Lenoir_Well Abandonment_20240731

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Ellingworth 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
3367-A wells abandoned:
NC Well Contractor Certification Number _ -. 7b.Approximate volume of water remaining in well(s): 0.5
Parratt-Wolff, Inc. E D FOR WATER SUPPLY WELLS ONLY:
Company Name J I J L 3 2024 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permit f fuifALrvCSuAry`,Sfafe3tRiidbtlje ijbtaN n
U'h•Ca$4�3 7d. kmount 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 ■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
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
PlMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation 13 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provides brief description of the ahandon men t procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Poured bentonite chips from bottom to top of well.
Hydrated with water. Removed surface completion and
4.Date well(s)abandoned: July 2, 2024
cut well below grade. Restored surface to match
51L N ell location:
surrounding area.
Covation Biomaterials NCDO03190386
8.(crtific on:
Facility/Owner Nwiic Facility ID#(ifapplicable)
4693 Hwy 11 North; Grifton, NC 28530 July 2, 2024
Physical Adds,_(lt�_;md lip S��awr e�Stic , r,,c e ner Date
Lenoir 4557-47-6137
BY signing his form, l hereby certify 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.
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 9.Site diagram or additional well details:
35.320742 -77.476375 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavaitable. For multiple injection or non-water supply wells
ONLY with the same con.simcnon abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-55 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 6.5 00 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: 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: 3.5 00 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 4) 10c.For Water Supply&Infection 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
6E Inner casing/tubing length(if known): 3.5 00 abandoned.
6p.Screen length(if known): 3.0 00
Donn(;w-?u North Carolina Department of Environmental Quality-Division of W ater Resources Revised 2-22-2016