Johnston_Well Abandonment_20230825

WELL A� (vraold)
A1)ANDO�N RJ CORJ For LttcinalUse ONLY: i
I21itop
1.Well Contractor Infornmtlons WELL ABANDONMENT DETAILS
Landon Phillips
7a.For Geoprobe/DPT or Cl sed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoningwell onbislherproperty) well construction/depth,only 1 GVW-30isneeded. Indicate TOTAL NUMBER of
' 3441 A wells.abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): Q
N.W. Poole.Well and Pump Company F (gala
FOR WATER SUPPLY WELLS ONLY:
Company Name • I'• HTH
��.. 7e.Type of disinfectant nsed:i
2.Well Construction Permit#:
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)if known 1/2 lb.
Id.Amount of disinfectant used:
3.Well use(check well use):
` Water Supply Well: , 7e.Sealing materials used(check all that apply):
i ❑Agricultural ❑Munici al/Publio ❑Neat Cement Grout ❑B
en tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Grout
❑Industiial/Commercial ❑Dry Clay
❑Residential Water Supply(shared) XIConorete Grout 0 Drill Cuttingi
❑hrigatlon 0 Specialty Grout 0 Gravel
Non-Water Supply c!IG.; ' '}
❑Monitoring ' `�^d c ❑Bentonite Sltrry 0 Other(explain under 7g)
ry
Injection Well: AUG 2 5'2023 7f.For each material selected above,provide amount of materials used:
❑AquiferRecharge uGroundwater Remediation
❑Aquifer Storagela tovg t7ryt P1#�lc.cataacg7 gtei y Barrier.• ye4 2 S Io �l0 g❑Aquifer Test 8Ots ❑Sto
rmwaterDrainage f ILL ao,*91arm/ 4440.661-A L /ti I x)
❑Experimental Technology ❑Subsidence Control
•
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑0ther(explain under 7g) thflo f�jf TEA. W��,(�
4.Date (s)abandoned: ///4jp•70a-Q flu- �'�� i"�t �� Co.✓CI�`
,
well
Sa.Well location:
ceeti✓ FeseL-6 Lt.t
weArfteit Fo?-U
Facility/Owner Name Facility 1Db(if applicable) S.Certitication:
I.
% 'a J c a0v CrNG t b, Ar lee NG 9 if / 3
Physical Address,City,and Zip
Q
GI�N S�a.� /1601 . Signature of Cem a or or Well Owner Date
i
By signing this form,I hereby certify that the well(s)was(were)abandoned in
CO1nty Parcel Identification No.(PIN) accordance with 15ANCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record 1tasbeen provided to the well owner.
(if well field,one at/long is sufficient)
9.Site diagram or additional well details:
35. 52-9:30__ N —.7 , (A-ii--t-I t g 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)Ifavailabla.For multiple injection or non-rvatersupply Wells +SUBMr 'ALINSTRUL'IIONS
ONLY with the same construction/abanilanmetu,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:
•
a 1 • Division of Water Resources,Information Processing Unit,
6b.Total well depth: ^^U (ti(ft.) 1617 Mall Service.Center,Raleigh,NC 27699.1617.
d
lob.For Iniectton Wells; In addition to sending the form to the address in 10a
6c.Borehole diameter: (m) above,also submit one copy of this 1form within 30 days of completion of well
abandonment to the following: I
�—
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Sunaly&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
6f.Inner casing/tubing length(if known): ofandon d well abandonment to the county health department of the county where
• (ft•)
•
6g.Screen length(if known): �. (ft.)
Form OW-3o North Carolina Department of EllviI011me111a1 Quality-Division of WaterResaurces 1 Revised 2-22-2016

i
WELL AB' wd ed ) .
�•
RECORD For Internal Use ONLY: 1
1.Well Contractor Information: 1 to
!, I, � �
Landon Phillips L�ABANDONMENT DETAIL s
• Well Contractor Name(or well owner personally abandoningwell on his/herproperty) 7a.For Geoprol/�pT or Closed-Loop Geothermal Wells,having the same
• 3441A P Y P .only 1 GVV- 0 is needed. Indicate TOTAL NUMBER of
wells abandoned: I I
NC Well Contractor Certification Number 7b. i O
N.W. Poole Well and Pump Company Approximate volume of wr"ter remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY: •
Company Name HTH
t^� 7c.Type of disinfectant used:l'
•
2.Well Construction Permit#:
List all applicable well construction permits(i.e.111C,County,Stale,Variance,etc.)tfknown , ' •1/2 lb.
