Wake_Well Abandonment_20240903 (11)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. W e rl e y 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
3 344-A wel Is abandoned:.—
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.8 (gal.)
ECS Southeast, LLC FOR WATER SUPPLY WELLS ONLY: F
Company Name Type ;
/� 7c.Te of disinfectant used:
2.Well Construction Permit#: N/A ') , �G2�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: l+�`:;.:::
3.Well use(check well use): -„r
..j
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public III Neat Cement Grout N 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)
R Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite — 30 lbs.
[]Aquifer Storage and Recovery ❑Salinity Barrier Neat Cement - 25 Ibs.
❑Aquifer Test ❑Stormwater Drainage
El Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite-Gravity fE!ed from 30 to 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Neat cement - pour from5' bgs to surface
4.Date well(s)abandoned: 8/10/2024
5a.Well location:
Kirk,Kirk,Howell,Cutler&Thomas LLP 00-0-0000047688
Facility/Owner Name Facility ID#(ifapplicable) 8.C tification:
3541 Wendell Blvd., Wendell, NC 27591 8/12/2024
Physical Address,City.and Zip Signature ofCcrtificd tor or Well Owner Date
Wake 1784619056 By signing this form, /hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PM) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.784482 N -78.369598 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(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)i(available. For multiple injection or non-toatersupptrwells
ONLY with the same construction/abandonment,you can submit one fotrn.
10a. For All Wells: Submit this forth within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 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: 7 (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: 14.54 (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 Supply&Injection Wells: In addition to sending the fort 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):.10 (ft,) abandoned.
6g.Screen length(if known): 20
Forni G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016