Sampson_Well Abandonment_20240610

WELL ABANDONMENT RECORD For Internal Use ONLY-
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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 I GW-30 is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:"
7b.Approximate volume of water remaining in well(s): 0.67 al.
NC Well Contractor Certification Number PP g (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NIA
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifbuown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.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 ` .❑ Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout �+ fd elii tings
❑rtri ation ❑Specialty Grout ,JUly 1 Q el
Non-Water Supply Well: ❑ Bentonite Slurry Cr(explain under 7g)
RMonitoring ❑Recovery Ir*IrRW�ENl pr<�
Injection Well: 7f.For each material select 1=44A1111t of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-40 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquiterTest ❑StormwaterDrainage Water-2.0 gallons
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Slowly added bentonite chips and ensured there was no bridging
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
taking place. Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 05.30.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway #6991 0-036875
Facility/Owner Name Facility iDli(ifapplicable) 8.Certifiealion: ��
110 west Martin Luther King Jr. Blvd.,Roseboro, NC 28382-9064 �.� 06.03.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Sampson 1443-69-0872 By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
County Parcel identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
34.957651 N 78.512235 `,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 ornan-water.supply wells
ONLY with the same construction abandonment,you can submit one form.
A 10a. For All Wells: Submit this form within 30 days of completion of well
M 6a.Well ID#• W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20.0 (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: 2.0 (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: 15.89 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): N/A (ft.) 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
611 Inner casing/tubing length(if known): 5.0 (ft.) abandoned.
6g.Screen length(if known): 15.0 ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016