Wilson_Well Abandonment_20220531 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 1
7a.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 ivells ONLY with the same
construction/abandonment,you can submit one form.
C -4421
NC well Contractor Certification Number 7b.Approximate volume of waterlremaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable ivell construction permits 0.e.County,State,Variance,etc.)ifknown 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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement ilt r' i � , Clay
❑ Concrete Grou t� "0 �E] 'ill Cuttings
❑lndustrialtCommercial ❑Residential Water Supply(shared) g
❑Irri ation ❑ Specialty Grout MAY 3 1 2022 ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery 1nfofi;raj'z l UDp
Injection Well: 7E For each material sel ibt 01�vc provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 0.75 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
- 5a.Well location:
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1313 WARD BLVD WILSON 27893 �°` "`"'"' 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 43' 15.82" N 770 56' 08.68" W You abandonment nt detay use the ils. You ack of this
Paso attach e to additionalde additional well site es if necessary. or well
Y P g
CONSTRUCTION DETAILS OF WELL(S)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#: SVE-3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 4.0 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For infection Wells: In addition to sending the form to the address in 10a
2.0 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 at) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Suoaly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELcanL ABA ND N p�ors.glOrmultE T 1�''Co
1.Well Contractor Ple wells 1W j
DAMES Mp Information; For lntemalUseO
RRISON NI'y.
Well contractor N
C-4421 a<tte(or well Owner Personally WELL A13
Y abandoning well on his/her 7a. ANDONII�NT DETA�S
NC Well Property) Number of wells �
Contractor C For multip/e being ahand I
Certification Number d, 1
GEOLOGICi"
construcrron/ab lec![on n andonmenr,y ur on�i', su
CompanylVame XPLORATION,INC 7b'APproximatevolu cansnbmrto"efrrm. wet/s ONLY wrrh the same
i Well °1e of water rertraining in well(s).
Construction Per FOR ATER
List at/appticab/e,wetl ca Permit#:
nstruc[ionpermi[s 7c.�. 'SUPPLY WELLS ONLY: —(gal.)
3 We1/use Vie•Couny,ware ype of disinfectant
(check well use); variance,etc,)jkno�vn used:
Water Supply Well:
ClAgricultural 7d•Amount of disinfectant
❑Geo used:
OlGe fiertnal�C(Heating/Cooling Suppl OMunicipa�Public 7e•Sealing materia
ommercial y) Residential
Ohri ation Water Neat Cement Gro' . 30"�{check all that
OResidential Supply(single) ❑Sand and Ce •� r .." apply):
Water S Water S ment Grout - g td�
Monitoring apply Well: apply(shared) ❑Concrete " mte Chips or Pellets
Grout A lay
Injection Well: 0 Special MqY `�
�Recove Specialty Grout 1 Drill Cuttings
�AquiferRecharge ry 0 BentoniteSl lnfcrp, v p
E3Aqu- Stora �3 � 1 Gravel
Storage and �G'ound nt'° '�`R�7
water 7f.For each in, selectedy OG r(explain
OAquifer Test Recovery Remediation under 7g)
OSalinity Barrie, 0.75 GALLONS above,Provide a Experimental Tec �StormwaterDrainag¢ mount ofmaterials used:
�Geothe hrtology
rural(Closed Loop) OSubsidence
ClGeothe Control
rural(Heating/Cvoting R¢tutn Tracer 7g,Provide a
) 0Other brief description of the
(explain under ABANDONED
abandonment procedure:
4•Date well(s)abandoned: 04/04/22 �A TREMIE PIPE
WITH BENTONITE SLURRY
Sa._Well location
KORETIZING CLEANERS
Facility/Owner Name
1313 Facility ID#(if applicable
WARD BLVD WILSON ) 8•Cerhfication:
Physical Address,Ci , 27893
WILSON ry and
County Signature of Certified Well Con tractor or Well Owaer 04120122
Parcel IdenHScation No.(Pl By signingDate 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:. this form I hereb accordance with ISfI ArC y cert that the
(if well field,one lat/long is sufficient) and that a co 01C•0100 well(s)was(were
copy of record has been provr'ded o�he well
owner Construction Stand, ds
350 43' 15,12" N 77° 56'08.32"
9.Site diagram or additional well details;
CONSTRUCTION DETAILS OF WELL S BEINGABANDO W You ma
abando y use the back of this page to provide additional well site details or well
Attach hell construction record(sJ if available. For multiple injection or non_water supply nment details. You may also attach additional a Ivells ONLYlvith the same construction/abandonment,you cansubmit one fo>oD pages if necessary
SUBMITTAL INSTRUCTIONS
69.Well ID#: SVE-4 1011. For All Weps.
abandonmenollowtng t this form within 30 days} of completion of well
6b.Total well depth:. 4.0 Division of Water Quality,Information Processing Unit,
(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6c.Borehole diameter: 2'0 In
IOb.For Infection Wells: 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: y
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: —�fr) 1636 Mail Service Center,Raleigh,NC 176994636
�h) 10c.For Water Suonly&Injection w n
(if known): the address(es) above, also submit one copy of dthist form sending
30 days
to
60uter casing length of
e. completion of well abandonment to the county health department of the county
where abandoned.
�I RevisedMacd�2°l3
r ! �e�,° ment ana�lahua\Resources-Dw�s�oo ofwa�ec QUaticy

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
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
construction/abandonment,you can submit one form.
C -4421 1.75
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check nil that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout „ p +t7 ptonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement GR „d� ,p -9 Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout f1 •,�gy�pp Drill Cuttings
❑h7i anon ❑ Specialty Grout MAY 3 1• Z1�2�❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry r r �� �<<rl((f1er(explain under 7g)
Efflonitoring ❑Recovery �ftt t.se
di
Injection Well: 7f.For each material selected aUUUUUove,i ve,
provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.25 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
5a.Well location:
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(if applicable) S•Certification:
1313 WARD BLVD WILSON 27893 �� �'M"'"` 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35e 43' 15.44" 77e 56' 08.02" 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 WELL(S)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#: M W-9 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 14.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
20 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: 3.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
611 Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.) j
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
II ,