Wilson_Well Abandonment_20240617 (2)

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:wA
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): 1-74 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.)ift sown
7d.Amount of disinfectant used: A
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout s 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
❑Iri ation •:`: ❑ Specialty Grout ❑Gravel
Non-Water Supply Wei:--� ❑ Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ecovery
Injection Well: J 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ',ram ❑.GNg1aterRemediation Bentonite Chips-26 Ibs
❑Aquifer Storage anork464W' SAnity Barrier
ah �'
❑Aquifer Test ❑Stormwaler Drainage Water-1.0 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 7g)
taking place. Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 05.29.2024 The well was abandoned in accordance with 15A NCAC
59.Well location: 02C .0113.
Speedway #7439 N/A
Facility/Owner Name Facility IDii(if applicable) 8.Certification:
4876 Bloomery Rd., Wilson, NC 27896 06.04.2024
Physical Address,City,and Zip Signature orCertified Well Contractor or Well Owner Date
Wilson N/A By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.768162 N -77.993249 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 record(s)ifavailable. Far multiple injection or non-watersupplywells
ONLY with the same construction abandonment,you can submit one Jorm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13.0 (tt) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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: 2.36 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-16M
N/A 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit one copy of this forth within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 3.0 (ft.) abandoned.
6g.Screen length(if known): 1 0.0 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016