Columbus_Well Abandonment_20240318 (2)

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 I 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): (gal.)
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 permrs(i.e.lift',County,State,Variance,etc.)rfknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑ Neat Cement Grout ❑ 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 S Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Prom ide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Well shield and casing was removed by excavator.
Surrounding soil collapsed into boring during removal.
a.Date well(s)abandoned: 2/12/2024
5a.Well location:
Wananish Store/Dedrick Anders Jr.
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1306 Sam Potts Hwy, Lake Waccamaw. NC 28450 2/19/2024
Physical Address,City,and/ip Signature of Certified Well Contractor or Well Owner Date
Columbus
By signing this form. /hereby certify 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 been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
34.32214936289811 N -78.50015486712041 You may use the back of this page to provide additional-wellaite details or well
abandonment details. You may also attach additional pag�tfee
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)(available. For multiple injection ornon-warer supply wells MAN 1 A
ONLY with the same construction abandonment,you can submit one form. a ��??
10a. For All Wells: Submit this form within 30 days of completion o �de4
6a.Well ID#• MW-4 abandonment to the following:
tit
Division of Water Resources,Information Processing c nlf�
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10h.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in•) above, also submit one copy of this forth within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 4.13 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 2 10c.For Water Suuoly&Injection 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
ISE Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): 13 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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MW-2
® MW-1
O TW-1
® MW-4 Mdt
M W-5
LEGEND
Monitoring Well
® (Type II) SAM POTTS HWY
® Abandoned Monitoring
Well (Type II)
OMonitoring Well
(Type III) 0
Proposed Excavation Area
❑ Approximate Location of
Former UST/AST Systems
E arttistar Geogr ph1',#,,nd the GIS User Community
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 30 15 0 30 60
Feet
PROJECT TIi_E FIGURE
WANANISH STORE
ATLIN 1306 SAM POTTS HWY SITE MAP
CLAKE WACCAMAW, NC
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BY/CHECKED BY
32108 221070 MARCH 2O24 AS SHOWN KMC/SJO