New Hanover_Well Abandonment_20240306 (8)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
r
Scott M. Werle '
y 7a.For Geoprobe/DPT or Closedr'Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GWi 30 is needed. Indicate TOTAL NUMBER of
3344-A
wells abandoned:o^e I
,
NC Well Contractor Certification Number 7b.Approximate volume of wate i remaining in well(s): 0'68 (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,Count),.State, Variance,etc.)ifknoivn I•
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 ® Bentonite Chips or Pellets
❑Gcothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I ❑ 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 ❑GroundwaterRemediation Neat cement —20 Ibs
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite 20 �bS
---
[]Experimental Technology ❑Subsidence Control I
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: 2/19/2024 �
5a.Well location: �� I
Richard Yang 00-0-0000035295 MAR 0
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Facility/Owner Name Facility ID#(if applicable) 8�ation: I
7617 Carolina Beach Roads° "tc°'r�'� r" ' v
pa
, , ��� 2/26/2024
Physical Address,City,and Zip Signature of Certified cll ntme or or Well Owner Date
New Hanover R08514-003-006-001 j
By signing this.forin, 1 hereby cert� that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 154 1VC4C 02C 10100 or 2C.0200 6Vell 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.4284419 N -78.0624517 `,l, 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 recor (s)tfavailabie. Formultiple injection ornon-watersupply ivells
ONLY with the same construction%abandonment,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft) 1617 Mail Service'Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6.25 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: 7.80 (ft.) Division of Water Resources=Underground Injection Control Program,
1636 Mail ServicelCenter,Raleigh,NC 27699-1636
t
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Inject i 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
6L Inner casing/tubing length(if known): 2 (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
1

i .-
WELL ABANDONMENT RECORD For Internal Use ONLY: y
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
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0'71 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
W M 0801240 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc)iftmown
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 @9 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: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat cement —20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite �20 ibS
❑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) Bentonite - gravity�feed from 12 to 5 ft bgs
Neat cement - pour from 5 ft bgs to surface
4.Date well(s)abandoned. 2/19/2024 rr-..i+-..
5a.Well location: 16"
Richard Yang 00-0-0000035295 '1
Facility/Owner Name Facility ID#(if applicable) frcation:
7617 Carolina Beach Road °7 "a`;�'' � /26/2024
, Qi-- -
Physical Address,City,and Zip Signature of Certified Wriltractor or Well Owner Date
New Hanover R08514-003-006-001 1 1
By signing this form, I hereby certify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well 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 wellldetails:
35.4284419 N -78.0624517 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 welt consn•ttction records)ifavailabte.Fot•nudtipte injection or non-watersttpplt•welts
ONLY with the same construction/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-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 6.25 (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: 7.64 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.)
N/A loc.For Water Supply&Iniectio"n 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.)
Fomi GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016