Harnett_Well Abandonment_20240731

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well('ontractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
4308-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number
7b.Approzimate volume of water remaining in well(s): 28 (gal.)
BIII's Well Dnlling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(1.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used: 1 Ibs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural [ZIMunicipaVPublic ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
Olndustrial/CommerclW ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ",*,'i ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: "' IF I—Li 0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharst,( fn �;rr� L G❑ dywaterRemediation 400 Ibs bentonite
❑Aquifer Storage and Reco�,-�JC4 ❑ mi Barrier
❑Aquifer Test ❑Storrnwater Drainage --
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure
❑Geothermal(Closed Loop) ❑Tracer pulled pump
❑Geothermal(Heating/Cooling Return) []Other lain under 7 ) —
Measured depth of wE!ll and SWL
a.Date well(s)abandoned: 1-12-24 Disinfected well
5a.Well location: pumped full of bentoinite
Well Co Contractors —
Facility/Owner Name Facility ID#(ifapplicable)
8.('ertifcation:
Poplar Dr, Spring Lake,NC 28390 &,,_ 1-12-24
Physical Address,City,and Zip Si of Certified Well Contractor or Well Owner Date
Harnett By signing this form, I hereby certify that the wells)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.degrm:
(ifwell field,one Iat/long is sufficient) 9.Site diagram or additional well details:
35.300958 -78.990337 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. 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#:
abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: (ft.)
87 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: 8 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
76 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: M) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunoly& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): O 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
6f.Inner casing/tubing length(if known): (h) where abandoned.
6g.Screen length(if known):
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013