Nash_Well Abandonment_20220808 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 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
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 .57
(gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WM 0501467 7c.Type of disinfectant used:
List all applicable welt construction permits(i.e.UIC,Comfy,Slate,Variance,etc.)tfknown
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 IN Neat Cement Grout IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
INIMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite - 25 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier Neat Cement ^35 Ibs
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 8/2/2022
5a.Well location: ,� y
Rocky Mount ARD CGP, LLC N/A AlJfj 0 8 027
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1450 Benvenue Rd Rocky Mount "' ''" �'� �`,L "" unN
DVV'Qi�aec z L2 Z-
Physical Address,City,and Zip Signature ofCertitied ontractor or Well Owner Date
Nash
By signing this./anti, 1 hereby certifi that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C 10l00 at-2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a coP),gfthis record has been provided to the well owner.I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
-77.80658493 N 35.97902696 N 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(.v)ifavailable. For nmlliple iniec•tion or non-water supply well.v
ONLY with the sane conviructiodabandonment,),ou can submit one form.
MW02 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: 30.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the fort to the address in 10a
6c.Borehole diameter: 4.25 (in) above, also submit one copy of this form within 30 days of completion of well
,f
abandonment to the following:
6d.Water level below ground surface: 20.34 (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&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
6C Inner casing/tubing length(if known): 10.0 (ft) abandoned.
6g.Screen length(if known): 20.0 (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

f
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werle
Y 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 G�V-30 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:
7b.Approximate volume of water remaining in wells • 0.40 at
NC Well Contractor Certification Number PP g O• (g )
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WM0501467 7c.Type of disinfectant used:
List all applicable well construction permits(i.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):
❑Agricultural ❑Municipal/Public a 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
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
C Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite - 20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat Cement 35 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of::the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement fro 5 ?T;urface
4.Date well(s)abandoned. 8/2/2022 r
5a.Well location: A� J
Rocky Mount ARD CGP, LLC N/A ,. t,r � ,c� na
8.Certification: kl (77t2wtC s
Facility/Owner Name Facility ID#(if applicable) tJ�d�'ul
1450 Benvenue Rd, Rocky Mount 7 2 bz Z
Physical Address,City,and Zip Signature of Certified Contractor or Well Owner Date
Nash
Bp signing this form, /hereby cei•ti/i that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.6100 or 2C.0200 Well Construction Standards
and that a Copp of this record has&,e n provided to the ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: If
(ifwell field,one lat/long is sufficient)
9.Site diagram or additional well details:
-77.80719742 N 35.9793561 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
Attcrchivellconstntctiotrrecord(.r)ifavuilable. Forntultiplein/ec•tionornort-watersupplvwelts
ONLY with the same construction%abandonment,3-ou can submit one,form.
MW04 10a. For All Wells: Submit this forni 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• 25.0 (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: 4.25 (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• 22.54 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft.) loc.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit onelcopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): 10.0 (ft) abandoned.
6g.Screen length(if known): 15.0 (ft.)
Fomt GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016