Brunswick_Well Abandonment_20240318 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 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
4629C wells abandoned:
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): �'27455 ( al 1
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.(11C,('ounty,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 ❑Municipal/Public ❑Neat Cement Grout N 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 18.99 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Topsoil 14 Ibs_
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) Well pad was removed from ground. Casing was left
in ground with the top cut off. Hydrated bentonite
a.Date well(s)abandoned: 2/27/2024 was used to fill casing. Topsoil was added on top
5a.Well location: to bring opening to grade.
Glenn Parker Property
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
7102 Ocean Hwy West. Sunset Beach, NC 28468 `` - 2/29/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Datc
Brunswick By signing this form, /hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0l00 or 2C.0? Q hell Construction Standards
and that a copy of this record has been providede well o�veTPr. -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l t � •Z� j
(if well field,one lat/long is sufficient) t V
9.Site diagram or additional well details: AA''
33.94684142261145 N -78.50255376332889 `1 You may use the back of this page to provide addit'f6Wt'wtll jute js or well
abandonment details. You may also attach additional pages if n�7ce
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED `
SUBMITTAL INSTRUCTIONSUJIN
Attach wellconslrucuonrecord(s)ifavaifable. For multiple in/ecuunornon-w titer supply wells ���3�
ONLY with the some construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
61b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 276"-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 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: 5.54 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276"-1636
6e.Outer casing length(if known): NA (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): 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