WQ0003945_GW-30 Well Abandonment Records_20210323

WELL ABANDONMENT RECORD
I. Well Contractor Information;
Town of Star
WdI Contractor Namc (or well owner personally abandoning well on hislher property)
NC WeII CcntractorCertifrcation Number
Town of Star
Company Nnmc
2. Well Co astrue [to n Permit #r
Lisi all applicable well co&vp7rclion permits T.e. U!C County, State, Var mce, efc.J if knows
3. Well use (check well use):
❑Agricultural
El Geothermal (HeatinglCooling Supply)
❑ IndustriallCarnnicrcial
Non -Water
❑Aquifer Recharge
❑Aquiter Storage and Recovery
❑Aquifer Test
DExperi mental Technology
❑Geothermal (Closed Loop)
❑Geothermal (lieatinglCooling
4. Date wells) abandoned: 03/ 1 012
52. Well location:
Town of Star
ClMunicipallPubIie
❑Retsidemial Water Supply (single)
❑Residential Water Supply (shared)
uRecovery
❑Groundwater Rernedialion
❑Salinity Barrier
ClStormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other _(explain under 7
NCOO58548
Foci IitylOwner Name Facility 1D# (ifapplicabJe)
end of Center St., Star, NC
Physical Address, City, and Zip
Montgomery
County
Parcel Identification No. (KN)
5b. Latitude and longitude !it degrees/ min uteslseconds or decimal degrees:
(if We II licld, one ladlong is sufficient)
N W
CONS RUCTjO IN DETAILS OF WELL(S) BEING ABANDONED
.trtuch well construrrlon record(s) ifavailable. For multiple injection or non -µveer supply wells
ONLY ivirh tke some consiructlonrabcndoament, you can submit one farm.
6a. Weil EN- MW-1
6b.'rotal well depth: 15 IN
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: (fL)
L
nlerna] L ABANDONMENT DETAILS
7a. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only l GW•30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate votume of water remaining in well(s): [gnL)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinrectant used:
7d. Ameaat of disinfee [ant used:
7e. Sealing materials used (check all that apply)-
❑ Neat Cement Grout 0 Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonitc Slurry Cl Other (explain under 7g)
7f. For eacb material selected above, provide amount of materials used:
50 lbs.
7g. Provide a brief description of the abandonment procedure;
8. Certific on:
01
tore oiCcrirli el ntracmr nr ell Owner t78tE
by signing this form, I hereby eert;fy that the well(s) was {were] abandoned in
accordance with I5A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy oj'this record has been provided to the well owner.
9. Site diagram air additional well details:
You may use the hack of this page to provide additional well site details or well
abandonment details. You may also atlach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
1111%. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Iinto rmadon Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
IOb. For Injection 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
abandonment to the Following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
be. Outer casing length (if known): (ft.) Ift. Far Water SopPly & injection Wells: In addition to sending the farm to the
addresses) 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 casingltubing length (If known): (f;.) abandoned
6g. Screen length (if known): n
5- 15
Form GW-30 North Carolina Department of Environmcnml Quality - Division of Water Resources Revised 2.22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Town of Star
Well Contractor Name (or well owner personally abandoning well on hWher property)
NC Well Contractor Certification Number
Town of Star
Company Name
2. Well Construction Permit #:
L4¢14II vppiicable well ronsimclion permits (Le. UIC, County, State, Variance, etc.) ifkanwn
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (HeatinglCoohng Supply)
❑ Industrial/Commercial
Non -Water Supply Well:
❑MunicipaUPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
[]Recovery
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
OSalinity Barrier
❑Aquifer Test
❑Stormwater Drainage
El Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loopy
❑Tracer
DGeothemial (HeatinglCooling Return)
❑Other (ex lain under 7 }
4. Date weli(s) abandoned: 03/ 1 0/2 1
5a. Well location:
Town of Star NCO058548
FacilitylOwnerNanw Facility lDa (if applicahlcl
end of Center St., Star, NC
Physical Address. City, and Zip
Montgomery
County Parcel ldcnri5cation No. (PIN)
5b. Latitude and longitude in degre"Intinutesisecuuds or dedrual degrees:
(if weil field, one laillong is sufficient)
N W
CONSTRUCTION DETAILS OF WELLtSI BEING ABANDONED
Aaoeh well owstruelion record(.$) Ifavailuble. For mulhtole ixjec6on or rron-ti,uter.ruppiy "10
ONLY with the same
t'conrairvctionlubandnnment, you can submit oneJvrm.
tlp
62. Well ID#. , V `y V'2
6b. Total well depth: 20
6c. Borehole diameter: 2
6d. Water level below ground surface:
For Intemal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Fur GeoprobeldPT or Closed -Loop Geoutermai Wells having the same
well cons truc[ion/depth. only I GW-30 is needed. Indicate TOTAL NUMBER of
Wells abandoned:
7b. Approximate volume of water remaining in well
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectan I used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
N Eentonite Chips or Pellets
❑ Sand Cement Grout
❑ my Clay
❑ Concrete Grout
0 Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
X For each material selet led above, provide amount of materials used:
50 lbs.
