Chatham_Well Abandonment_20221007

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WELL ABANDONMENT RECORD F �, � '­_� i
or Internal Use ONLY:
I , OCI o
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E. Meyer
7a.For GeoprobetDPT or Closed-Loop Geothermal, e 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
2527-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):R_(gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: na I
Lim all applicable well construction permits(i.e.UIC,Calmly,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: 8 oz.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural 0Municipal/Public 9 Neat Cement Grout 0 Bentonite Chips or Pellets
DGeothermal(Heating/Cooling Supply) RResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
El Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
OIrrigation 0 Specialty Grout N Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
-OMonitoring DRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ElGroundwater Remediation pea gravel 0.75 yd
DAquifer Storage and Recovery OSalinity Barrier I-
DAquifer Test DStormwatcr Drainage neat cement grout 120 gallons
OExperimental Technology
OSubsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer well pumped pulled, soun ded,found free of obstructions
DGeothennal(Heating/Cooling Return) 00ther(explain under 7g)
chlorinated,filled with pea gravel to within 10-feet of casing bottom
4.Date well(s)abandoned:August 23, 2022
filled to top of casing with neat cement grout
Sa.Well location: top 3-feet of casing removed capped with 1-foot of concrete
Vickers Bennett Group LLC na
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
400 Vickers Road Chapel Hill NC 27517
At- �i 8/25/2022
Physical Address,City,and Zip Signature of Certified Wei ontracto,or Well Owner Date
Chatham 9775-63-8144
County By signing this.1brin, I hereby cerliA,that the ivell(s) was(were)abandoned in
Parcel Identification No.(PIN) 0ecordance with 15,4 NC.4C 02C.0100 or 2C.0200 Well Consmuction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a eop),of this re cordhas been provided to the well awner.
(if wel9l field,one fat/long is sufficient) a 9.Site diagram or additional well details:
35 49' 11.054" N79 04- 49.130" 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 WELL(S)BEING ABANDONED
INSTRUCTIONS
Allacillix,liconstnictioiti-ecordts)il*avtiilfjble. SUBMITTAL
ONLY with the same coji.viriic-tioulabeindoniiietit,roe can submit one fbmi. I Oa. For All Wells: Submit this'font form within 30 days of completion of well
6a.Well ID#: na abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 161 -00 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 103
6c.Borehole diameter: 6.5 (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: 32.90 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ciinter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 81 10c.For Water Sunnty&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
6f.Inner casing/hibing length(if known): na (ft.) abandoned.
6g.Screen length(if known): na (ft.)
Form GW-30 North Carolina Department of Environmental Quality-.Division of Water Resources

4
WELL ABANDONMENT T RECORD 2022
For Internal use()NI.V':
InI V5i1r '.
1.Well Contractor information: WELL ABANDONMENT DETAILS
aVld I_-' Meyer 7a.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor name(or well owner personally abandoning well on hivher property) well construction/depth,only I GW-30 is needed. indicate TOTAL NUMBER of
n�r-r,•�`!a
NC wells abandoned:
II C'ontrnelor Certification Number
Sampling
Approximate roximate volume of water remaining in well(s): 0 (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
k
(Company fear,:: u
7c.Tvpe of disinfectant used: HTH
3.We!I Construction Permit#: na
List all•Ipplir.n+le well collsinrrlioa perarits(i.e.UIC.CulnuiL Slab.I'arialla""lc.)#'knou'r 1 5 oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Sappiy Well: 7e.Sealing materials used(check all that apply):
ClAgrlculturni ❑Municipal/Public 10 Neat Cement Grout ❑Bentonite Chips or Pellets
:116cothernial(Beating/Cooling Supply) gResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑!nd:u::i '. :'c:mmercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑tn•igation ❑Specialty Grout l9 Gravel
\on-Water supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
CiA4oni:ar::'.r ❑Recovery
Vejection':Y-'Il: 7C For each material selected above,provide amount of materials used:
❑Aquife.Rc.hargc ❑GroundwaterRennediation pea gravel 2.25 yd
❑Aquif',Si:,age and Recovery ❑Salinity Barrier
u.4gtrifcr Tea ❑Stor nwater Drainage
neat cement grout 180 gallons
1-1Exncrilncrta:Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Gc•e,l+.?rn:.!(Closed Loop) ❑Tracer
well pumped pulled, sounded,found free of obstructions
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
chlorinated,filled with pea gravel to within 10-feet of casing bottom
?.Jafc well(e)abandoned: August 23, 2022 filled to top of casing jwith neat cement grout
sa.'dreli 1nc:xian: top 3-feet of casing removed,capped with 1-foot of concrete
V:ckars 6enneft Group LLC na
I'ucility llY.1(ifapplicable) 8.Certification:
31'6 Vickers Road Chapel Hill PVC 27517 �„ j _ 8/30/2022
Peysic:i:\d::r,s.City.and lip Signature of Cenified Well Contractor or Well Owner Date
9775-63-4165
-- BY signing This fin-ni. 1 hembv cerli/i'that the nrUty) was(were)abandoned in
Parcel Identification No.(PIN) accordance with 1 SA NCAC OX.0100 or 2C'.0200 Wn11 COBW171Ctian Standards
Ji).Lalftudc and longitude in degrees/minutes/seconds or decimal degrees: and that a ropy gl7his record has been provided to the well nwner.
