Johnston_Well Abandonment_20240610

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELLABA ON NT DETAILS
David E. Meyer 7a.For Geoprobe/D 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
2527-A wells abandoned:
0
NC Well Contractor Certification Number 7b.Approximate volu a of water remaining in well(s): (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPP YWELLSONLY:
Company Name na - dry
7c.Type of disinfects It used.
2.Well Construction Permit
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinte teat used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
Olffistation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slung a Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material s lected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 7.5 yds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief des ription of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer well sounded, ound free of obstructions, filled with
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
backfilled to su ace and compacted
4.Date well(s)abandoned: May 17, 2024
5a.Well location: t L��'•
Mattamy Homes na JUN 1 0 424
Facility/Owner Name Facility IDk(if applicable)
305 Turnipseed Road Wendell NC 27591fl /2024
Physical Address,City,and Zip Signature of Certified Well on ctor or Well Owner Date
Johnston 178200-04-1575
By signing this form, / ereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A N AC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this r cord has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 9.Site diagram or addi'oral well details:
35.74045 N -78.39158 W You may use the back f this page to provide additional well site details or well
abandonment details. Y u may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTR NS
Aiiach well construction record(s)ifarailable. For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: ubmit this form within 30 days of completion of well
6a.Well ID#: 1 abandonment to the foll wing:
Division of W ter Resources,Information Processing Unit,
6b.Total well depth: 16 (ft.) 1617 Mai Service Center,Raleigh,NC 27699-1617
10b.For In'ecti n Wei s: In addition to sending the form to the address in 10a
6c.Borehole diameter: 48 (in.) above, also submit one opy of this form within 30 days of completion of well
abandonment to the foll ing:
6d.Water level below ground surface: dry (fL) Division of Water R sources,Underground Injection Control Program,
1636 Mai Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): na (R,) 10c.For Water Su In' n W IL
: In addition to sending the form to the
address(es)above,also s ibmit one copy of this form within 30 days of completion
of well abandonment t 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 Wat r Resources Revised 2-22-2016