Wake_Well Abandonment_20220621

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
27��b wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorox pnool shock
7c.Type of disinfectant used: N
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown
7d.Amount of disinfectant used: 6 oZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) eResidential 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)
❑Monitoring _ ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite Chips 33'to land surface Poured in top of well
❑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)
Well was filled from 33' bls to land surface with
a:Date well(s)abandoned: 6'16-22 bentonite clay chips to land surface
5a.Well location:
Legacy Creedmoor, LLC na
Facility/Owner Name Facility Il)b(if applicable) 8.Certification: _-
5200 Creedmoor Road, Raleigh NC 27612 6-16-22
Physical Address,City,and Zip Signature o erhfied Well Contractor or Well Owner Date
Wake 0796458456 By signing this form, I hereby certi&that the �(wgre abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0,69 e�C,gxstr�i tigmi ards
and that a copy of this record has been provided to the well owner..P -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JU�y)
7
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: r F �D
35 51' 10.58" N -78 40' 48.27" W You may use the back of this page to provide additital well site details or well
abandonment details. You may also attach i Tonal i fg `ffiJ* eLsis .
t'ir,i'tvri�l9 '){?CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED_ rkCL,� i 1�Jl\iT
-SUBMITTAL INSTRUCTIONS � J 1 1
Attach well construction record(s)if available.For multiple injection ornon-waters G7)�upply 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#: W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 33 (ft) 1617 Mail Service Center;Raleigh,NC 27699-1617
I 10b.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: 0 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 33 +feet (ft) 10c.For Water Supply&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 where
6E Inner casing/tubing length(if known): f 1�'V/A (ft) abandoned.
6g.Screen length(if known): N/A (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorox pool shock
7c.Type of disinfectant used: p
2.Well Construction Permit##: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown
7d.Amount of disinfectant used: 6 oZ
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) BResidential 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)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Screenings placed from 80'to 40'bls Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite Chips 40'to land surface Poured in top of well
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal g/ g 6 oz of pool shock poured.in well followed by filling
(Heating/Cooling Coolin Return) ❑Other(explain under 7g
with screenings to 40' bls. Final 40' of well
a.Date well(s)abandoned: 6-16-22 was filled with bentonite clay to land surface
Sa.Well location: 141
Legacy Creedmoor, LLC na
Facility/Owner Name Facility ID#(if applicable) S.Certify
5114 Creedmoor Road, Raleigh NC 27612 6-16-22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 0796458278
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
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 51' 08.00" N -78 40'47.35" 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 well construction record(s)ifavailable.For multiple injection ornon-watersupply wells"
ONLY with the same constructiohlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID##: W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 80 (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: 40 (f�) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 30 feet (fE) 10c.For Water Supply&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 h
It;h-d . m my where
6E Inner casing/tubing length(if known): NIA (ft.) abandoned. p.oyhrc
JI►nl 2 � 9112?
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources VVM:?,:17JIli rl P I-^L 'Re sed 2 22-2016
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