(i�t;eil:ieic'.. arc!ut.%!ong is sufficient)
iF 9.Site diagram or additional well details:
n 0 't.G�: 1 1.091" N 79 04' 45.649" 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.
:TION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS'i
Harr:!;:r,li c•ur:suvrlinn rerordLcl i/'urailuh/r. For uudriple iniretian urvlan-traleranpph,re/!s
01vL}',;,)r; lit.•:roc•Coil ctrurtinr!'ahrurdnnnrrrrr.eau can submit wic Jin'nl.
10a. For All Wells: Submit this form within 30 days of completion of well
E•:. ;.riii,,. i�9e! abandonment to thelidlowing:
Division of Water Resources,Information Processing Unit,
depth: 340 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: in addition to sending the form to the address in 10a
rc.aor t?o.. diameter: 6'S (in.) above, also submit one copy of his form within 30 days of completion of well
abandonment to the l'ollowing:
y
i
6u.`X-,.z1c:-!ecd below ground surface: 24.45 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Cu.CA ter c::=ing length(if known): 80 (ftJ 10c.For Water Sunaiv&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
6C. nner c<:,in(;/tubing length(if known): na abandoned. I
6,;.Screen:_-nth(if known): na
Forst i\';..?.. North Carolina Mnartmen(ofEmironmenlalOualiiv-ni�i6i ,1'Wru,•ra...�,„•,. o....:..,,.r,•„•.� <

�� 0 C T U 72022
EII�'L ABANDONMENT RECORD
���C®H0Alpp��n For Internal Use ONLY:
Un;;
11..lt�I�/Well Contractor Information: WELL ABANDONMENT DETAILS
LJIld E. Meyer 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor N;nne(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2527-A wells abandoned:
NC well Contractor C'ertitication Number 7b.Approximate volume of water remaining in well(s): 0-(gal.)
protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
C:,upany N;mt,
7e,Type of disinfectant used: HTH
2.Well Construction Permit#: na
List ull uppiiruidr u•el!ranso•urtiun pernrirs(i.e.1.11C.C'orwtr,S'uuc,llariturcr,rtn)iij'knmrn 9 oz.
7d.Amount of disinfectant used..
