Wake_Well Abandonment_20240814

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMIENT DETAILS
David E. Meyer 7a.For Geoprobe/D or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her properly) well Construction/dep[ ,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2527-A wells abandoned:
20
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfecta t used: HTH
2.Well Construction Permit#: GW-129544-2024
Lief all applicable well consrniction permits(i.e.UIC.County.State, I in•ianc•e,elc.)ifkiwwn 8 oz.
7d.Amount of disinf tent used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials sed(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material lected above,provide t�tnopn�of mwtCt+iats bid:'.
❑Aquifer Recharge ❑Groundwater Remediation 30 x 50# bags chips
❑Aquifer Storage and Recovery ❑Salinity Barrier I.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment ptCOCed4rt:_
❑Geothermal(Closed Loop) ❑Tracer Well pump amJ pipe pulled from well. Well sounded
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Found free of abstructions. Chlorinated. Fill with beneilllTC
4.Date well(s)abandoned: August 2, 2024 to top. Top 35 feet of casing will be removed when NEa
5a.Well location: municipal war r line is installed through wellhead.
Carolyn Harward na
Facility/Owner Name Facility ID#(if applicable) S.Certification:
3200 Hinsley Road New Hill, NC 27562 8/2/2024
Physical Address,City,and Zip Signature of Certified Well ontractor or Well Owner Date
Wake 0720378505
By signing this form. I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A N AC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this r cord has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablong is sufficient) 9.Site diagram or add tional well details:
35.69379 -78.91962 w, You may use the back f this page to provide additional well site details or well
abandonment details. u may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTR I TION
Allach well conctnictinn ree•ord(v)ifm-ailahle. !•iirnudiiple iniecrion urnun-walcr.supply a elLc
ONLY with the same constniclian abandonment,you can.cuhmit one Jimn.
10a. For All Wells: ubmit this form within 30 days of completion of well
6a.Well ID#: 1 abandonment to the foil wing:
Division of ater Resources,Information Processing Unit,
6b.Total well depth: 112 (ft.) 1617 Mai I Service Center,Raleigh,NC 27699-1617
10b.For Iniection We s: In addition 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:
6d.Water level below ground surface: 36 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mai I Service Center,Raleigh,NC 27699-1636
Un 10c.For Water Su 1 &In'ec' n Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also bmit one copy of this form within 30 days of completion
of well abandonment o the county health department of the county where
6f.Inner casing/tubing length(if known): na (D) abandoned.
6g.Screen length(if known): na (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Wat r Resources Revised 2-22-2016

W LEE ADA1V 1 UN IV1EN 1 RECORD For 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 l 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): 0 (gaL)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name none-dry
2.Well Construction Permit#:
GW-126746-2024 7c.Type of disinfectant used:_
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)ifknown none-dry
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 S Neat Cement Grout ❑ Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) HResidential 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)
❑Monitoring ❑Recovery _
Injection Well: 7E For each material selected above,provide amou0t otass eriahi used:r
❑Aquifer Recharge ❑GroundwaterRemediation 200 gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedi re;:;;❑Geothermal(Heating/Cooling Return) ❑Ctther(explain under 7g) Well found during landscape activities. Sounded fot.
plugged at-30' bls. Well filled with 200 gallons neat
a.Date well(s)abandoned: June 14, 2024 grout to 4 bls. Covered with soil to surface.
5a.Well location:
Claire L. Huene na
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
4019 Glen Laurel Drive Raleigh, NC 27612 v�;�, 7 6/14/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 0795095878
By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NeAC 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 well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.837578 N -78.6942805 W You may use the back of this page to provide additional well site details or well
abandonment details. Ybu may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Al/ach well construclion records)ifavailahle. I-or multiple injection or non-water supply wells
ONLY with the.same construction abandonment,you can submit one,form.
10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30+ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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: dry (ft_) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): none (ft) 10c.For Water Suonly&Injection Wells: In addition to sending the form to the
address(cs)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): na (ft.) abandoned.
6g.Screen length(if known): na (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016