WI0600068_Permit (Completion)_20240812

Department of Environmental Quality-Division of Water Resources
STATUS OF INJECTION WELLS)/PERMIT RESCISSION REQUEST FORM
Permit Number: WI0600068
Permittee Name(s): Smitty's Cleaners DSCA Site#26-0003
Mailing Address: 5834 Wade Park Boulevard, Suite 200,Raleigh,NC 27607
Physical Address of Well(s)(if different than mailing address): 3060 Owen Drive
City Fayetteville County Cumberland Zip Code 28306
Daytime Telephone No.: 919-461-1485 Cell No.: 804-690-9212
Email Address: [e-mail]
Please check the selection which most closely describes the current status of your system:
1) ( Well(s) still used for injection activities
2) ( Well(s)not used for injection but used for other purposes: a)(Water Supply
b) (Recovery
c) (Irrigation
d)(Monitoring
3) X Injection discontinued and: a) (Well(s)temporarily abandoned
b)X Well(s)permanently abandoned
c) (Well(s)not abandoned
4) ( Injection well(s)never constructed ( N/A injection well(s)never proposed
Well(s)Abandonment/Comments:
If you checked(3)(a) or(b), attach a copy of the GW-30 (Well Abandonment Record). If not applicable,then describe
the method used(or to be used)to abandon the well(s),including a description of how the well were sealed and material
used. If the work below is proposed,a GW-30 will need to be submitted to the UIC Program 30 days after abandonment.
Injection was completed via temporary DPT wells which were abandoned followingtjection event. GW-30 record
is attached.
Permit Rescission:
If you checked(2),(3),or(4)and will not use a well for injection on this site in the future,you should request rescission
of the permit. Do you wish to rescind the permit?
X Yes ( No
Certification:
"I hereby certify,under penalty of law,which I have personally examined and am familiar with the information submitted
in this document,, and that to the bes of my knowledge the in ation is true, accurate, and complete."
`
(f f C-4 r;k Q c Z 6000 3 August 12,2024
Signature Date
Ford Nicholas Shore Project Manager
Print or Type Name Title
GW-68 Injection Well Status Form Rev.3-1-2016 Page 1 of 1

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
4^-( li.L-A-C-Ae-A-IL A-V-( 7s.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
ie 0/7 i Z construction/abandonment,you can submit one form. .�
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
e-c-P FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well permits Q.e.County,State,Variance,b jection,etc.)iil known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 77e.Sealing materials used(check all that apply)-
❑Agricultural ❑Municipal/Public Sd Neat Cement Grout entonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residengal Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: � 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge lJGroundwater Remediation 1�/k de
❑Aquifer Storage and Recovery ❑Salinity Barrier � l
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer / w
/ 6-
❑Geothermal Heatin Coolin Return) ❑Other ex lain under 7
�/ !j] (]�
G� Cer�)ol�aC Q �hCL. U�L �Y t 11]ft+q�
4.Date well(s)abandoned: !
5a.Well location:
Facility/OwncrName Facility IDA(ifapplicable) 8.Certification
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner D06
By signing this form, 1 hereby certify that the wells)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 laulong is autliciem) 9.Site diagram or additional well details:
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 WELLS)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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
)6b.Total well depth: Z . ft 1617 Mail Service Center,Raleigh,NC 27699-1617
(
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) 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
6e.Outer casing length(i[known): —(ft.) 10c.For Water Suonly&Iniection 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
6f.Inner casing/tubing length(if known): (ft) where abandoned.
6g.Screen length Of known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013