3.Well use(check well use):
Water Supply Neil: 7e.Scaling materials used(check all that apply):
❑Agricultuai DMunieipal/Public ®Neat Cement Grout ❑ Bentonite Chips or Pellets
DGeothenrtal(Heating/Couling Supply) IgResidential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
DlndustriafCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑h•rigation ❑ Specialty Grout 0 Gravel
Nion-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
lvi on it orinz ❑Recovcry
Injection Xcll: 7f.For each material selected above,provide amount of materials used:
❑Agt:ifer Rc,:harge ❑Groundwater Rentediation pea gravel 0.25 yP
❑Aquifer Siora110 and Recovery ❑Salinity Barrier
gallons
110
D.duifl:•Test ❑Stotmtwatcr Drainage neat cement grout 9
DExperimental Technology ❑Subsidence Control
❑iieutherrn;; (Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) well pumped pulled, sounded,found free of obstructions
chlorinated,filled with pea gravel to within 10-feet of casing bottom
=4.Dale ive!l(s)abandoned: August 23, 2022
filled to top of casing�with neat cement grout
5n.Woli location: top 3-feet of casing remover/,capped with 1-foot of concrete
Vickers Bennett Group LLC na
Numc Facility 11M(ifapplicable) H.Certification:
f
9408 US 15-501 Chapel Hill NC 27517 4 f /��----- 8/30/2022
I'hy:i.al Ad,lress.City,andZip Signature of Certilied Well ontractC or cir Well(honer Date
9775-52-1331
Sv signing this./brtn, I hereby certili'that the well(s) was(were)abandoned in
Ct''r': Parcel Identification No.(I'IN) accordance with 15A NC4C 02C.0100 or 2C.0200 Well Consnvtct1an Standa,-,&
Sb.Latitu[ie and longitude in degrecshninutes/seconds or decimal degrees: and that a Copp gf'this rerand has been provided to the well owner.
0!tvcfl:i_:d,m.e bt/long is sufficient)
�. 9.Site diagram or additional well details:
35 4•tj• D2.114"t \, 71 05t 02.365" �, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
C GNS T RZl,7TION DETAILS OF WELL(S)BEING ABANDONED
4uucLnx•llrnncuvrtinnrerordtlilnrni!able. rm.nrnhiplrim)rcuun ell.will SUBMITTALINSTRUCTIONSI
O:S'_Y,rid;rL;scum rnn.ru•ucrion/uhunrhnuncnt.ruu rtm.eulnrritJiu•nr. ,:
IOa. For All Wells; Submit this form within 30 days of completion of well
ti .:: Ilia abandonment to the following:
Division of Water Resources,Information Processing Unit,
6L.'_'otal.:ell depth: 25® (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in IOa
6e.Bonne!: diameter. 6.5 (in,) above,also submit one copy of tl)is form within 30 days of completion of well
abandonment to the following:
75
6�.\\:eer=eve1 below ground surface: 17. (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Gute:,cuing length(if known): 28 1 Oc.For Water Sunniv&Injection Wells: In addition to sending the form to the
address(es)above,also submit one'co'py of this form within 30 days of completion
of well abandonment to the cot Vmty health department of the county where
fi' facer esinQ/fubirtg length(if known): na (ft.) abandoned.
6 .Scree teergth(if known): Pia (ft.)
i
Perm Gov-3, North Carolina henartmeiu of P.m,irmmrnral n,e.Gnr_flw;.i ,.i W"".,gov......•o:.

k
1
OCT
WELL ABANDONMENT RECORD For internal Use ONLY: �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E. (Meyer
79.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hi,/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
252 -A wells abandoned:
NC Well Contractor Certification Number 7h.Approximate volume of water remaining in well(s): 0 (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS1 ONLY:
('na:pany Nnmc I
7c.Type of disinfectant used: HTH
y.Well Construction Permit#: na
Lisr all applirahlr❑vll ron.strurnun permit-Y(i.e.VIC.Coanp'.Slate,Variance,erc.)ifknoult 8 oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Weil: 7e.Sealing materials used(check all that apply):
❑Aericulnu-al ❑Municipal/Public 19 Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating'Cooling Supply) ®Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑lndustrial'Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout a Gravel
Non-water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation pea gravel 0.25 yd
❑Aquifer Storage and Recovery ❑Salinity Barrier
DAquift:r'rest ❑Stom neat cement rout 110allonsnvater Drainage g g
❑F,xperimentil Technology ❑Subsidence Control
00cc2herm:tl(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) well pumped pulled, sounded,found free of obstructions
chlorinated,filled with pea gravel to within 10-feet of casing bottom
-1. sate well(s)abandoned: August 23, 2022 i
filled to top of casingiwith neat cement grout
s"Well location: top 3-feet of casing removed,capped with 1-foot of concrete
Vickers Bennett Group LLC na
P::.:i!it}:U„'a;.rName Facility ll7k(ifapplicaahlc) S.Certification:
271 Jack Bennett Road Chapel Hill NC 27517 _ ly � 8/30/2022
Physic:a Addr_,ss.Citv,and`Lip �---
Signature ofCa7ilictl\Vell Contractor or Well Owner Date
Cha`Ena�� 9775-61-4937
/Y signing this 1brin, I herebt�cerli&that the ir•ell(s) was(were)abandoned in
t`°'-k'•^)' Parcel Identification No.(PIN) are-orlanrr a ilh 15,1 NCAC 02C.0100 nr•2C.0200 9re/1 Conctntation Standards
cute!that a copy q/7his record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one lat/long is sufficient)
,,_ .1 9.Site diagram or additional well details:
35 48• 58.417" NA 04' 46.967" " You may use the hack of this page to provide additional well site details or well
abandonment demils. You may also attach additional pages if necessary.
