Camden_Well Abandonment_20240514 (11)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeovany Gutierrez Bautista 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
4125 A wells abandoned:
7b.Approximate volume of water remaining n wells Unknown
NC Well Contractor Certification Number PP g r O: (gal•)
A.C. Schultes of Carolina, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Hypochlorine
7c.Type of disinfectant used: _
2.Well Construction Permit 4:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1 Gallon
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 Ill 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
OIrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Slurry 1 Cubic Feet
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7
,, P,„N idc a hricl'descri ption of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Disinfect
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) ` _'
Inject from Bottom Up
4.Date well(s)abandoned: 4/24/2024 - Z024
Sa.\%ell location:
South Mills Water Assoc.
Facility/Owner Namc Facility ID#(if applicable) 8.Certification: )
phyical Address nCiti ,and Zip i ed Well C actor or Well Owner Date
By signi this form, I 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field.one lat/long is sufficient) 9.Site diagram or additional well details:
36.43986 N 76.30616 N 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 records)ifavailable.For multiple injection or non-water supply 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 IDN: 26 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 63 (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: 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: 8 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection 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
6E Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016