Chatham_Well Abandonment_20240423

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 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
4630C 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 permits(i.e.UIC,County,State, Variance,etc)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipali'Public ❑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 $,:D pall Cuttings
❑Uri ation ❑Specialty Grout li n'114vel
Non-Water Supply Well: ❑Bentonite Slurryp t' a Other ex lain under 7
SMonitoring ❑Recovery APR L�2 ( p g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 150 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Soil 501bs
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geotherma((Heating/CoolingReturn) ❑Other(explain under7g) Hydrated bentonite was used to fill and seal to one
foot below land surface. Well shield and concrete were
a.Date well(s)abandoned: 3/28/2024 removed along with six feet of casing. The remaining
5a.Well location: opening was filled with native soils to ground level.
Robert and Kimberly Wagner Unknown
Facility/Owner Name Facility ID#(ifapplicable) 8.Certitication:
2343 New Elam Church Road, New Hill, NC 27652 ii 04-10-2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Chatham 0005786
By signing this form, /hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with!SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field.one lat'long is sufficient) 9.Site diagram or additional well details:
35.660037 N -79.040221 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)(available. For multiple injection or non-a-atersupply wells
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#• MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 86 (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- 8.25 (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: 49.20 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Supply&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
6C Inner casing/tubing length(if known): 26 (ft.) abandoned.
6g.Screen length(if known): 60 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

�C"
FORMER
Al" MW-1
FORMER
PUMP ISLAND
�I
i
WSW-1
d WS,W-1A
LEGEND
® Abandoned Monitoring r
Well (Type II)
© Inactive Potable
Water Supply Well
® Abandoned Non-Potable
Water Supply Well
DApproximate Location
of Former UST System
® Parcel Boundary
WSW-6
Source:E- Ma,, , EaRhstarfGeographics,and the GIS User Com'
NOTE: Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 40 20 0 40 80
Feet
PROJECT MABLEBURTON TITLE FIGURE
PROPERTY
ATLIN 2343 NEW ELAM SITE MAP
CCHURCH ROAD
Engineers and Scientists NEW HILL, INC
INCIDENT NO JOB NO DATE SCALE DRAWN BYICHECKED BY
46077 221041 APRIL 2024 AS SHOWN KMC/SJO