CGNST f:UCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS�
�tuachn•rllron.co•nc4ionrecardlcli%available. For nndiiplrinjecrionornan-n•uten•.cupplrurlJe
ON!,y with the.crone rnnstracrionriehundomnenl.t'oa can submit one.fortn.
10a. For All Wells: Submit this form within 30 days of completion of well
ur..\Veli 1 e3 1: na abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Tot::t well depth: 84 (ft•) 1617 Mail Service Center,Raleigh,NC 27699-1617
6 5 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 0n.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the lollowing: j
6.1 Water level below ground surface. 37.40 (tt) [Division of Water Resources,(Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 68 (ftJ 1 Oc.For Water Suumly&Inieeti In 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
61'.Inner casing/tubing length(if known): na (ft•) abandoned.
6g.Screen length(if known): na (itJ
For:,,e�tv_;h r,....r..•.._..,:....�.._......._..._«....:..._..-_..._,,. ,. ... ..... .. ; .

h_
WELL ABANDONMENT RECORD For internal Use ONLY: 7 2022
1.Well Contractor Information: ABANDONMENT DETAILS
David E. Meyer
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
\Voil Contractor Name(or well owner personally abandoning well on his/her property) well constniction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2527-A wells abandoned-.
NC Well Contractor Certification Number 71).Approximate volume of water remaining in well(s):.9-(gal.)
.Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Nanio I
7c.Type of disinfectant used: HTH
2.Well Construction permit#: na
List all appliveihie well(.1))1s11-11j-1io01 pe)-1)1i1s(i.e.(11C('(j1m1Y,Slate,Varionce.e1c.)iftnown 7d.Amount of disinfectant used: 8 oz.
3.Well use(check well use): 1 -1
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricuintral []Municipal/Public 9 Neat Cement Grout 0 Bentonite Chips or Pellets
0Gcotherinal(I teat i ng,'Cool ing Supply) ®Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Ind ustria l.'Commercial DResidential Water Supply(shared) 11 Concrete Grout 0 Drill Cuttings
011-rigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
0N,lonitor:.n& ORecovery
Injection Wc7l: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge CGroundwater Rernediation pea gravel 0.75 yd
ElAquiller Storage and Recovery OSalinity Ban-ier
neat cement grout 110 gallons
111Aquifer Test OStormwatcrDminage
ElExperiinental Technology OSubsidence Control
IlGeotherimil(Closed Loop) C]Tracer 7g.Provide a brief description of the abandonment procedure:
ElGeothermal(Heating/CoolingReturn) 00ther(explain under 7g) well pumped pulled, sounded,found free of obstructions
August.23,2022 chlorinated,filled with pea grav'el to within 10-feet of casing bottom
4.Datewell(s)abandoned:
filled to top of casing with neat cement grout
qn.Well location:
Vickers Bennett Group LLC na top 3-feet of casing removed,capped with 1-foot of concrete
Facility IDft(if applicultle) 8.Certification:
341 Jack Bennett Road Chapel Hill NC 27517 Ll % 8/30/2022
Phv,icai Addrcs,.City.andZip
Ch_'Lharn 9775-61-7807 Signature of Certifid W eell tonunctor or Well Owner Date
B signing
Court% g this./brin. I hereby certffy that the ivell(s) was(ivere)abandoned in
Parcel Identification No.(PIN) accordance with 1511 MCAC62C.0100 or 2C.0200 Well Cnnsti7ictini,Standards
5b.Lalicude and longitude in degrees/minutes/seconds or decimal degrees: and that a cop),q(lhis record has keen prnvided to the well turner.
