Martin_Well Abandonment_20240731

WELL-ARAi7 DQNMEi-`IT"RECORD For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS •
Stuart Spruill 7a.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well awner personally abandoning well on his/her propert)) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2193-A wells abandoned:
NC Well Contractor Certification Number 0 ' VF'j��'V 7b.Approximate volume of water remaining in well(s): (gal.)
SGI FOR WATER SUPPLY WELLS ONLY:
JUL 3 1 2024 1/2 "HCL Tabs
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N•/A Ifr! :a-lep ?rf�•�Air rvyut;-� !.melt
list all applicable well caatnurtion permits(Le i;It'.('ouNM.Miireut itJtr¢,etc.)ijknown 10 1/2"tabs
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 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry a Other(explain under 7g)
❑Monitoring ❑Recover}
Injection Well: 7E For each material selected above,provide amount of materials used: •
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier •
2 yards clayey soil and 20 80 lb bags of concrete
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Deg out le 5.5 9 bobw IS.ed pound nci tabs h,mugb now sugar bore now mn,comps.a:on to.b below cs the roan.20 b.9g x ib pear,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 06-27-2024
5a.Well location:
Former 9321 Hwy 17 DOTRight of Way
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
9321 Hwy 17 Williamston, NC 27892 06/27/24
Physical Address,City.and Zip Signature of Certified Well ctor or Well Owner Date
Martin
By signing this form, I hereby cert(that the well(s)was(were)abandoned in
County • Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0/00 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 degrees/minutes/seconds or decimal degrees:
(if well field,one lat9ong is sufficient) 9.Site diagram or additional well details: •
35.72580 N 77.07554 W, 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(Sl BEING ABANDONED SUBMITTAL INSTRUCTIONS
.•I welt lb ell construction record(s)iJ'm ailable.1.4 multiple inlecnott or non-water.supply wells
ONLY with the.sante construction abandonment,you can.submit me(urns
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well!Mt
30" well abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: unknown (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 30 inches (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: 6 ft (R) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&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): (ft.) abandoned.
•
6g.Screen length(if known): (fl.)
•
Form GW-30 North Carolina Depamncnt of Environmental Quality-Division of Water Resources Revised 2-22-20;6