Robeson_Well Abandonment_20240514 (9)

WELL ABANDONMENT REC RD
O For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS i
Nathaniel Newman 7a.For Geoprobe/DPT or Closed-L I p!Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-301 isineeded, Indicate TOTAL NUMBER of
4630Ci wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLI N Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: J. IU24
List all applicable srell 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 materials used(check all that apply):
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❑Agricultural ❑Municipal/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 ❑Drill Cuttings
❑hrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry a Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 25 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Soil 25lbs
❑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) Abandoned well using hydrated bentonite to —6
inches below land surface. Concrete and well shield
4.Date well(s)abandoned: 4/17/2024 removed and then remaining opening brought to
5a.Well location: grade using topsoil.
Nic's Properties, Inc. 00-0-0000018540
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
150 West Martin Luther King Jr. Drive "A'2r� 4/19/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Robeson 839549600700
By signing this form. I 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.
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:
34.736059 N -79.350995 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 constrtction record(s)ifavailable. For multiple injection or non-watersupply 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-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (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:
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6d.Water level below ground surface: 7.53 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): Unknown (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): (ft.)
abandoned.
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6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016