__20220830

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1•Well Contractor Information: I
n A .. ��{ C� WELL ABANDONMENT DETAILS
Well Contractor Name(or well owner personally abandoning well on his/her property) For7a.Nmmbpleofwectibeinon g abandoned:r supply
wells ONLY wilt the same
388 r construction/abandonment,you can submit one forme
NC Well Contractor Certification Number7b.Approximate volume of water remaining in well(s): 50
(gal.)
u [ `1 5 e( I , /1, 1 t` FOR WATER SUPPLY WELLS ONLY:
Company Name ��� '�
�— 7c.Type of disinfectant used:
2.Well Construction Permit#:
ail
List all applicable well permits(ale.County,State,Variance,Injection,etc.)if known
7d.Amount of disinfectant used: ?OZ.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that a 1❑Agricultural ❑Municipal/public 0 Neat Cement Grout PP y)
1 0 Clay
Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply)Y) idential Water Supply(single) 0 Sand Cement Grout 0 Dry Cl
❑Industrial/Commercial ❑Residential Water Supply(shared)
Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout
Non-Water Supply Well: ❑ Gravel
❑Monitoring 0 Bentonite Slurry 0 Other(explain under 7g)
❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
(Heating/Cooling❑Geothermal Return) ❑Other(explain undert
( xp7g) - eCCULICL )0C in VJ Q G 4
4.Date well(s)abandoned: /-! `�O�a- `‘ W 1 J�`�`� 4' �s2Jkl t�C, ,
Sa 11 location: �' ^�' M ` z�'�
)G.Ul'ems R,r-, j.s AUG 3 0 2022
Facility/Owner Name1\ S\a 1!^ /� Facility[p9 ID#(ifa livable) 8•Certifiicati
b 0 E\ vi 7cto Ct ! ' c . Wct C `Vui I1Y1�.I f"f9-Yi i n 7-Iv�'�k,il� Ulf'•
Physica Address,City,and Zip /-4? DWQR3Oc• / f _
Si attire ofCertifie.Well Contractor or Well Owner (t
�c� � Ir �� Date
County J By signing this font,, I hereby cert fy that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) 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.
(if well field,one lat/long is sufficient)
�j 9.Site diagram or additional well details:
34 /91t7 l3G 7 O N ceo. 750 s'yV.° 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
Attach well construction record(s)(available. For multiple injection or non-[rater supply SUBMITTAL INSTRUCTIONS
wells ONLY with the same construction/abandonment,you can submit one form.
.�/� 10a. For All Wells: 5ubrriit this form within 30 days of completion of well
6a.Well)D#: abandonment to the following:
•
91 Division of Water Resources,Information Processing Unit,
6b.Total well depth: LJ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
( 1 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources,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): /Lk (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
6f.Inner casing/tubing length(if known): (ft) where abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources
Revised August 2013

WELL Al3ANI)O NTIVYENT RECORD
This form can be used for single or multiple walls For Internal Use ONLY:
1.Well Contractor Information:
WELL ABANDONMENT DETAILS
4 1S
/Well Convector Name(or well owner a 7a.Number of wells being abandoned:personally abandoning well on his/her property) For multiple injection or non-crater supply wells ONLY with the same
construction/abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s):
(gal.)
NC Well Contractor Certification Number
4'5 ell. FOR WATER SUPPLY WELLS ONLY:
1 Company Name
7c.Type of disinfectant used: li T
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,I jection,etc.)if known
7d.Amount of disinfectant used: j� -1_,----::— iC 3.Well use(check well use): o _�, a__1_ �`'
Water Supply Well: 7e.Sealing materials used(check all that apnl.):
❑Agricultural ❑Municipal/public 4;,Teat Cement Grout
❑Geothermal(Heating/CoolingSupply) jsy nite Chips or Pellets
PP 3) [�dential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 'oncrete Grout
❑Irri•ation 0 Drill Cuttings
Non-Water Supply Well: 0 Specialty Grout 0 Gravel
❑Monitoring 0 Bentonite Slurry 0 Other(explain under 7g)
❑Recovery
Injection Well:
7f.For each material sel cted above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier I f
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4 hP fl t
4.Date well(s)abandoned: 51):: -' ?6. 2
5aa.Well lloo�ca/tion:` 1 /� P"",I`�' =' s.* z
V �tq mNe,� s p
Facility/Owner Name Facility ID#(if applicable) 8•Certification: AUGV {
Phystcarl Address,City,and Zip / ' 1 J t}la _ L
/�� S. of Certified Well Contractor or Well Owner Date
6l /V 1 O
County By signing this form,I hereby certify that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) 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)
J�� 9.Site diagram or additional well details:
J O N 4 , J o 3e You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED Attach well construction record(s)if available. For multiple injection or non-water supply SUBMITTAL INSTRUCTIONS
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#: abandonment to the following:
if /1 Division of Water Resources,Information Processing Unit,
6b.Total well depth: CJ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
�� 10b.For Injection 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:
6d.Water level below ground surface: + 'ti (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): P / (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
6f.Inner casing/tubing length(if known): 6 (ft) where abandoned.
6g.Screen length(if known): 6 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013