Hertford_Well Abandonment_20240318 (2)

WELL ABANDONMENT RECORD For Internal I se Oa Y
1.Well Contractor Information: %%'ELL AB.%NDONMEN'l DETAILS
Austin Fowler 7a.For Geoprobc'DP 1 or Closed-Loop Geothermal%%'ells having the same
%Veil Conira,tor Name(or ucll owner personalIN abantiming well on his her property) well conslniction depth,only I GW-30 i,needed Indicate TOI AL NU6IBI R of
4366-A wells abandoned
\( Well(oniractor Cenificalion Number 7b.Approximate volume of water remaining in vi ell(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.'1'3pc of disinfectant used:
2.Well Construction Permit q: N/A
List all applicabe well construction perndra(i.e.UIC,Counre.State,Variance,etc.)it Anoun
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(I feating/Cooting Supply) ❑Residential Water Supply(single) O Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Im ation O Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwatcrReutediau°n Bentonite Pellets +/- 5 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStonntvater Damage
❑Experimental Technology ❑Subsidence Control 7g•Proside a brief description of the abandonment procedure:
OGeothennal(Closed Loop) ❑Tracer
❑Gcothennal(1-lealing/Cooliit Return) LOther(explain under 7 ) All well materials removed from boring then backfilled
with bentonite pellets to surface
a.Date well(s)abandoned: 2-13-2024
Sa.Well location:
Geosyntec
Facility Owner Namc ractht)ID,4ifapphraW) 8.C cation:
100 Farmers Chemical Road, Winton, 27986 ,(�� 'Lt r—edCG4-,6' 3-5-2024
Physical Address,City,and lip Signature ofCertificd Well Contractor or Well Ouner Date
Hertford Bt signing this fibrin. I hereby ceriffi that the well(s) was(here) abandoned ui
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or-2C.0200 Well Construction Standards
and that a copy ofthis record has been provided to the well owner
Sb.Latitude and longitude in dcgrecs/ntinutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 9.Site diagram or additional well details:
36.372188 N -76.861623 W You inay 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 er ell construction record(s)iforailable. For nathiple injection ornon-iraiersoppi)uells
ONLY oidi the sane cotisiruuionlabotidonntent,you cats submit one jbrot.
IOa. For All Wells: Submit this form within 30 clays of completion of well
6a.Well IDq: C-28 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10h.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.25 (in) above,also submit one copy of this font within 30(lays of completion of well
abandonment to the following:
6d.Water lc%el belost ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mai)Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): (ft.) 10c.For%%ater Suooh•&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this fora within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft•) abandoned. -�
6g.Screen length(if known): (ft.)
MAIL 1 8 2024
Iromt G W-30 North Carolina Dcpannem of Environmental Quality•Division of Water Recou•r py�n,, �C.1 7r.-._,•y�..2 u�vised 2-22.2016
flN DWCW30113

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CATLIN REDUCED LEVEL NOTES
Engineers and Scientists
CLIENT'S CATLIN
NAME: PROJECT:
CATLIN PROJECT#: PHASE:
BENCH MARK DESC.: 13GW-161 TOC INSTRUMENT it:
ELEVATION(TBM): 100.00 DATE: ROD It: UNITS(FT./M):
POINT ANGLE DISTANCE TOP MID(-) (+) HI ELEV.(feet) CHECK(T+By2 NOTES
(degrees) (feet) BOTTOM
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
(+)=MID at TBM or BM (TOP-BOTTOM)* 100=DISTANCE
TBM+(+)=HI (TOP+BOTTOM)/2=MID (-)
HI-( )=ELEV. `A sketch must be provided with the level notes.
FIELD NOTES BY: DATE: INSTRUMENT BY:
NOTES REDUCED BY: DATE: ROD PERSON: