Robeson_Well Abandonment_20240514 (12)

WELL ABANDONMENT RECORD For Internal Use ONLY:
I :
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: I
NC Well Contractor Certification Number 7b.Approximate volume of water r emaining 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#:
1 2024
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc)ifknorvn n,
7d.'Amount of disinfectant used:
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check all;that apply):
❑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
'❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry a Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,"provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 25lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage SOII 25IbS
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the'abandonmentpiocedure:.
❑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 the remaining opening brought to
5a.Well location: grade using topsoil.
Nic's Properties, Inc. 00-0-0000018540
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
150 West Martin Luther King Jr. Drive /
4/19/2024
Physical Address,City,and Zip Signature ofCertiBcd Well Contractor or Well Owner Date
Robeson 839549600700
By signing this form, 1 hereby certify'that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0d 00,or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has heen provided to the well owner.
(ifwcll 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
Aaaclim,ellconstructionrecord(s)ifavailahte.For multiple hyectionornon-water supply wells
ONLY with the same consiructiorr'abandonnrent,you can submit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW 14 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 additionjto'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: 7•04 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
Unknown (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): 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