Wake_Well Abandonment_20220719

WELL ABANDONM"�`T R CORUI For Internal Use ONLY:
RECEIVED-
1.Well Contractor Information: e [.2 WELL ABANDONMENT DETAILS
Thomas Will JUL 19 2022 7a.For Geoprobe/DPTorClosed-Loop Geothermal�Vellshaving the same
Well Contractor Name(or well owner perso lly abandon 6+tl�eiA}+� ) well constmction/deptb,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2700b ' N wells abandoned:
NC Well Contractor Certification Number Central Office 7b.Approximate volume of water remaining►n wells PP g• O• (bat.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name None Well D
7c.Type of disinfectant used:
ry
None
Well Construction Permit#: na
List all applicable well construction permits f e.UIC,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):
❑Agricultuml ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑hri 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 ❑Groundwater Remediation clay from 28► to 2' bls Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stotmwater Drainage Concrete 2' to V Poured in top of well
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer Filled well with eta to 2' BLS
❑Geothermal(Heating/Cooling Return) 130ther(explain under 7g) Y
V concrete plug followed by covering
4•Date well(s)abandoned: 7' 14-22 with soil to land surface R�r f0 � tom'
W aa.Well location: v� — �
April Minh na �..,
Facility/Owner Name Facility ID#(ifapplicable) 8.Certifreatio 2022
4301 Graham Newton Road P. Ul*
Physical Address,City,and Zip Signlnare of Certified Well Contractor or Well Owner Date
Wake 0770769354
By signing this fonn,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards•
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has bee n provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35 41► 23.17° N -78 44' 14.36►r 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 SUBMTl"CAL INSTRUCTIONS
dvaclnvellcottstnictionrecord(s)ifavailable.FormulriplebjectionorPion-watersupplyuplLs
ONLY with the same constructionlabandonmetu,you can submit onefortn.
��! 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: p V-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 28 —(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
be.Borehole diameter: 24 lob.For Iniection Wells: In addition to sending the form to the address in 10a
fin.) 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• 28 + (it,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
28
6e.Outer casing length(ir known): + —(ft.) 10c.For Water Sunnly&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
6f.Inner casing/tubing length(if known): N/A abandoned.
6g.Screen length(if known): N/A
Form GNV-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT 1 RECORD --_ For Internal Use ONLY:
1.Well Contractor Information: REC'EIVO
Will
WELL ABANDONMENT bETAILS
ti�
Thomas V V i I I 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
1Ve11 Contractor Name(or well owner personally aba II on er property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2700b I wells abandoned:
NC Well Contractor Certification Number®E oo 7b.Approximate volume of water retraining in Ivell(s): (gal.)
East Coast Environments V"t FOR WATER SUPPLY WELLS ONLY:
CompauyNamc Chlorox tool shock
7c.Type of disinfectant used: p
2.Well Construction Permit#: n a
List all applicable well consimclian permits(i.e.UIC,Como,,State,Variance,etc.)ifknowvr
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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑lrri 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 clay from 38' to 2' bls Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 2'to 1' Poured in top of well
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer 6 oz of pool shock poured in well followed by filling
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
with clay to 2' bls. 2'to 1' concrete plug
t.Date►vcll(s)abandoned: 7'14-22 followed by covering with soil to land ��
e
Sa.Well location: AL L i Q .2022
City of Raleigh na
Facility/OwnerName Facility IDtr(ifapplicable) 8. nation: lnkA*U n PMCmcM4 Ur*
2616 Holloway Road 7.1, 2 °o
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner pate
Wake 1722476075 By signing this fonn,I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15ANCAC 02C.0100 or 2C.0200 Me71 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 IaUlong is sufficient) 9.Site diagram or additional well details:
35 44' 49.35It N -78 34' 46.93" 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
Allaclastirl/constructionrecord(,)ifavailable.Formultiple injection ornon-watersupply}vel/s
ONLY ivith the same constrtctiatdabandomment,you can submit one form.
10a. For All Wells; Submit this form within 30 days of completion of well
6a.Well ID#: W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 38 (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• 24 (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• 38 4) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 38 feet (ft) 10c.For Water Sunnhv&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
6f.Inner casing/tubing length(if known): N/A M.) abandoned.
i
6g.Screen length(if known): A (ft.)
Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016

RECEIVE®
WELL ABANDONMENT RECORD For Internal Use ONLY:
JUL 19
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will NC DEQ/Dwa
xI
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well an 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 Ct.e.UIC,Couaq,,State.Parlmtce,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) NResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commeteial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑bri 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 in: used:
❑Aquifer Recharge ❑GroundwaterRemediation Gravel.from 165`t0 100'bis Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier —
❑A ferTest Bentonite Chips 100!to land surface Poured in top of well
qm ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control .
❑Geothemtal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑other(explain under 7g) 6 oz of pool shock poured in well followed by filling
with gravel to 100' bls. Final 100' of well
4.Date well(s)abandoned: 7-14-22 was filled with bentonite clay to land surface
5a.Well location:
City of Raleigh na
Facility/Owner Name racilityID#(ifapplicable) 8.Certifteation:
2616 Holloway Road < /- 7-14-22
Physical Address City,and Zip Signature ofCertificd ell Contractor or Well Owner Date
Wake 1722476075
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance will,15A NCAC 02C.0100 or 2C.0200 IPell Cot t t&n ards
and that a copy of this record has been provided to the ivell o 'V�D
56.Latitude and longitude indegrees/minutes/seconds or decimal degrees: � �
(ifwell field,one lat/long is sufficient) 9.5ite diagram or additional well details: I
35 44' 49.59't N -78 34' 47.96" W You may use the back of this page to provide additional well sited Ubils�r�e1p022
abandonment details. You may also attach additional pages if necessary_
CONSTRUCTION DETATLS OF WELL(S)BEING ABANDONED SUBIIITTALIlV5TRUCTIONS � ��9 V1111
Attach well construction record(s)ifavailable.For multiple injection orran-watersupply wells
ONLY with the satire constrtetioMabandannent,you can submit one form.
10a. For All Wells: Submit this form.within 30 days of completion of well
6a.Well IN: W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 165 (ft) 1617 Mail Service Center,Raleigh,NC 276994617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also sutimit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 40 {ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 276994636
6e.Outer casing length(if known): 90 feet A) 10c.For Water Supply&Iniection Welts: 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
6f.Inner casing/tubing length t(if known): N/A (ft) abandoned.
6g.Screen length(if known): N/A 00
i
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I