79. Provide a brief description of the abandonment procedure:
8. Ce Pica ti:
S. t.Cart�tractor ur cll owner Dale
By signing this form, I hereby cerllfy that the well(s) was (were) abandoned in
accordance with I5A NCAC 02C .0100 or 2C A200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additioaal pages if necessary.
SUBMITTAL INSTRUCTIONS
10a, For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: hi 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
abandonment to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): (ft.) lk. For Water Supply & Injection 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 casin gltubing length (ir known): (ft.) abandoned.
4g. Screen length (if known): 1 O-20 (ft.)
Fvrm G W -30 North Carolina Ilepartment of Environmental Quality - division of Water Resources Revised 2.22-2016

WELL ABANDONM ENT RECORD
1. Well Contractor Information:
Town of Star
Well Contractor Name (or well owner personalty abandoning well an hisllterproperty)
NC We II Contmcwr Certification Number
Town of Star
Company Name
2. Well Construction Permit #:
L isl off applirable well construction permits li. E. (11C Coun(y, State, Variance, era) ifktrown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heat inglCooling Supply)
❑ Industria l/Commcrc ial
Well:
❑MunicipailPulrlic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquiter Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwatcr Drainage
❑Experimental Technology
❑Subsidence Control
[]Geothermal (Closed Coop)
❑Tracer
❑Geothermal (Heating/Coo I inRemm)
❑Other (explain under 7g)
4. Date well(s) abandoned: 03/10/21
Sa. Well location:
Town of Star
NCO058548
FacilitylOwnerNarw Facility t17t1 (ifapplicable)
end of Center St., Star, NC
Physic®I Address, City, and Zip
Montgomery
County Parcal Identification No. (PfN)
Sb. Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field, one lstltong is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Arlach we11 tmnstruction reeord(s) ifavoilabie, For multiple injection or non-woler suppiy IwHs
Oft y with the same
l �evirttctionlobandonmenl, you cars submir one f nw-
6a. Well 1D#- 1VI-3
6b. Total well depth: 1 (ft.)
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: (ft.)
of latcmaI Use ONLY:
WELL. ABANbONMENT DETAILS
7a. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed, Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in wen(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing nmter] als used (check all that apply):
❑ Neat Cement Grout ■ Bentonite Chips or Pellets
❑ Sand Cement Grout p Dry Clay
❑ Concrete Grout ❑ drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected •above, provide amount of materials used:
50 155.
7g. Provide a brief description of the abandonment procedure:
S. Certinesti :
Si at o Ccrtifi ell Contractor or Well Owner Date
By signing this form, 1 hereby certify that the well{sj was (were) abandoned in
rtccordonce with 15A MCA 62C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL 1NSTRUCPIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing (fait,
1617 Mail Service Center, Raleigh, NC 27699-1617
lob. For Infection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of ,umpiction of well
abandonment to the following.
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): (ft) Ipc. Fvr Water Sunnly & Iniection 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
6f. Inner cas ingltubi ng length (if known): (n) abandoned.
6g. Screen length cif Mown): 5-15 (fta
Form G W -30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
t. Welt Contractor In far mation:
Town of Star
Well Cc ntractor Name toe well owner persoimlly abandoning well on his!l rcr property)
NC Well Contractor Certiftcnoon Number
Town of Star
Company Name
2. Well Construction Permit #:
Uri all appl+rahle well cunsirmction permilr {i,e, UIC, Oman-, Stare, Yurianre, erc.J if1mown
3. Well use (check well use):
CAgricultural
❑Geothermal iHeatinglCooling Supply)
Q 1ndustriallCommcrcial
Nan -Water Supply Well.
❑Aquifer Recharge
[]Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loup)
❑Geothermal (HeathiglCooling
❑MunicipallPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Traver
❑Other(explain under
For ]rnernal Use ONLY!
