Dare_Well Abandonment_20240119

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIL'S
Justin Radford 7a.For Geoprobe/DPT or ClosedFLoop 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
3270-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of wate`remaining in well(s). 3.19 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c:Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)(known
7d.Amount of disinfectant used:':
i ,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check;pll that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 30 Ibs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 Ibs Concrete
❑Experimental Technology OSubsidence Control 7g,Provide a brief description ofithe abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer s, r ,r,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) our f ','y r
4.Date well(s)abandoned. 01/03/2024
5a.Well location:
.I D
Ballance Oil=Hatteras Village n/a j
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
57194 C Deering Ridge Road, Hatteras, NC
Physical Address,City,and Zip Signature of Certi Well Contractor�,Well Oyer Date
Dare 9584-0899-9915 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i,
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.215660 N 75.685100 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 well construction record(s)ifavailable.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
IVI W-4 abandonment to the following:
6a.Well 1D#: � .
Division of Water Resoiirces,Information Processing Unit,
26.00 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft)
i ,
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this(form within 30 days of completion of well
abandonment to the following:
I
i
6d.Water level below ground surface• 6.41 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
i
6e.Outer casing length(if known): n/a 10c.For Water Supply&Iniecti 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
6f.Inner casing/tubing length(if known): 20 Alto) abandoned.
6g.Screen length(if known): 5 Aft.)
i
Form GW-M North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

• G
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAII:S
Justin Radford 7a.For Geoprobe/DPT or ClosedTLl op 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
3270—A wells abandoned: I�
NC Well Contractor Certification Number 7b.Approximate volume of orate±ri maiming in well(s). 1.95 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS 0.NLY:
Company Name 7c.Type of disinfectant used.
2.Well Construction Permit#: N/A
List all applicable well construction pennits(i.e.WC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well rise):
Water Supply Well: 7e.Sealing materials used(check!all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 15 Ibs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 Ibs Concrete
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour v' nay��r @._-,• 44' �_._s_._
. JAIN 1 9 HIM
4.Date well(s)abandoned: 01/03/2024
5a.Well location: ^ a
Ballance Oil-Hatteras Village n/a
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
I,
57194 C Deering Ridge Road, Hatteras, NC
Physical Address,City,and Zip Signature of Ce ' ed Well Contra or or We weer Date
Dare 9584-0899-9915 By signing this form, I hereby certify that the ivell(s) was (were) abandoned in
County 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 ivell owner.
(if well field,one lat/long is sufficient) 9.Site diagram or.additional well details:
35.215660 N 75.685100 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.
1.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS,
Attach well constriction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
1�A`n' 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 'V I V V—3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13.00 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• I
10b.For Iniection Wells: In addition to sending the form to.the address in 10a
6e.Borehole diameter• 2 (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:
1.01 (ft.) Division of Water Resources,JUitderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
n/a (ft.) 10c.For Water Supply&Iniection*ells: 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
6E Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

r
WELL ABANDONMENT RECORD For Internal Use ONLY:
li
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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 GM 4 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned:
2
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '1
(gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc)iflmown j
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 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 15 Ibs of.Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
15 Ibs Concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
01/03/2024
5a.Well location: I€t vr"a�iBII e'r,^.a;?.; ( rqj-
Ballance Oil-Hatteras Village n/a
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
57194 C Deering Ridge Road, Hatteras, NC f t
Physical Address;City,and Zip Signature of Certi d Well Contractor r Well O r Date
Dare 9584-0899-9915 By signing this form, I hereby certify that the ivell(s) ivas (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]at/long is sufficient) 9.Site diagram or additional well details:
35.215660. N 75.685100 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 well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same consiniction/abandonrnent,you can submit one form.
It A`n' 10a. For All Wells: Submit this form within 30 days of completion of well
V I 6a.Well ID#• I V V—9 abandonment to the following:
r
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13.00 (fk) 1617 Mail Service Center,Raleigh,NC 27699-1617
b
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 0.00 (ft) Division of Water Resources,lUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
n/a (ft.) 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 health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
I �
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016