Person_Well Abandonment_20240610 (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.%%el l('o n t ra c for Information: WELL ABANDONMENT DETAILS
Gary Sim cox 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
2944-B wells abandoned:NC well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 6.3 (gal.)
S&M E, Inc. 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,Variance,etc.)ifknown
7d Amount of disinfectant used:
3.Well use(check well use):
"ater Supply Well: 7e.Sealing materials used(check Al that apply):
❑Agricultural ❑MunicipaYPublic ❑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'= t— `t-q�i11 Cuttings
❑Irri tion ❑ Specialty Grout , J ✓=,,el
Non-Water Supply Well: ❑Bentonite Slurry JUN 1 �24 ❑Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: 7L For each illfipria1jmteged AD%W lde amount of materials used:
❑Aquifer Recharge ❑GrotmdwaterRemediation 90 lbs DVb1Q'§�; tiR�
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled well casing with bentonite chips to
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
surface and hydrated.
4.Date wells))abandoned: 05/29/24
5a.NN ell location:
Huffman Oil Company
Facility/Owner Name Facility IDk(if applicable) 8•Certification:
9353 NC-157 Hurdle Mills, NC 27541 ��_ 05/31/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Person By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 1C.0100 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one Wong is sufficient) 9.Site diagram or additional well details:
36° 16' 25.47" N 79° 02' 48.40" ,1 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 construction records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6s.Well ID#: M W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b. 1 otal well depth: 55.0 (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: 2 (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: 16.51 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 00 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): (fL) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016