Duplin_Well Abandonment_20240731

WELL ABAIVUUINML]N't KI:C:UKU For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor M ize I le 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
4629C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2•9
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 0 Neat Cement Grout • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Groat„ .. •. f;€1:11DryiClay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout • V 4 Cuttings
❑Irrigation 0 Specialty Grout JUL 3 i 202f Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery Ifi;,,,�d-,� +-• ;- r
Injection Well: 7f.For each material selecits'Twfk;4'ovtde amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 12.5 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
:Aquifer Test ❑Stormwater Drainage Topsoil 0.5 cu ft
❑Experimental Technology ❑Subsidence Control
7g. Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed pad from ground. Cut off top of well,
abandoned in place.
4.Date well(s)abandoned: 7/23/24
Fill in bore hole with bentonite.
5a.Well location: Fill in hole with topsoil to level ground.
Wagon Wheel
Facility/Owner Name Facility lD#(if applicable) H.Certification: I:we
114 Wagon Wheel Ln, Rose Hill, NC 28458 7/23/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Duplin By signing this form, 1 hereby cert(that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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 in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.8583230985985 N -78.03445976501938 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. For 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#: MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9.83 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in l0a
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: 4.35 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.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
6f.Inner casing/tubing length(if known): 4'83 (ft.) abandoned.
6g.Screen length(if known): 5'0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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Water Supply Well
--- Former System Lines J
0 Approximate Location
of Former UST System
ElParcel Boundary
P Source. Esri, Maxar, Earthsta-Geographics, and the GIS User Community
NOTE: Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 40 20 0 40 80
��mmm Feet
PROJECT TITLE
WAGON WHEEL FIGURE
cATLIN 114 WROASGEONHILLHENECL LN SITE MAP
Engineers and Scientists I
INCIDENT NO. JOB NO. DATE SCALE DRAWN BY/CHECKED BY
48604 223107 JULY 2024 AS SHOWN KMC/SJO