Wilson_Well Abandonment_20220531 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply ivells ONLY ivilh the same
construction/abandonment,you can submit one form.
C -4421
NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): 4'0 (gal.)
GEOLOGIC EXPLORATION,INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable ivell construction permits(i.e.County,State,Variance,etc.)ifknown 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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Gr 1' A• p.,_ Drill Cuttings
❑Irri ation ❑Specialty Gr SIR, ��� �� ravel
Non-Water Supply Well: El Bentonite SlurryMAY Lll''ZZ ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4.5 GALL�'I�� �ta.' Unh
�irsC)�i�
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
5a.Well location: .
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1313 WARD BLVD WILSON 27893 �" '"'"` 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 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:
350 43' 14.56" 770 56' 09.10" 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 if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY ivith 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-31 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 29.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
20 above,also submit one copy of this form within 30 days of completion of well
.
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 4.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandol ed: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-ivaler supply wells ONLY with the same
construction/abandonment,you can submit oneform.
C-4421
7b.Approximate volume of water'remaining in well(s): 4'0
(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 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 Cem '�v � A.,� Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty GrouMAY 3 1 202Z ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry UiQ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material VflAQd9e,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 5.0 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
5a.Well location:
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(ifapplicable) $•Certification:
1313 WARD BLVD WILSON 27893 TM"'"'"` 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON By signing this form, I hereby certify that the ivell(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 tivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 43' 06.20" 770 56' 07.17" 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 if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach tivell construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IIMI:
M W-32 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 30.0 (ft) 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 5.0 (ft,) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
611 Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being aband Ined:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
C -4421
NC Well Contractor Certification Number 7b.Approximate volume of water!remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits O.e.County,State,Variance,etc.)tfknown 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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
PP Y) PP Y( g ) = .--,m—pa .I—
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ' v,3 \�o�rilttings
❑Irri ation ❑Specialty Grout pp ❑Gravel
J
Non-Water Supply Well: El Bentonite Slurry MAY 1 2Fbther(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each materie G�#e�igbp;g,Trtttt({>ttMt of materials used:
[]Aquifer Recharge ❑Groundwater Remediation 4.0 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
5a.Well location:
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification-
1313 WARD BLVD WILSON 27893 y �"` "'"'"` 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON By signing this form, I hereby certify that the tivell(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 Nell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 43' 15.12" 770 56' 08.32" 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 if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the some construction/abandonmem,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 6.0 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
[}.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAM ES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple in
or non-water supply wells ONLY with the same
C -4421 construction/abandonment,you can submit one form.
NC Well Contractor Certification Number
7b.Approximate volume of waterIremaining in well(s): (gal.)
GEOLOGIC EXPLORATION,INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 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 ❑Bentonite Chips or Pellets
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) ❑ Sand Cement Grout ❑Dry Clay
9^a,—
❑Concrete Grout ' n Cuttings
❑Industrial/Commercial ❑Residential Water Supply(shared) "�" g
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: IZ1 Bentonite Slurry MAY J 11 202�i Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7E For each mafjt$IrgftM ffims!zporo[ jpunt of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 0.5 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
Sa.Well location:
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1313 WARD BLVD WILSON 27893 �" �'""" 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON By signing this form, I hereby certify that the well(s)tvas(were) abandoned in
County Parcel Identification No.(PIN) accordance ivith/5A 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 43' 15.36" N 770 56' 08.82" You W abandonment detay use the ils. You ack of ma Paso attach e to additionalde additional es ifnecessetails or well
Y pages arY•
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well 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 DM: SVE-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 3.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
20 above,also submit one copy of this form within 30 days of completion of well
.
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&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
6E Inner casing/tubing length(if known): (ft.) Where abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department ofEnvironment and Natural Resources—Division of Water Quality Revised March 2013