Person_Well Abandonment_20240610 (10)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary S i m co x 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: p
7b.Approximate volume of water remaining in wells 10.8 (gal.)
NC Well Contractor Certification Number PP g O'
S&ME, 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,Coun),State,Variance,etc.)tfknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 11 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' Mel
Cuttings
❑bTi tion ❑Specialty Grout Mel
Non-WaterSupph NN"ell: ❑BentoniteSlury JUN I 0 A?4 ❑Other(explainunder7g)
MMonitoring ❑Recovery
Injection Well: 7t For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 130 l bs
❑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 7 )
surface and hydrated.
a.Date well(s)abandoned: 05/29/24
Sa.Well location:
Huffman Oil Company
Facility/Owner Name Facility ID#(ifapplicable) 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 I5A NCAC 02C.0100 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 been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36° 16' 25.30" N 79° 02' 48.50" 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available.P or multiple injection or non-water supply 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
6s.Well ID#: M W-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.'I otal trell depth: 85.0 00 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For loiection 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: 18.63 at) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A) 10c.For Water Suooly&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
6L Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 2-22-2016