WELL ABANDONMENT RETAILS
7a, For GeoproWDPT or Closed -Loop Geothermal Wells having the same
well constructionidepth, only 1 GW-30 is needcd. Indicate TOTAL NUMBER of
wells abandoned;
7b. Approximate volume of water remalning In well(s): [gal.)
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used,
7d. Amount of disinfectant used:
7e. Sea Hug materials used (check all that apply):
❑ Neat Cement Grout
s Bentonite Chips or pellets
❑ Sand Cement Grout
❑ Dry Clay
❑ Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f For each material selected above, provide amount of materials used-
125 lbs.
7g. Provide a brief description of the abandonment procedure:
d. Date well(s) abandoned: 03i10/21
5a. Well location:
Town of Star NCO058548
FacilitylOwner Name Facility IDN (if applicable) 8• Certific"ell
end of Center St., Star, NC
Physical Address, City, and Zip tore oorWell Qwner to
Montgomery
Ay signing this form, I hereby certify that the well(5) was (wvere) abandoned in
County Parcel Identification No. (PIN) accordance with 15A NCAC 02C A100 or 2C .0200 Well Construction Standards
and that a conv of this record has been Provided to the well owner.
5b. Latitude and longitude in degreWminuteslseconds or decimal degrees:
of well field one la111ong is sufficient)
N
W
CONSTRUCTION OETAILS OF WELLS BEING ABANDONED
Attach well construction rword(s) ijaveilable. For mutriple injection or non- warer supply wells
ONLY with the same can r-fruclivnlahandunmenl, you can submii one form.
6a. Well ID#: MW-4
6b. Total well depth: G r (ft.)
6c. Borehole diameter: 4 tin.)
6d. Water level below ground surface: (ft.)
9. Site diagram or additional well details:
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.
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, information Processing UnIt,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells- In addition to sending the form to the address in 10a
above, also submit uric copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): VL) Idc. For Water Sup P ly & In I ection Weirs: 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): (ft-) abandoned.
6g. Screen length (if known): 17-27 (ft.)
Form OW-30 Nonh Carolina Department of Environmental Quality - Division of W ater Resources Revised 2-22-=6

WELL ABANDONMENT RECORD
I- Well Contractor Information:
Town of Star
Well Contrackor Name (or well awaer petsonaily abandoning well on his/her properly)
NC Well Conmactor Corti fieation Number
Town of Star
Company Name
2. Well Construction Permit il:
List all applicable well ronsimclion permits rL,e. UIC County, Store, F"rrrianre, via) ilk yawn
3. Well use (check well use):
Water Supply
❑Agricultural
❑Geothermal (HeatinglCooling Supply)
❑ IndustriatlCornmercial
Non -Water Supply Well:
❑Aquifer Recharge
QAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
CMunicipallPublic
❑Residential Water Supply (single)
❑ Res idential Water Supply (shared)
OGroundwater Remediation
❑ Satin ity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Traver
❑Other (explain under
4. Date well(s) abandoned: 031 1 0/21
5a. Well location:
Town of Star
NCOO58548
FacilitylOwnerName Facility ID# (ifappIicablrt
end of Center St., Star, NC
Physical Adilmss, City, and "Lip
Montgomery
County
Parcel Identification No, (PIN)
5b. Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(if well field, One latllang is sufifcielit)
IJ
For Internal Use ON LY-
WELL ABANDONMENT DETAILS
7a. For GeoprobelDFT or Closed -Loop Geothermal Wells having the same
well construction/depth, only i GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (gal,)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant us4d:
7e. Seating materials used (cheek all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
100 lbs.
7g. Provide a brief description of the abandonment procedure:
8. Certiiflca n:
Si ❑ Fe cl ontractorar Well Owner SK
By signing ►his form, I hereby certify char the wells) was (were) abandoned in
accordance with 15.4 NCAC 02C .0100 or 2C ,0200 Well Construction Standards
and (hat a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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
Alrac•h well canstrucrion record(s) ifavailable. flor maieiplc injection ornou-w❑ler supply we11s
ONLY alh the same cpnstruclianlubvndvnmenr, 3roa can submit one form.
6a. Well ID#: MW-5
6b. Total well depth: 35 (fit.)
fie. Borehole diameter: 2 (in.)
6d. Water level below ground surface: (ft,l
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of eompletiou of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): (g,) 10c. For Water Supply & Injection Wells: in addition to sending the form to the
addresses) 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 casingltubIng length Iifknownn): (ft.) abandoned
6g. Screen length (if known): 25-35 (fo
Farm G W -30 North Cam hall Department of Environmental ixuslity - Division of W attar Resources Revised 2-22-2016