Brunswick_Well Abandonment_20240514 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor MIZ@Ile 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
4629-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4'3 (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.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materi'15'used-(check,a)1-'that apply):
❑Agricultural ❑Municipal/Public El Neat Cement Gr �,r,,,R.;�y;". �•1)entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout A� i ❑ 6'ry'Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout MAY t 20240 Drill Cuttings
❑Irrigation ❑ Specialty Gr9 ry : ❑Gravel
Non-Water Supply Well ' t by
• ❑ Bentonite Slurry [)��'f3;�� =�`bther(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,!provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets 23 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Topsoil P 25 lb
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well abandoned in place with hydrated bentonite
pellets and topped with topsoil to existing grade.
a.Date well(s)abandoned: 4/30/2024
Well shield and pad removed.
5a.Well location:
NCDEQ-Varnamtown Contry Store Unknown
Facility/Owner Name Facility ID#(if applicable) S.Certification:
325 Varnamtown Rd., Supply 28462 Certification:
�� 5/2/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Brunswick NA
By signing this form, 1 hereby certify,that the ivell(s) ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0106 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
33.9416019739221 N -78.24007568281651 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. For multiple in jection ornon-iratersupply tine/is
ONLY with the same construction aba tionnent,you can submit one fornn.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.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 forrri within 30 days of completion of well
abandonment to the following:
i
6.44 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (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
6f.Inner casing/tubing length(if known): 5 (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