7d.Amount of disinfectant used:
i 3.Well use(check well use):
Water Supply Well: 7e.Sealing materiels used(check all that apply):
' ❑Agricultural ❑Munich e!/Public CT NeatContent Grout 0 Bentonite Chips or Pellets
• ❑Geothermal Meeting/Cooling Supply) l Residential Water Supply(single) ❑Sand Cement Grout
❑IndustriaUCommeroial 1.
❑Dry Clay
❑Residential Water Supply(shared) Concrete Grout 0 Drill Cutting's❑Irrigation • ❑Specialty
Grout
I
Non-Water SuppirWo elFZ F0 Gravel❑Monitoring 1�'E pReCovery 0 Bentonite Slurry
0 Other(explain under 7g)
• Injection Well: AUG 2 5 ZOZ3 7f.For each material selected above,provide amount f, -of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1 _
°AquiferStorageN PltCtt it I Barrier ��/N�1 J� 1
p �'`0/�� �� F�`G
• ❑Aquifer Test DWO1306 ❑StormwaterDrainage I fOlaffe0A/etgij * M I
❑Experimental Technology ❑Subsidence Control X
❑Geothermal(Closed Loop) DTracer 7g•Providea brief description of the abandonment procedure:
•
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /t1'�/,lo 1Q i tt/A T P) �F1-(..
• 4.Datewells)abandoned: ///Y4 6)0 Fi`teb 14AA) b 'lK G (./;Li,
5a.Well loca io : to TA tio.41 C Ay t ��
0N Fi rib
wEAtiint Ird Rb uG
Facility/Owner Name Facility MR(if applicable) 8.Certification:
•
goo giltlao i Ail 0 i2e I ;fir m e .
Physical Address,City,and Zip /I/ / " O
(kPS.IO^/
County By signing this form,I hereby crtify that the wags)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C1.0100 or 2C.0200 Well Construction Standards
•
5b.Latitude and longitude in degreed dnutes/seconds or decimal de andthat copy of thus record/uzs I been provided to"tke well owner.
(if well field,one lat/long is sufficient) ��
7 r '30 9.Site diagram or additional well details:
35 �izi... N "I,.1 m... t gyp �r 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 records)ifavailable.For multiple Injection or non-seatersuppty wells $UBbIIT'PAI INSTRUCTIONS
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#: abandoatnent to the following.
•
6b.Total well depth:
Division of Water Resources,Information Processing Unit,
(ft) 1617 Mall Service Center,Raleigh,NC 27699-1617
6e.Borehole diameter:
10b.For Irdection Wells: In addition to sending the form to the address in 10a
(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: (ft.) Division of Water Resources,,Underground
Injection Control 1636 Mail Service Center,Raleigh, C 27699-1636
Program,
6e.Outer easing length(if known): r—_ (ft.)
l0e.For stet Supply&In1ectlo�n 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/tubing length(if known): (ft.) abandoned.
6g.Screen length(if'known): ~—
(ft.) i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 1.11.1016

"fie��
WELL ABANDONMENT RECORD
For Internal. Use ONLY: (• ,utritlixtfad '11 li r
Y/
1.Well Contractor Information: FELL ABANDONMENT DETAILS
. Landon Phillips
7a.For Geoprobe/DPT or Clos led Loop Geothermal Wells having the same
well Contractor Name(or well owner personally abandoning wall on his/her property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
3441 A wells abandoned: ¢ 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): O
•
N.W. Poole Well and Pump Company + (gal.)
• FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
.-...... - 7c.Type of disinfectant used: I
2.Well Construction Permit//:
List all applicable well conSnt ci Ian permits(I.e.UIC,County,State,Variance,etc.)if known 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well:
7e.Sealing materials used(check all that apply):
OAgricultural ❑Munici al/Public 0 NeatCement Grout • ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Grout
❑Industrial/Commercial 0 Dry Clay
❑Residential Water Supply(shared) Concrete Grout 0 Drill Cuttings
❑Irrigation
Non-Water Supply Well;:' j 0 Specialty Grout 0 Gravel
❑Monitoring "0 ❑Bentonite Slurry 0 Other(explain under 7g)
Injection Well: ry
AUG 2 5 2U23• 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑Groundwater Remediation •
❑AquiferStorage and$ecoYety 1 �o4 R t S i o f Flo i1-g .E
(„n tpreX: Sittin arrier
I
❑Aquifer Test l `QOStormwaterDrainage f ru LY.✓vi 2o:./.µf,1 AL ttl 1 K)
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑/Other(explain under 7g) t
1OIe f�✓it TE i lP�,(�
4.Date weil(s)abandoned:
i//3/ioao FiLt, j. L EPI a,t 7tf c4,�cR6TEi
Sn.Well location: .
