Durham_Well Abandonment_20220701 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Todd Muench 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 l GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:t I
3371 I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.24
Parratt-Wolff FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well consiruclion permits(i.e.UK.',County,Slate,Variance,ele.)iJ7arown
' 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 S 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.2 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) Surface capped with concrete
4.Date well(s)abandoned: 6-14-22
5a.Well location: Q
601 Willard St Acquisition, LLC JUL 0 1 222
0
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: , •tJr it
601 Willard Street, Durham, 27701 'J
JVi,.`•y�l�
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Durham 103350
By signing this form. /hereby certify that the rvell(s)was (ivere) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 3C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.993991 N -78.905953 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Ailach hell cauintction record(s)ifarailable. For mulliple ii#ection or non-watersupply wells
ONLY with die same construction abandonment,you can subinit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: B-10 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14 (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: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Suoaly&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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Todd Muench
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
3371 wells abandoned:t 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 349 (gal.)
Parratt-Wolff FOR WATER SUPPLY WELLS ONLY:
Company Name ' 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable wel/construction permits(i.e.(11C,County,Stale,Mariance,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 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.5 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) Surface capped with concrete
4.Date well 6-14-22s)abandoned: F ti .v,;� I�-.. ''�'t
a , tt i
5a.Well location:
601 Willard St Acquisition, LLC 11 III�c�c�
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
601 Willard Street, Durham, 27701
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Durham 103350
By signing this form. I hereby certify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 a•2C.0200 Well Constriction Standards
and that a copy of this record has been provided to the ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one]at/long is sufficient) 9.Site diagram or additional well details:
35.994176 N -78.906240 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 consiruci/on records)ifarailable. For nwhiple hyection or not-watersupply wells
ONLY with rile same co»stnictiotiabaulonmeitt,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: B-1 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 21.8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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: 7 (ft.) Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suaaly&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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016