Wake_Well Abandonment_20220708

1 ELLL1BANDOl\111L'N1 RECORD For Internal Use ONLY:
L Well Contractor Information: WELL ABANDONMENT DETAILS
VU Si\t\ �.e�{J\•u (- 7a.For GcoprobdlIPT or Closed-Loop Geothermal Wells having the same
Well Contractor Nana:(or w Il owner personally abandoning well on Mather property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Clarification Number 7b.Approximate volume of water remalafag is well(s):J� 116 (gal.)
�('C)(\t FOR WATER SUPPLY WELLS ONLY:
CoWmaky Na� TU
//�� /1 —1 7t.Type of disinfectant used:
2.Well Construction Permit#: 1,4J v W—�916-702E
liar all applicable well construction permi s#.e.U1C,Canary,Brute, Variance,etc)ifMawn
7d.Amount Of dialnfeehnt used: � C
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
Agricultural ❑M//unicipal/Public ❑Neat Cement Groat U/Bemaritc Chips or Pellets
OGeothermal(Heating/Cooling Supply) [ esidenhal Water SupRly( ' e) El Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial tdent)ir1 F 5 ( j ) ❑Concrete Grout ❑ Drill Cuttings
ElIrrigation -•l"'n.. ❑ Specialty Grout Dltnavel
Non-Water Supply Well: Q s Z O Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ORecoI, 11
Injection Well: 7E For each material selected above,provide amount of materials used:
OAquifer Recharge It�Cdrry9 M
OAquifer Storage and Recovery OSalinity Barrier TC �
ClAquifer Test OStormwater Drainage I I Q U ] �,Se nL p r 1 d
OExperimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer 7g.Provide a brief descriptions of the abandonment procedure:
OGeothermal Hestia Conlin Rebus OOther(explain under 7
o e>3 Z S i rl
2 2l)2Z 4vi f, 11 4rot^ 6llTforj\ c�F isf II +o to t^6
a.Date welts)abandoned: G P43 arrl - k%x re S-Y w i k RQ p—kwi#&_
pWell
e;�,tis'-:5 �Va c�erso� ✓ r� �,
Fecdity� Facility lD#(if applicable) &Certjfica[io�'�!�
H7' (�Ic clQnS r,r iLl � tV6�/'-� old
3
Physical Address.City,and zip Signature l Cie ni ed wen Cannaua a wen Owner— TC 7--7
JA hf/C- By signing this form, I hereby certify that the well(s) was (were)abandoned in
County parcel Ideanfication No.(PIN) accordance with 15A NCAC 02C.0100 or,1C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and thar a copy of this record has been provided to the well owmr.
(ifrrell field,one Na/long is sufficient 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconstructionrecord(s),fawnlable Formultiplemjeaimarnan-wmersupplywells
ONLY with the same cansbuaianlabatdonment,you can submit ane form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: Od (it) 1617 Mail Service Center,Raleigh,NC 276"-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: /y pa.) 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: (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 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
61.Inner casing/tubing length(if known): (D,) abandoned.
6g.Screen length(if known): (ft.)
Form O`x'-10 North Carolina Deparonent of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For lntemal Use ONLY:
1.Well 1 lC`onlra Contractor Information: WELL ABANDONMENT DETARS
U Yf 1 A Le ���W dl'f Y 1 7s.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning w 11 on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
LI-�lT c—T n wells abandoned:
NC Well lContract or Certification Number 7b.Approximate volume of water remaining in we6(m): y (gal.)
1 J Q fy n FOR WATER SUPPLY WELLS O ILY:
Co�Naame
��� _O`— 7e W Type ofdnkh cot used:
2.Well Construction Permit 8: XU j n
List all applicable welt consimcnon permits(i.e.UIC,County,State. Variance,etc.)tfbmwn
7d.Amount of disinfectant I�Qtant used: J/
3.Well use(check well on):
Water Supply Well: 7e.Setting materials used(check all that apply):
DAgricultural ❑/Municipal/Public ❑Neat Cement Grout 2iemmnite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ldResidentiai Water Supply(single) ❑ Sand Cement Grout O Dry Clay
Oindust ial/Commercial ❑Residential-Watery Supply( ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation 'i b' ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: r1 ❑ Berlarite Slurry ❑Other(explain under 7g)
OMonitoring OR Uecovery L 0 2022
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroamhvlitdr, g Un
: ", /Z S �a/�S
OAquifef Storage and Recovery OSalinity Barrier
OAquifa Test OStormwater Drainage
OExperlmental Technology OSubsidcnce Control l
7&Provide a b of description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer
OGeothevoal (Heating/Cooling Return OOther(explain under 7 ) C)L1
4.Dam well(s)abandoned: 2, 'Z.'L
5m.We6 location:
t 1(Vy fL-1[yC7—
FacitiryhDwner Name r Facility ON(if applicable) 8.Certification:
2 :I2 wok Rale.a 9h
Phys a,City,and Zip Signorine of Certified Well Contractor Weil Owner
By signing this form, 1 hereby certify that The weU(s) was (ware) abandoned in
County Parcel identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degiets/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 9.Site diagram or additional well details:
N W You may use the back of this page toprovide 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
Aitacbwe/Iconsnuctimrecord(s)tf vailable Formultiple injeaionornrm-wwersupplywelL.
ONLYwah the same constmnion abandonment,you can submit one form.
IOa. For All Wells: Submit this farm within 30 days of completion of well
6a.Well IDN: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Tonal well depth:7(R) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: r 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: ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) ion.For Water Suuoly&luiection Wells: In addition to sending the form to the
adihms(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 casing/tubi ng length(if know n): (ft.) abandoned.
6g.Screen length(if known): (ft.)
turn�w'-�tl North Carolina Department ofEnvimomentd QtWity-Division of Wmu Resources Revised 2-22-2016