Wayne_Well Abandonment_20240311 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. W e rley 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:OAe
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 .06 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: WM0701289
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):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic a Neat Cement Grout 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
❑Itri 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 Neat Cement -30 I b s
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑AquiferTest ❑StormwaterDrainage Bentonite -r25 IbS
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite - gravity feed from 20 to 5 ft bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
3/1/2024 Neat Cement - pour from 5 ft bs.to surface
4.Date well(s)abandoned: �. f�L ( V i.�
5a.Well location: Mf`I`^p j 1 LGZ�
Prop Wawa Goldsboro N/A
Facility/Owner Name Facility[Dti(if applicable) 8.Certification: tft(G'
2608 Medical Office Place, Goldsboro, NC 27534cil�
3 S zoZy
Physical Address,City,and Zip Signature ofCcrtifred We ontractor or Well Owner Date
Wayne 3610127533 By signing this.fortn, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 lavlong is sufficient) 9.Site diagram or additional well details:
35.401083 N 77.954034 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 well construction record(s)ifavailable. Formultiple injection or non-water supply wells
ONLY with the same construction/abandonment,von can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-2 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: 6.25 (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: 1 3.53 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Infection 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): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016