Pender_Well Abandonment_20240731 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Chalmers 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
4146 - A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal.)
Applied Resource Management FOR WATER SUPPLY WELLS ONLY:
Company Name HtH
7c.Type of disinfectant used:
2.Well Construction Permit#(: E H W P-01265-2024
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)tf known 1 TBS
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 ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply),. e esid, al Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial �.r t l Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: JUL 3 1 ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recov
Injection Well: .�„'-„ • 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge Ul.';-!S'�;roundwater Remediation < 1 bag of bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Found well to be broken obstruction +/- 1' down.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7 )
4.Date well(s)abandoned: 5/28/2024
5a.Well location:
Pender County
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
415 KNollwood Dr. Hampstead, NC 28443 T a',IedC0�Qit,� 6/14/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Pender 3263-77-4768-0000
By signing this form, !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 in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 39' 74.45" N 77 78' 17.86" 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. 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 EN: N/A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: N/A at.) 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: N/A (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: N/A (fC) Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-16M
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Sunnlv&Infection Wells: In addition to sending the form to the
addresses)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
6L Inner casing/tubing length(if known): NIA (ft) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016