Nash_Well Abandonment_20230109

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor'Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply ivells ONLY with the same
construction/abandonment,you can submit one form.
NC 3322-A
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
Regional Probing Services 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(HeatinglCooling Supply) ❑Residential Water Supply(sin(single) ❑ Sand Cement Grout— '-= tO.Dry:Glay
�..•->:.:�4 _ ; :.�,t�R.�
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout �- m" � = F ❑.Drill,Cuttings
[Irrigation ❑ Specialty Grout J^N 0 9 [nn�Gravel
Non-Water Supply Well: ❑ Bentonite Slurry H l' Other(explain under 7g)
@Monitoring ❑Recovery
Injection Well: 7E For each materra�'selec ed above;Qrovide•arrihlu�t of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips: 2"wells 1.6 Ibs/ft 40lbs/well
❑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 Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MW-2(2"x 3%MW-3R(2"x5%MW-9(2"xlT),EMW-2(4"x9'561bs bentonite)
4.Date well(s)abandoned: 12/17/2022
Sa.Well location: i
Circle K Store#2723106
Facility/Owner Name Facility IDfl(if applicable) 8•Certification: I,
1630 Sunset Avenue., Rock Mount Lawrence O er °
y pp � "°'°"�""�°s""°' 12/30%2022
Physical Address,City,and Zip Signature of Certified Well Contractor or,Well Owner Date
Nash By signing this form, I hereby cert fy that the well(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 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:
35.9504950 77.8185786 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 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#: See 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 3-13 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
well dia: 2-4 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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approx 2-3 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 Suoaly'&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
6E Inner casing/tubing length(if known): 10 (ft.) where abandoned.
6g.Screen length(if known): 15 (ft.)
f � '
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
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WELL ABANDONMENT RECORD For Internal Use ONLY:
k
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Wesley J. SorrellS 7a.For Geoprobe/DPT or Closed- lop 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
3577 wells abandoned:2
163
NC Well Contractor Certification Number 7b.Approximate volume of water ire,maining in well(s): . ,1.53 (gal-)
Terraquest Environmental Consultants FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta)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 N Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout '� ��,'y� Q;Dry•Glay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
B g❑Irri ation ❑ Specialty Grout JAN '0 9 [ avel
Non-Water Supply Well: ❑ Bentonite Slurry inyC�Y„C nr,-❑.Other(explain under 7g)
eMonitoring ❑Recovery t �9"'' _•^.� Un:l
Injection Well: 7E For each material selected ai o ;'Oro Ede amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.5 Gals Water
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
47 Lbs. ! Portland Grout
❑Experimental Technology ❑Subsidence Control,
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Poured Portland Cement through tremmie pipe from the bottem of well to surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 12/21/2022
5a.Well location:
L&L Food.Store#8
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2558 Hunter Hill Road, Rocky Mount NC 6b 5e4A,¢� 12/22/22
Physical Address,City,and Zip Signature of CertAfed Well Contractor or Well Owner Date
Nash By signing this form,1 hereby certify that the well(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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one]at/long is sufficient)
9.Site diagram or additional well details:
35.984424 N -77.837748 �, 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)ifavoilable.For multiple injection or non-water supply wells SUBMTITALINSTRUCTIONS '
ONLY with the same consiructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# MW 1,MW2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
6.25 (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:
5.01,5.63 (ft.) Division'of Water Resources,buderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
5 (ft.) loc.For Water Supply&Iniection Wells: In addition to sending the form to the address(es)above,also submit oneiedpy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing(tubing length(if known): N/A (ft.) abandoned. i
C
6g.Screen length(if known): 10
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Wesley J. Sorrells 7a.For Geoprobe/DPT or Closed, I op 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
wells abandoned:2
3577 G -
NC Well Contractor Certification Number
`V i? 71it.Approximate volume of water r Imaining in well(s): 1.54,1.49 (gal)
Terraquest Environmental ConsultantM 0 q [QZ,1 FOR WATER SUPPLY WELLS I ONLY:
Company Name
-7e.Type of disinfectant used: i.
2.Well Construction Permit#: ti,'.'0 1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 a 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 Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation .3.5 Gals Water
❑Aquifer Storage and Recovery ❑Salinity Barrier
47 LbS. Portland Grout
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of ithe abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Poured Portland Cement through tremmie pipe from the bottem of well to surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 12/21/2022
5a.Well location:
L&L Food Store#8
Facility/Owner Name Facility IDff(ifapplicable) 8.Certifi ation:
2558 Hunter Hill Road, Rocky Mount NC 12/22/22
Physical Address,City,and Zip Signature of Ceni ed Well Contractor or Well Owner Date
Nash By signing this form, I hereby certify that the well(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 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:
35.984424 N -77.837748 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 i
Attach well constructionrecord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form. I'
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW3,MW4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6.25 (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: 5.56,5.87 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length
5 (ft.) 10c.For Water SUDDtV&Inie'cti I n Wells: In addition to sending the form to the
(if known):
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
6L Inner casing/tubing length(if known): NIA (ft) abandoned. ! .
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6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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