Perquimans_Well Abandonment_20221205

WELL A$ANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIL(I S
i
F G W T- Mz 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hisll:or property) well constiuction/depth,only l GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: '
P:C Well Co:tradorCestificstion un ?�- 7b.Approximate volume of water remaining in well(s): ('2L)
Ai' E-e i Ca•N i A ELL Er �� � FOR WATER SUPPLY WELLS ONLY:
CompanyName
7c.Type of disinfectant axed: A'. c:,may, f�.�.�,,c.0 ., .7T'
2.Weil Construction Permit M 1JU P&(^ f d
List all applicable well caintruction permits(Le.UIC,County,State,Variance,etc){f known
7d.Amount of disinfectant used: 6 2
3.Well use(check well use):
Water Supply well: 7e.Sealing materials used(check all that apply):
m7iculturs-1 ❑MnicipalIPublic f7 Neat Cernettt Grant 'Wq-eanfanite Chips nr pellet-
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑ihy Clay
❑lndustrial/Cornmereial ❑Residential Water Supply{shared) ❑Concrete drout ❑Drill Cuttings
0krigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
nitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount oEm tf rials used.,
❑Aquifer Recharge ❑GroundwaterRemediation 1'
ClAquift Storage and Recovery OSafinity Barrier /
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology CISubsidence Control
❑Geothermal(Closed Loop) t7Ttacer
7g.Provide a brief description of the 4bandonmen'009PA-9tp✓71 ar+'`� Z L,�q rb
OGeothemlal Hearin Cooling Itetum) [Other lain under 7g) ' u
I A(Fo w4 'rAfm- 5CCC-AM L'owri S
4.Date well(s)abandoned: C404y S -?PA—f4''tE�Ckitrl-I i� CAt�weiL_
Sa.Well.lecauaw. imire �& I u oFF
C4$� 10e 1Qcic
Facility/Owner Name Facility IDtf(if applicable) 0.Certification:
Physical Address,City,and Zip Signature of Certified Well Contra Well Owner Date
UiMA"S By signing this Arm, I hereby certify that the wells) was(were)abandoned in
County Pared Identification No.(PIN) accordance with ISA NC.4C 02C.0I00 or 2C.0200 Well Construction Standards
and that a copy ofthts record has been provided to the well ottner.
5b.Latitude and longitude in degreWralautp&Wcoads or decimal degrees:
(iEVveittietd.ltne iattlbhg is erff&ciftt) 9.Site diagram or additional well details:
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 WELLN)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellcominuctionrecord(s)i&wllable.Formadtfplctnfectlonornon-twiersupply:mlly
ONLY wfrh the same constntetlon(abaadonmcnt,you can submit line form. 10a. For All Wells: Submit this form within 30 days of completion of well
ba.Well W& _ abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b ToWweH•depth:- aQ- f S' (Ll 1617 Mail Service Center,Raleigh,NC 276994617
V Z113Ll+ �) 10b.For Infection Wells: In addition,to sending the form to the address in 10a
6e.Borehole diameter: above,also submit one copy of this form within 30 days of completion of well
abandonment to the following.
(id.Water level below ground surface: (R,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i I
6e.Outer casing length Of known): S (it) 10c.For Water Suonly&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy,ofthts form within 30 days of completion
d� of well abandonment to the county health dg tment of the county where
611 Inner casing(tableg length(if lmown): OV 07 (ft,) abandoned.
6g.Screen length(if lmown):
� as
Form GW-30 NoM Carolina Department of Environmental Quality-Division of Water Resort s ; Revised 2 22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
L II _7= 7a.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same
Weft Contractor Name(or well owner personally abandoning well on hidhorproperty) well construction/depth.only 1 GW 30 is!needed. Indicate TOTAL NUMBER of
wells abandoned-
2 SS �.
NC Ncll:Contractor.Certification'Numbcr 7b.Approximate volume of water re�alning in well(s): /t7 2- . feaL)
\ � e , „P g FOR WATER SUPPLY WELLS O Y:
CmnpanyNamo =-�Y 7c.Type ofdtsinfectantused; C,4 tt t AA �.1 A,ay1C+•iLn�t Ti-
t.Weu Construction Permit#:�v ,,( t n Cj L J
Listoll applicable swell constnrefion permits(Le.U1C,CMmty,S4ate.Variance etc)(fkrmwn
7d.Amount of disinfectant used: _
3.Well use(check well use): II
Water Supply Well: 7e.Sealing materials used(check all that apply):
Agricultural: ❑MunicipaUPublic, 0.Neat Cement Grout �' *entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑I»dustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout . ❑Drill Cuttings
131frigation ❑Specialty Grout ❑Gravel
Non-Water Supply well: a Bentonite SIurry 0 Other(explain under 7g)
onitaring DRecovery
Injection Well: 7f.For each material selected above,,provide amount of mates is se :i
❑Agaiferl2echarge DGroundtvaterltemediatian r� _ d 5 pEr
ClAquifr Storage and Recovery 0Satittity Barrier `;
❑Aquifer Test ❑StormwaferDrainage i s r-
17Experimental Technology )]Subsidence Control
7 .Provide a brief description of the abandonment rocedu "
❑Geothermal(ClosedLoop) DTraeer '7'-4Ka REtibhwtC7h5 7lli Ne Wk-1C Zy �+1;°;
❑Geothermal Heatin whili Return 00ther(explain under 7)