01'weil flcl,� ore 120ong is sufficient)
9.Site diagram or additional well details:
ra
You may use the back of this page to provide additional well site details or well
35 48" 57.831 79-04' 43.694" W abandonment details. You may also attach additional pages if necessary.
COINST RUCTION DETAILS OF WELL(S)BEING ABANDONED
SUBMITTALINSTRUCTIO NSI
6:1.Well 1,119, na abandonment
For All Wells: Submit thi.8 form within 30 days of completion of well
abandonment to the following:
Division of Water Resop; rces,Information Processing Unit,
6b.Total it ell depth: I 10 1617 Islail Service Center,Raleigh,NC 27699-1617
101).For Iniection Wells: In addition to sending the forni to the address in 10a
6c.Boreltole(linnicter: 6.5 above, also submit one copy of this form within 30 days of completion of well
abandonment to[fie ibilowing: I
i
6d.Wztev level below ground surface: 31.80 _(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6.,.Outer casing length(if known): 21 1 9c.For Water Sumalit&Inlection Wells: In addition to sending the form to the
address(es)above,also submit one'cc;py of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.lkiner easing/tubing length(if known): na abandoned.
6g.Screen length(if known): na
(ft.)
Vorn)OW-.310 .......... ............ ...........
I

WELL ABANDONMENT RECORD For Internal Use ONLY:
7.2022
1.Well Contractor Information: ABANDONMENT OCT 0
David E. Meyer D unii
7a.For Geoprobe/DPT or Closed-Loop'-Gel��6rQa,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
wells abandoned:
2527-A
N('Well Contractor Certification Number 7b.Approximate volume of water remaining in welf(s):-q—(gal.)
froilocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ,TH
2.Well Construction Permit#: na
List all PO-111i's 0.e.VIC('611110%State.Variance,e1c.)fl,known 7d.Amount of disinfectant used: 8 oz.
3.Well use(check well use):
Water Supply,Well: 7e.Sealing materials used(check all that apply):
' Supply,
'i' "
Ei-Agricultural Oklunicipal/Public El Neat Cement Grout 0 Bentonite Chips or Pellets
r -�t FEIGeothernial(Heating'Cooling Supply)
i, ®Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
01ndustrial!Commercial 0 Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
ElIrrigation 0 Specialty Grout IM Gravel
Non-Water Supply Well:
0 Bentonite Slurry 0 Other(explain under 7g)
LIMonitoring ORecovery
Injection Well:
7f.For each material selected above,provide amount of materials used:
OAC]Llifer Recharge CGroundwater Remediation pea gravel 0.50 yd
0AqUillbr Storage and Recovery OSalinity Barrier
0Aquiler Test OStornawater Drainage neat cement grout 160 gallons
ElExpeiinictual Technology OSubsidence Control 7g.Provide a brief description of:the abandonment procedure:
EXicollicnin!(Closed Loop) DTracer
DGeothormal(Heating/Cooling Return)... 1301her(explain under 7g) well pumped pulled, sounded,found free of obstructions
chlorinated,filled with pea gravel to within 10-feet of casing bottom
4.Date vvell(s)abandoned: August 23,2022
filled to top of casing with neat cement grout
Sa.V Veh jocadon; i
top 3-feet of casing removed,capped with 1-foot of concrete
Vickers Sennett Group LLC na
Nam,, Facility 11M(if applicable) S.Certification:
395 Jack Bennett Road Chapel Hill NC 27517 8/30/2022
Physical Address.City.andZip Z��Owner Date
Chatham 9775-71-1836 131,signing this fiw-in. I hereby cer 1ify that the wells) tags(were)abandoned in
-I
Parcel Identification No.(PIN) at-cordanve with ISA NCAC 02C.0100 o,-2C.0200 Well ConsImctimi Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a cop),of this record has been provided to the well owner.
(i',vel!field,one lat/lona is suflicieno
- a 0 9.Site diagram or additional well details:
115 48' 56.089" 79 04' 39.394" 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 WELL(S)BEING ABANDONED
For nitthipleiii'1 SUBMITTAL INSTRUCTIONS
.t,0111H Irells
0A'L Y with thesanit,corrstrrretioniabandonnient,roe can submit oile bt-111.
