beach Road Dvia)n r 2/26/2024
Physical Address,City,and Zip Signature of Certified WeNk Cont for or Well Owner Date
R08514-003-006-001
New Hanover By signing this form, 1 ereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C 10100 or 2C.0200 IVell Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.4284419 N -78.0624517 " 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
Aaach well constriction record(s)ifavailable.For multiple injection or non-watersnpply wells
ONLY ivith the same coatsi-nction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service iCenter,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6.25 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: 7.72 (ft.) Division of Water Resources Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NIA (ft) 10c.For Water Suaaly&Iniecti I on 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
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Forni GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016