Wake_Well Abandonment_20240514

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 7a.For•Geoprobe/DPT or Closed-�oop 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:
NC Well Contractor Certification Number 7b.Approximate volume of water ire maming in well(s): (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.UIC,County,State, fiariance,etc.)iflatown MAY 4 2024
7d.Amount of disinfectant used:
3.Well use(check well use): ;,;f by ;•:'t;r 5,c�w = J�-;.v
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
❑hrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry S Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 50 IbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete 25 1bS
❑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 to within 10 inches of the surface and topped
a.Date well(s)abandoned: 4/10/2024 with concrete to existing grade.
5a.Well location:
Bobby and Anne B. Harrington NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1200 Broad Street, Fuquay-Varina, NC 27526 4/11/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 0657931229
By signing this form, 1 hereby certify that the ivell(s) teas (1vere) 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: j!
(ifwell field,one lat/long is sufficient) 9•Site diagram or additional well details:
35.599613 N -78.801153 W You may use the back of this page to provide additional well site details or well
abandonmenfdetails. You may also;attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(g)BEING ABANDONED SUBMITTAL INSTRUCTIONS.
Attach well construction records)ifavailable. Foranultiple injection ornon-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-1 abandonment to the following:
Division of water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.). 1617 Mail Service Clenter,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:
l I
6d.Water level below ground surface 13.06 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
NA 10c.For Water Suuuly&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): 5 (ft.) abandoned. i
6g.Screen length(if known): 20
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016