Facility/Owner Name Facility 1Dit(if applicable) 8.Certification: I.
ri& Jrtt '0d krAG Pb, AY}9;ev NG , 0 i/ / (^ Q
�Physical Address,City,and Zip 2� 1'
JGI�NSTQ • , Signature e "1. Well Owner Date
County Parcel rdentificedoa No.(PIN) By signing this form,I hereby certify that the well(s)was(were)abandoned in
accordance with 15A NCAC 02CI.01,00 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/secoads or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one let/long is sufficient)
9-Site diagram or additional well details:
35.5L4--3_0_ N 7g-, WM It g 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 Jfnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well constructionrecord(sJiifavailabie.Far multiple injection ornon-water supply wells $�M�T�+IN UCFIONS
ONLY with the same construction/abandonment,you can submit one force..
�— 10a.For All Wells: Submit this form within 30 days of completion of well
6a,Well ID#: abandonment to the following:
•
a t Division of Water Resources;Information Processing Unit,
6b.Total well depth: (B,) 1617 Mall Service Center,Raleigh,NC 27699.1617.
• 106.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: tO (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1
6d.Water level below ^-
ground surface: (g� Division of)Voter Resources Unde,) rgronind Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniecti I n 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/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known); (ft.)
I
i
Form GW-30
North Carolina Department of Environmonial Quality-Division of WaterResouires
Revised 2-12-1016
I

WELL ABANDONMENT RECORD
Forternal Use ONLY: f `
1.Well Contractor Information: I(2)./f‘attizsa_41 i co
'
Landon Phillips WELL ABANDONMENT DETAILS
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 1 GW-30 is needed. IndIuate TOTAL NUMBER of
3441A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 N.W. Poole Well and Pump Company (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name j; HTH
1"'"".... 7c.Type of disinfectant used:'.
•
2.Well Construction Permit ll:
List all applicable well construction permits(I.e.U/C,County,State,Variance,etc.)ifbtown ', •1/2 lb.
Id.Amount of disinfectant used:
I 3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Monioipal/Public ❑Neat Cement Grout
❑Geothermal(Heating/CoolingSupply) Bentonito ChipsorPellets
[ esidentiel Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑IndustriaUCommerciel @R ential Water Supply(shared) Concrete Grout
�rV 0 Drill Cutting's Obligation r a �. 0 Specialty Grout
Non-Water Supp134Weilr ❑Gravel
( l� 5' Q Recovery
0 Bentot»ta Slurry ❑Other(explain under 7g)
❑Monitoring ^�
Injection Well: l? 7f.For each material selected above,provide amount of materials used:
' ❑Aquifer Recharge
ern prmeo+ dOrot ter Remediation d,►�� _
OAquifer Storage ai 'LT O'OSalinity Barrier /�jN a ,J57 " 0f Hot gL E Fla
• ❑Aquifer Test ❑StormwaterDrainage (1A1Vio4/P17I. M 1
[]Experimental Technology ❑Subsidence Control x
❑Geothermal(Closed Loop) OTmcer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Othher(explain under 7g) t<kl9 t I M•A 7 L/5L IL
4.Date wells)abandoned:
//V/Y 47id0 F ltfti a 14& D t' Do.6 (4,F Li,
5a.Well loca io :
tvi Ili &Ai eA
WE*1.14I .Fa RD L1°G
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
9,0 /Adafifi iiiii,& la. 1 Polgifr N C .
Physical Address,City,and Zip I D 1670a0
4 0(4 P SIOit/ 2150‘ • Sr ° o ctor or Well Owner
1i Date
By signing this form,I hereby Certify that the wells)was(were)abandoned in
CO1nty Parcel Identification No.(PIN)
accortlttnce with 15A NCAC 02C or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/tninutes/seconds or decimal degrees: that a copy of this record./tand asbeen provided to the well owner.
(if well field,one lat/long is sufficient)
15•Cam.4, +2O 9.Site diagram or additional well details:
. J 2 J N 40-1 L`m p 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 construct Ionrecord(s)ifavailable.For multiple injection ornon-walersupplywells SLIBMLTI'AL INSTRUCTIONS
ONLY with the same constructioniabandoiiment,you can submit one farm.
• II
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandoiunentto the following: P
6b.Total well depth: Division of Water ResO urces,Information Processing Unit,
(ft) 1617 Mail Service'Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in I0a
6c.Borehole diameter: v (in.) above,also submit one copy of this form within 30 days of completion of well •
abandonment to the following: 4' '
1--,—
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground de rg Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): .
(ft.) 10c.Fos-Wat_ ar Snnn�&Injection We 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/tubing length(if known): (ft.) abandoned.
6g:Screen length(if known): r- (ft.)
Form GW-30 North Carolina Department of Enyironmontal Quality-Division of Water Resources
Revised 2-22-2016