Brunswick_Well Abandonment_20240514 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS 7
Trevor MIZeIIe 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: i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3'1 (gal.)
CATLI N Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well consiruction permits(i.e.VIC,County,Slate,Variance,etc)ifknown 1
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials gd(check all that apply):
g pGrout p t M, e'tonite Chips or Pellets
❑A ricultural ❑Munici aUPublic ❑Neat Cement "
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑UP'Clay
❑hidustriaUCommercial ❑Residential Water Supply(shared) ❑Concrete Grout MAY 1 h. 2004Drill Cuttings
❑Irri ation ❑Specialty Grout i ❑ Gravel
Non-Water Supply Well: , ne- );r.rgr,. -
❑Bentonite Slurry e''6tl•k��explain under 7g)
RMonitoring ❑Recovery CY.`6 Ca
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets 18 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Topsoil 251b
❑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.
4.Date well(s)abandoned: 4/30/2024 1
Well shield and pad removed.
5a.Well location:
NCDEQ-Varnamtown Contry Store Unknown
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
325 Varnamtown Rd., Supply 28462 ee� 5/2/2024
Physical Address,City,and Zip Signature ofCortificd Well Contractor or Well Owner Date
Brunswick NA
By signing this form, !hereby certify that the ivell(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 ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
33.9416019739221 N -78.24007568281651 11 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 it jection or non-water supply wells
ONLY with the sane corrslrirctioerabandonrrrent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition;to,sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 5.93 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
N/A (ft.) 10c.For Water Supply&Iniection 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. Ij
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 7a.For Geoprobe/DPT or Closed-L lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-3Q is needed. Indicate TOTAL NUMBER of
4629-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water reimaining in well(s): 2.9 (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.U/C,County,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 a Bentonite Chips or Pellets
or❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water SuPPIY(single) ❑ Sand CementuT~ �I _- LFDU Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout p���nV "Z'5nll Cuttings
❑hrigation ❑ Specialty Grout MAY l 2024 ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry - e Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material sei_eW'"9C@Q1 provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets 23 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Topsoil 251b
❑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#(ifapplicable) 8.Certification:
325 Varnamtown Rd., Supply 28462 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 certifythat 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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell 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 tnithiple injection ornon4vatersupplywells
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#• M W 8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12 (ft.) 1617 Mail Service Cente'r,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition'.to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 6.54 (ft.) Division of Water Resources,Unde ground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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. i
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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® Abandoned Monitoring
Well (Type II)
Inactive Non-Potable
Water Supply Well
Abandoned Non-Potable
Water Supply Well
❑ Approximate Location
of Former UST System
Approximate Location
of Septic Tank `y
Parcel Boundary t,
Sow -Sri. axar:Ea s ar Geograph ics#and the GIS User Community,
NOTE: Well and tank locations were obtained from previous reports
prepared by other consultants and are approximate. 50 25 0 50 100
Feet
PROJECT T:TLE
VARNAMTOWN FIGURE
ATLINCOUNTRY STORE SITE MAP
325 VARNAMTOWN RD
Engineers and Scientists SUPPLY, NC
INCIDENT NO. JOB N0. DATE SCALE DRAWN BY/CHECKED BY
32319 220304 MAY 2024 AS SHOWN KMC/SJO