Johnston_Well Abandonment_20220607 (3)

WELL ABANDONMENT RECORD L7=LY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Virgil Wilson 7a.For Geoprobe/DPTor Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4473 wells abandoned:WIN I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0'78 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name N/A
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.f//(,Counil.State, Variance,etc.)it known N/A
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
R Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.81 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 Added bentonite pellets to well
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 5-9-22
5a.Well location:
Kinder Morgan Terminal 3 N/A JUN O q
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: / 2OZZ
4383 Buffalo Road, Selma 27576 /.�/ ina�ima4ic;, Qr4; ) -x
'�`'.4 af�,l�li
DI!t/Q, S
Physical Address.City,and Zip Signature of Certified Well Contractor o Well Owner ` a
Johnston 260502-77-7402 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 IaUlong is sufficient) 9.Site diagram or additional well details:
35.554200 N -78.299771 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 melt construction record(v)it at•ailable. For mutriple injection or non-water supply a ells
ONLY with the.came construction abandonment,You can submit one/brnz.
' 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-13 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
11.3 1617 Mail Service Center,Raleigh,NC 27699-1617
(ft.)
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
6d.Water level below ground surface: 6.41 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service C P enter,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): N/A (ft) 10c.For Water Suooly&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
6E Inner casing/tubing length(if known): 5 (ft.) abandoned.
i
6g.Screen length(if known): 7.5
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201 G

's
WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS
Virgil Wilson 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 I GW-30 is needed. Indicate TOTAL NUMBER of
4473 wells abandoned:NIA
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0'76 (gal)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name N/A
7c.Type of disinfectant used:
2.Well Construction Permit##: N/A
List all applicahle well construction permits(i.e. (I1C,Coun(rt Stale. Variance,etc.)ifknown N/A
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
e Monitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.08 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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Added bentonite pellets to well, removed
surface completion, cut well below grade, and
4.Date well(s)abandoned: 5-9-22 restored surface cover to match surrounding area.
5a.Well location:
Kinder Morgan Terminal 3 N/A ..
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
4383 Buffalo Road, Selma 27576 JUN Q 7 2:0
Physical Address.City,and Zip Signature of Certified Well Contractor or WI'lfli ran D1 �'1r"1G'
Johnston 260502-77-7402 DIV
By signing this form. /hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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 lattlong is sufficient) 9.Site diagram or additional well'details:
35.553468 N -78.301440 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
Anach well construction records)ifavailable. For multiple b?lection ornon-iratersupply wells
ONLY with the same construction abandonment,you can submit one form.
Ion. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# MW-18 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 6.75 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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
6d.Water level below ground surface: 2.02 (ft•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft) loc.For Water Sunaly&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
611 Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Virgil Wilson C
g 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 I GW&is needed. Indicate TOTAL NUMBER of
wells abandoned:NIA I
4473
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0'81 (gal.)
l
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NIA
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.U/C.C'ounty,State, I%ariance,etc.)ifknosrn 'N/A
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.47 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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Added bentonite pellets to well, removed surface
completion, cut well below grade, and restored
4.Date well(s)abandoned: 5-9-22
surface cover to match surrounding area.
5a.Well location:
i
Kinder Morgan Terminal 3 N/A a Facility/Owner Name Facility ID#(ifapplicable) h
8.Certification: 4 aV
4383 Buffalo Road, Selma 27576 0 7 202�
Physical Address.City,and Zip Signay of Certified Well Contractor or Well Owner Date
Johnston 260502-77-7402 Info`nation Pr cw.,-,;n.g Urg,
By signing this form. 1 hereby certify that i&,VW(t')Or(as (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 wellidetails:
35.554147 N -78.298488 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.
Aaach well construction records)ifarailable. For multiple injection or non-watersttpply wells
ONLY wish 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#: MW-33 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9•2 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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: 4.14 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft) 10c.For Water Supply&Infectio i n 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
611 Inner casing/tubing length(if known): 5 abandoned.
i
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016