Robeson_Well Abandonment_20240918

WELL ABANDONMENT RECORD For Internal Use ONLY:
.4.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford
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
3270 A wells abandoned:NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'23 (gal.)
Geological Resources, Inc. FOR-WATER SUPPLY WELLS ONLY:
Company Name I'
lc.Type of disinfectant used: i•
2.Well Construction Permit#: N/A I, .
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown r
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) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Othen(explain under 7g)
MMonitoring ❑Recovery ii
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite I. 15
❑Aquifer Storage and Recovery ❑Salinity Barrier Grout 15
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑ r.,
Geothermal(Heating/Cooling Return) ❑ Pour as placement �,_
Other(explain under 7g)
4.Date wells)abandoned: 04/03/2024 it
5 EP 1 S 2024
5a.Well location:
Corner Store 00-0-0000018366 ' °x''�
i e�+.,.w�x;
Facility/Owner Name Facility ID#(if applicable) 8•Certifica
2402 North Elm Street, Lumberton, NC 04/03/2024
Physical Address,City,and Zip Signature of ified Well Contractor. Well Owner Date
Robeson 3209-01-0001 By signing this form, I hereby cert6 that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02Ci:.0100 or'2C.0200 Well Construction Standards
and that a copy of this record hasibeen 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:
34.634451 N 79.007785 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)ifavailable.For multiple injection or non-water supply wells d
ONLY with the same`constructian/abandonment,you can submit one form. 10a. For All Wells: Submit tliis,form within 30 days of completion of well
6a.Well ID V'#• ' V V—1 abandonment to the following: ,};
Division of Water Resources,Information Processing Unit,
1617 Mail Service!Center,Raleigh,NC 276994617
6b.Total well depth: 15 (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: I;
7.34 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Servicej,Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 (ft,) 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): (ft.)
abandoned.
I
6g.Screen length(if known): 10 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource s' Revised 2-22-2016
. P I �

1
Geological Resources,Inc.
SITEINFORIVIATION
Site Name: Corner Store Date:04/03/2024
Project Number: 6206 Completed By:L. Weathersby
DRILLING`INFOR'MATION` ra}'
Company: Geological Resources, Inc. License Number: 3270 A
Driller:Justin Radford
ELL ABANDONMENT INFORMATION,,
Bentonite (Ibs): 15
Boring ID: Mw-� Grout(Ibs): 15
Total Depth Outer Casing
15 Fro To (ft) Length (ft)
0 m (ft) 0
Depth to Water Inner Casing
7.34 From (ft) To (ft) I Length (ft)
0 15 15
"Water Volume (gal) Screen
1 .23 From (ft) To (ft) Length (ft)
5 15 10
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Pre-Abandonment Post Abandonment