41 ALL 'Ti�l Eti/l.f3lIGC.Ft t..C. urj St:�.tta n[i m Gi,�t/•S.
yr C R4 v/l4•rP— A0c ib 4:aG 1z no&mx-
4.Date well(s)abandoned. Lo1-
�c3c�tCPS_'tE SYrZL FAjQbe,t U. '64W C-v
Sa.Wefllocatiao: FA G I Sft.IC�� i$1FLEltr1:
lkt�'e e4P :raw
Facility/Owner Name Facility M#(ifopplicablc) It.Certification:
Physical Address,City,and* Signature of Certified Well Contractor or We11 Owner Date
Pf►k j,rtn.a"C By signing this form,I hereby certify abut the well(s)way(were)abandoned in
County Parcel,Identification No.(PIN) accordance with 15A NCAC 02C.0100 or,2C.0200 Well Construction Standards
and that a copy ofthis record furs been provided ro the well miner.
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: i
(ifwcll fiend:one lattlong is sufficient) 9.Site diagram or tidditiontil well details:
_ 3(j. 3 o R-q N 76. 5 A/S'9 5------ .- 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 WELLM)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaacliwellconstructionrecard(.jifarailable.Formultiplelnfectlouornnn-swa(ersupplyKalts
ONLYwith thesame cdnstruction(abandonment,you can submit oneforta, 10a.Egg Ali Wells: Submit this within 30 days of completion of well
6a.Well M#, Id7 8 abandonment to the following:
Division of Water Resource),Information Processing Unit,
6b.Total well depth: .Z..Z S'- (ft) 1617 Mail Service Center,!Palclgb,NC Z70M617
10b.For Infection Welts: In addition to sending the form to the address in 10a J
6c.Borehole diameter-VI�kNlt�rl[ (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following.
I
6d.Water level below ground surface: i' (R,) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Cent I Raleigh,NC 27699-1636
6e.Outer taring length(if known): ( ) 10e.For Witter 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
6f.Inner casing/tubiag length(if known): H! (M) abandoned.
6g.Screen length(if Anown): j's'
eg
• i
Form dW-30 North Carolina DepaNueat of Environmental Quality-Division of Water Rcaotum Revised 2 22 2016

44
I
WELL ABANDONMENT RECORD For Internal Use ONLY.
1.Well Contractor Information: WELL ARANDONMENT DETAILS
k 1 C 7a.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/herproperty) well construction/depth,only t GW 30'is needed. Indicate TOTAL NUMBER of
wells abandoned:
hk[.W C _emu 1
VC well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 10 4(a 9 (gaL)
��LN•( 14 el.L Ru W FOR WATER SUPPLY WELLS ONLY:
CompanyNarna 7c.Type of disinfectant used: fL'C�Ij&I rZ8v C1![r7ILf Z�
2.Well Construction Permit
List all applicable well consintedon permits CIA UIC,County,State,Variance,etc.)iflwaxN
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(cheek all that apply):
DAgricultutal. OU[unicipal/Public O Neat Cement Grout Bentomte Chips or Pellets
OGeothemtal(Heating/Cooling Supply) OResidential Water Supply_(single) _O Sand Cement Grout ❑Dry Clay
Olndustrial/Commercial OResidential Water Supply(shated) ❑Concrete Grout ❑Drill Cuttings
13H don O Specialty Grout O Gravel
Non-Water Supply Well: O Bentonite Slurry ❑Other(explain under 7g)
onitoring ORceovery w
qqjectiou Well: 7f.For each material selected above,provide amount''of*_ el+�iais pose -1
DAquiferRecharge OGroundwaterRemediation
QAquitbr Storage and Recovery OSafinity Barrier - ti 2022
1JAquiferTest ❑StormwaterDrainage
�sd�7 tsi+
DExperimental Technology OSubsidence Control �-,
�t� may; ,
7g.Provide a brief description of the abandonment procedu Q/v� o Uri.
❑Geothermal(Closed Loop) ❑ ',q.Tracer -yk eG Rs4btr. Gfc/ la-fAzZ�t1f51 S'YArnal 11�1Fv oN
OGeothermal Heatin Coolin Rettlm) OOther(explain under 7g) -fR SG T f:
-T+dEAJ,34Gc 0i1-4 w/6"I-ram I7r--Ct4%eS. Al YC.4Vt gita
4.Date wells)abandoned: 2 Z. " Sv— �a�o �Cr�CO Reza - EZL
1 JD'?H,��/ Cuy Cs�-F G/4-Srnl•�, err ���� G,2A��
Sa.Well lacatiao: 9 C AP '?ad aN A cK 4 .
