Robeson_Well Abandonment_20240514 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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 re maining in well(s): (gal.)
CATLI N Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
t Company Name' _7c.Type of disinfectant used: r
2.Well Construction Permit#: � ! f•• �
List all applicable well construction permits(i.e.UIC,County,Slate,variance,etc.)ifknown
7d.Amount of disinfectant used: IG=rfr;c r� 7
3.Well use(check well use): .. .;
I
Water Supply Well: 7e.Sealing materials used(check all;that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑hrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry N Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 25 Ibs
❑Aquifer Storage and Recovery PSalinity Barrier
Concrete 251bs
❑Aquifer Test ❑StormwaterDrainage
❑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) All well materials abandoned in place using
hydrated bentonite to approximately six inches
4.Date well(s)abandoned: 4/17/2024
below land surface. Concrete was used to bring
5a.Well location: remaining opening to grade.
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 of Certified Well Contractor or We'll Owner Date
Robeson 839549600700 1
By signing this form, 1 hereby certify'that the wells) 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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hullong 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
Altaclnvellconsiruclionrecord(s)ifavailable. porntultipleiiyectionornon-rraterstrpplytrells
ONLY with the same constzeclion'abandonttent,you can subrnil one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW 16 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 22 (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: 8.25 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
5.56 Division of Water Resources,Und Irground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,, Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.)Unknown 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copyiof 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): 20
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016