Moore_Well Abandonment_20240617 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nate Newman 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
4630C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (KaIJ
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.Uk',County,State, I inane,etc.)tfkmnrn
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 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
❑Uri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry a Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 40lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete 171bs
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Abandoned well in place using hydrated bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
to approximately 6 inchE!s below land surface.
4.Date well(s)abandoned: 5/7/2024 Concrete used to seal casing and brin ,Qpenin to
5a.Well location: grade. — `e t••' �)
Ciba-Geigy NA JUN 1 7 2024
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Aberdeen, NC 28315 UMt
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Moore NA 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
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,one lat'long is sufficient) 9.Site diagram or additional well details:
35.1267700800 N -79.4251229700 N 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)ijavailable. Por 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
6a.well ID#: GEIWP13X abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 29 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 8 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: 2.64 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft) 1 Oc.For Water Suuuly&Injection 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
617.Inner casing/tubing length(if known): 24 (ft.) abandoned.
6g.Screen length(if known): 4.6 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016