Pender_Well Abandonment_20240814

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 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
4629-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4.8 (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.WC,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 ❑ Neat Cement Grout- • • lirBetonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement tirdut..-. ` '►.. ' {�dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout AUG 1 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite SI A -*
YF,YJ: anC/^.+ ter(explain under 7g)
•Monitoring ❑Recovery ot•+�C j SC,'
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 25 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Topsoil 14 lbs
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Concrete pad and well removed from ground.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Hydrated bentonite pellets and topped with topsoil
4.Date well(s)abandoned: 7/2/2024
to existing grade.
5a.Well location:
NCDEQ-Vera Howard DOT Unknown
Fa,11 m Owner Name l v.lily ID#(if applicable) 8.Certification:
22545 US Hwy 17 N, Hampstead 28443 G 7/3/2024
Physical Address.City.and Zip Signature of Certified Well Contractor or Well Owner Date
Pender NA By signing this form, 1 hereby certi/y 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:
34.45036974531768 N -77.61721733373446 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)if available. For multiple injection or non-water s 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 01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 13.9 (ft.)
10b. For Iniection Wells: In addition to sending the form to the address in 10a
Gc.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: 3.33 (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 (R) ilk.For Water Supply&Iniection 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): 3.9 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 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
4629-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4.8 (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,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 Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grgqrt. ,.• ; l 1 grill Cuttings
❑Irrigation 0 Specialty Gro t�...` 1 j._0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry AU G '• 2Q24 I Other(explain under 7g)
@Monitoring ❑Recovery
Injection Well: 7E For each nlAtexA(t.l 0ected aboutslitoti‘ki amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellefg-• 25 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑Aquifer Test ❑StormwaterDrainage Topsoil 14 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) '7Tracer
OGeothermal(Heating/Cooling Return) 7Other(explain under 7g) Concrete pad and well emoved from ground.
Hydrated bentonite pellets and topped with topsoil
4.Date well(s)abandoned: 7/2/2024
to existing grade.
5a.Well location:
NCDEQ-Vera Howard DOT Unknown
Facility/Owner Name Facility IDt!(if applicable) 8.Certification: larize
22545 US Hwy 17 N, Hampstead 28443 7/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Pender NA
By signing this form, I hereby cert(fy 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:
34.45036974531768 N -77.61721733373446 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)i/avai/able. 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#: M W-02 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14.2 ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. 2 litt l 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: 3.51 (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 Suanly&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
6L Inner casing/tubing length(if knon n is 4.2 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
4629-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in ssell(s): 4.8 (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
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 ❑Neat Cem rirGmtit I I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand CemAnt Grout'. 4• - ' 57-1=0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 ConcreteGrout^u `•• 2O�A ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout' U t 0 Gravel
Non-Water Supply Well: 0 BentonitrAM.,it-, *-n„r`;a t.'•9!,jam Other(explain under 7g)
(Monitoring ❑Recovery Df SC.-3
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Pellets 25 lbs
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Topsoil 14 lbs
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Concrete pad and well removed from ground.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Hydrated bentonite pellets and topped with topsoil
4.Date well(s)abandoned: 7/2/2024
to existing grade.
5a.Well location:
NCDEQ-Vera Howard DOT Unknown
Facility/Owner Name Facility ID#(if applicable) R.(ertification:
22545 US Hwy 17 N, Hampstead 28443 Inesze
7/3/2024
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Pender NA
By signing this form. 1 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.
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:
34.45036974531768 N -77.61721733373446 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 we/I 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#: MW 03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 14.0 (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
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: 3.87 (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 Sum*&Iniection 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): 4.0 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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r1
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ie
'40 ' .
# '4111 •
MW 03 r
•
TMW-01
..,., s A° : MW-01'�
APPROXIMATE`et
LOCATION OF
t;,M. FORMER STORE FORMER 500-GAL.
``" GASOLINE USTS
°TMW-02 \�
FORMER
DISPENSER,,"
ISLVAD
r
.w
LEGEND Cit,
, OL
® Abandoned Monitoring FA
Well (Type II) • O�
Abandoned Temporary AO
�> Monitoring Well (Type I) .
1
❑ Approximate Location
of Former UST System '
6Iomm.,E tt Galt ro l J c`ogr.o1 „mil0'AG SOO W:4 a ity
NOTES:
1.Tank locations were obtained from previous reports
prepared by other consultants and are approximate. 40 20 0 40 80
2.Well locations obtained during field activities 1 iimommiFeet
conducted by CATLIN.
PROJECT TITLE
VERA HOWARD NCDOT FIGURE
CATLIN 2HAM5 PSTEAV V D, NCN SITE MAP
Engineers and Scientists
INCIDENT NO JOB N: DATE SCALE DRAWN BY CHECKED BY
22841 222183 AUG 2024 AS SHOWN KMC/SJO