10a. For All Wells: Submit this form within 30 days of completion of well
6t,..v,,cll na abandonment to the l'ollowing.
Division of Water Resources,Information Processing Unit,
65.Total well depth: 140 1617 Mail Service Center,Raleigh,NC 27699-1617
1
10b.For infection Wells: In addi,tiop to sending the form to the address in 10a
6c.Borehole diameter: 6.5 -(in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
66.Water level below ground surface: 25.25 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Cater casing length(if known): 57 file.For Water Suppiv&Injection wells: In addition to sending the form tothe
address(es)above,also submit one copy of this form within 30 days of completion
I
of well abandonment to the county' health department of the county where
6f.hitter casing/tubing length(if known): na ft.) abandoned.
61-'-Screen length(if known): na

FF�
WELL ABANDONMENT For OCT 0 7 2022
or Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E. Meyer
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
2527-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in welf(s):9—(gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name I
7c.Type of disinfectant used: HTH
2,Well Construction Permit#: na
List all applicable tt-ell consio-liction permits(i.e.UIC,Coun(.Stale,Pai-itilice,etc.)ifknow,11 7d.Amount of disinfectant used: 8 oz.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
t
CAgicuI rural OMunicipal/Public 9 Neat Cement Grout 11 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) 13 Sand Cement Grout 0 Dry Clay
01ndustrial/Commercial OResidential Water Supply(shared) 11 Concrete Grout 0 Drill Cuttings
DIrrigation — 0 Specialty Grout 9 Gravel
Non-Water Supply Well: D Bentonite Slurry 0 Other(explain under 7g)
OMonitoring 0 Recovery
Injection Weil: 7f.For each material selected above,provide amount of materials used:
0Aquifer Recharge OGroundwater Remediation pea gravel 0.5 yd
ElAquifer Storage and Recovery CSalinity Barrier
OAqLlifcr Test OStormwater Drainage neat cement grout 120 gallons
OExperimental Technology 0 Subsidence Control
ElGeothermal(Closed Loop) OTracer 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Hearin Cooling Retum) 00ther(explain under 7g) well pumped pulled, sounded,found tee of obstructions
chlorinated,filled with pea gravel to within 1 0-feet of casing bottom
4.Date well(s)abandoned:August 23, 2022 filled to top of casing(with neat cement grout
5 1 a.Well location: top 3-feet of casing removed,capped with 1-foot of concrete
Vickers Bennett Group LLC na
Facility/Owner Name Facility ID#(ifupplicable) B.Ce tin!cat io�—
493, Jack Bennett Road Chapel Hill NC 27517 8/24/2022
Physical Address.City,and Zip
Signatilrie of Certified Well Contractor or Well Owner Date
I
Chatham 9775-71-5890 By signing this Joan, I herebi,certify: that the ivell(s) was(were)abandoned in
County
Pirc.1 Identification No.(PIN) aernrdanc-e with 15A 1VCAC 62C.0100 or 2C.0200 Well Construction Standards
Sir.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a cope ql'this record has been provided to the well owner.
(ifwall field,one latflong is Sufficient)
it 9.Site diagram or additional well details:
3b You may use the back of this page to provide additional well site details or well
48' 55.592 7�f 04' 32.356" W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Alifichii,eliconst),uctio)?i-eco)-dts)ifavaii(ible. SUBMITTAL INSTRUCTIONS
ONLY with the some eent submit alle.ffirl". 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: na abandonment to the following:
Division of Water Resou i rees,Information Processing Unit,
6b.Total well depth: 125 1617 Mail Service C enter,
nter,Raleigh,NC 27699-1617
10b.For ln*ection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6.5 (in.) above,also submit one copy of this form within 30 days of completion of well
abandomnent to the following:
6d.Water level below ground surface: 30.15 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 46 10c.For Water ulgPlY&Infection Wells: In addition to sending the form to the
address(es)above,also submit one dopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
61'.Inner casing/tubing length(if known): na abandoned. iI
0g.Screen length(if known): na
(ft.)