�Cll L 4w h 1=tke-,
FaciliVOwncrName Facility M#(if applicable) 0•Certification:
752 . X c &t /C'„9. :G.Ir "e":- -0 1A Gcka�rr'�
Physical Address,City,and Zip Signattuc of Certified Well Contractor or Well Owner Date
TE
83'sigrrfng this form, F hereby certify that the wells)um(were)abandoned in
County Parcel rdentification No.(PIN) accordance with ISA NCAC 02C.0100 ori2C.0200 Well Construction Standards
5b.Latitude and longitude in d and Muir a copy of this record has been provided to the well owner.
ngi egrees/Morinteteslsoxands or decimal degrees: �
(ifweil'fitrd;one latllong is sufficient) r� 9.Site diagram or additional well dettiils:
3 �. _�O 9� N '" 7te. S T�e 7 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 wellconstructionrecord(s)ifavaflable.Fornrdtoleinjecdonornon-rvatersappo-imllr
OIPLYwith the saw
peons!ntction/abandonmenryottcmtsubtnttorreform. IU For Woftj Submit this form within 30 days of completion of well
6a.Well ID#4. A abandonment to the following:
Division of'......Resources;Information Processing Unit,
6b.Total well depth.- 245.Q G (ft-) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e Borehole diameter-V$AkAWtV IJ On.) above,also submit one copy of this forin within 30 days of completion of well
abandonment to the following. j
6d,Water level below ground surface: +F� (It) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1 .
6e.Outer casing length Of known): � ` (ft.) lOc.for Water Suonly&Infection WeiIs- In addition to sending the form to the
addreas(es)above,also submit one copy ofthts form within 30 days of completion
of well abandonment to the county h"eaith department of the county where
611 Inner casing(tubing length(if Imown): abandoned
f t ,
6g.Screen length(if!mown): 5
va
Form OW-30 North Caroline Department of Environmental Quality-Division of Water Resources Revised 2 22-2016

tlaL->,t\DONMENi RECORD For
WELL I `
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or..Glosed Loop Geothermal Wells having thg:same
Well Contractor Name(or well owner personally abandoning well an his./her property) well construction/depth,only I GW-30 is needed.'Indicate TOTAL NUMBER of
wells abandoned:
ACinf Q--557-- —04
NC Well Contractor Certification Numbcr 7b.Approximate volume of water remaining in well(s): /a. L—(gaL)
44 r ><l►.i �� f l <iLl FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: c-4?'r--(y mit_ ��owoyer,
2.Well Construction Permit#: (IM K OV--JLI
List all applicable well construction permits O.e.UIC,County,State,Variance,etc.)(/'known
7d.Amount of disinfectant used: n'z
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
_ DGeothennal-(Heating/Cooling Supp)y),_ ❑Residential.Water Supply_(single) _❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
[Ifirigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry �' ❑Other(explain under 7g)
Monitoring ❑Recovery
Nection Well: 7f.For each material selected abov i provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
I
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonmggttprucedure: 7�
❑Geothermal(Closed Loop) ❑Tracer �/a. .�f✓{471µ6tS.t TG7'A4Z,bt �r1+��I! Fb �g.�/
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) _ -
TN&-nI Race--FItL W, gfY
4.Date weil(s)abandoned: /10V .23 _Zo11 AP.a AO t,4&t4— RE/QAA, CO"C'ee.-Ce 4S--gy GKCWSUe',
Sa.Well location: $Aa<FIL
Li�•ii�i✓1 LF
Facility/Owner Name Facility lD#(if applicable) 8.Certification.'
r
Physical Address,City,and Zip Signature of'Cettified Well C6=-r-actor or We]]Owner Dare
pezot,I M_IA,.4ss By signing this form,I hereby certify that the wells) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0160 or 2C.0200 Well Construction Standards
and that a copy of this record has beet provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) // 9.Site diagram or additional well details:
"G 3'O 9 q,,3 N '7lra You may use the backof 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 wellcoartructionrecord(s)ifavailable.For multiple injection or non-watersupplywells
ONLY with the same corismuction/abandonmetrt you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: *' R abandonment to the following:
's
Division of Water Resources;Information Processing Unit,
6b.Total well depth:� ,Q_(ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: yAl d (n.) 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: {ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
11
6e.Outer casing length(if(mown): '. (fo 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 lieaith department of the county where
6f.Inner casing(tubing length(if known).y/' (ft) abandoned.
t e
6g.Screen length(if(mown):
Fomn GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2.22-2016
1