Franklin_Well Abandonment_20220817

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WELL ABANDONMENT RECORD For Internal Use ONLY:
I
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1.Well Contractor Information: V1ELL ABANDONMENT DEVILS
I
Mike Tynan 7a.For Geoprobe/DPT or ClosedtLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 Gilt 30 is needed. Indicate TOTAL NUMBER of
2725-A wells abandoned:
a <1
NC Well Contractor Certification Number 7b.Approximate volume ofwater remaining in well(s): al.)
ET FOR WATER SUPPLY WELLS ONLY:
Company Name y �. n
7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Cott*t� .7prTc�l4ii`)' kit �T D
ItwVr ' = 7d.Amount of disinfectant used:
J��ll.tl
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(cheekall that apply):
❑Agricultural ❑MunicipaLPublic N Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
Oh-i ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
IlMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 94 Ibs portland cement ^-6.5 gallons water
❑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) Filled MW completely with neat cement through
tremie pipe.
9.Date well(s)abandoned: 8/17/22
5a.Well location:
Franklinton Landfill
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
737 Main St, Franklinton 27525 Z- 8/18/22
Physical Address,City,and Zip Si,anatme of -ei 'red Well Contractor of Well Owner Date
Franklin
By signing this form. I hereby certify that the ivell(s) was (were) abandoned in
County Parcel identification No.(PrN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Conduction Standards
and that a colt of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: If
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 05 21.575 N 78 27 52.963 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 VIELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atrach well constnicdonrecord(s)ifavailable. Formrdtiple injection ornon-waters*pplvwells
ONL F with the same constntetion:abandonment,you can submit one firm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.%Veil ID#: M W 5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 31 (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 (PVC) (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: -29 (ft.) Division of V1`ater Resources,Underground Injection Control Program,
1636 111Iail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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): (g,) 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: R ELL ABANDONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed=L.00p 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
wells abandoned: I
NC well Contractor Certification Number r S 9f+ fig q f 7b.Approximate volume of wale I remaining in well(s): 1 (gal.)
I ET r ^n FOR WATER SUPPLY WELLS ONLY:
Company Name '—�{�
7c.Type of disinfectant used:
l}ft`
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Corarn.State,&MoV.W J'knoun
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 0 Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
01ndustriallCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry f ❑Other(explain under 7g)
191vionitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑AquiferRecha ae ❑GroundwaterRemediation 100 Ibs portland cement ^-7 gallons water
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of4he abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heat ing/CoolingReturn) ❑Other(explain under 7g) Filled MW completely with neat cement through
tremie pipe.
4.Date well(s)abandoned: 8/17/22
5a.Well location:
Franklinton Landfill
Facility/Owner Name Facility IDti(if applicable) S.Certification:
737 Main St, Franklinton 27525 �NttQ.� 8/18/22
Physical Address,City,and Zip Si nature offer ed Well Contractor or Well Owner Date
Franklin
By signing this form. I hereby cerlif} that the nvell(s) was (were) abandoned in
County Parcel Identitication No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 of ell Construction Standards
and that a cope ofthis record has bl ch provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 9.Site diagram or additional well details:
36 05 21.023 N 78 27 50.234 `y, You may use the back of this page to provide additional well site details or avell
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
-41tachwallconsh7tctlonrecord(s)ifm,ailable. For multiple injection or non-water supply wells
ONLY mth the same constr-uction;abandonment,you can submit one fonrc
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 34.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 2 (PVC) (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: -30 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection Wells: fit addition to sending the form to the
address(es)above,also submit onecopy 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): (ft.) abandoned.
6g.Screen length(if known): (ftJ
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22=2016
• I

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan 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 heeded. Indicate TOTAL NUMBER of
2725-A wells abandoned:
7b.Approximate volume of water remaining in well(s): <1 (gal.)
NC Well Contractor Certification Number 5` Pp d
IET
FOR WATER SUPPLY HELLS ONLY:
Company Name r 2�27 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Counn,.State,Ga;�ar�rft je t vrt
7d.Amount of disinfectant used:
3.Well use(check well use): �11tirm J�aii
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaltPubhc 0 Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑bmdustrialiCommeroial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑ln-i ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry i ❑Other(explain under 7g)
RMonitoring ❑Recover
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 94 Ibs portland cement ^-6.5 gallons water
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothernmal(Closed Loop) ❑Trncer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled MW completely with neat cement through
tremie pipe.
4.Date well(s)abandoned: 8/1 7/22
5a.Well location:
Franklinton Landfill
Facility/Owner Name Facility ID*(if applicable) S.Certification:
737 Main St, Franklinton 27525 % 8/18/22
Physical Address,City,and Zip Sianiture of Cent d Well Contractor of Well Owner Date
Franklin
By signing this form. I herebi•eerti5, that the mvell(s) was (were) abandoned in
County ParGelidentiticationNo.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 05 20.109 N 78 27 52.808 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
$ttaclnvellconsMtctionrecord(s)ifat•oilable. For multiple injection or non-water supply wells
ONLI'with the same conshvclion-abandonment,you can submit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-8 abandonment to the following:
Division of Water Resources,Information Processing Link,
6b.Total well depth: 30 (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 (PVC) (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: -29 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7 699-1 63 6
6e.Outer casing length(if known): (ft.) 10c.For Water Supply_ &Infection Wells: In additions 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): (ftJ
t
Form GIV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD ForinternalUseONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hislher property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2725-A wells abandoned:
NC Well Contractor Certification Numl�Fi > a sP-°-, s�1% 7b.Approximate volume of water remaining in well(s): 1 (gal.)
I ET FOR WATER SUPPLY WELLS ONLY:
Company Name i, '
P.J 7c.Type of disinfectant used:
2.Well Construction Permit Unit
List all applicable well construction pl4biits i 'Jbu+ 1e, itriance,etc.)iJ known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipabPubkc IN Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heat uig/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑hndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 85 Ibs portland cement -6 gallons water
❑Aquifer Storage mid Recovery ❑Salinity Bat-tier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsideiice Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heat ing/Coolina Return) ❑Other(explain under 7g) Filled M W completely with neat cement through
tremie pipe.
a.Date well(%)abandoned: 8/1 7/22
5a.Well location:
Franklinton Landfill
Facility/OumerName Facility IDA(if applicable) 8.Certification:
737 Main St, Franklinton 27525 XW 8/18/22
Physical Address,City,and Zip Signature of Cer ted Well Contractor or Well Owner Date
Franklin
By signing this form. I hereby certifp that the well(s) ivas (were) abandoned in
County Parcel identification No.(PIN) accordance irith 15A NC.IC 02C.0100 or 2C.0200 i4'ell Constivaton Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a cop)'of this record has_been provided to the well aivner.
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
36 05 19.565 N 78 27 51.192 `Y, 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 V►'ELLfS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constnictionrecord(s)ifavailable. For multiple injection or non-water supply wells
ONLI'with the saute constntetionlabandonment,You can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (B•) 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 (PVC) (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: -23 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ftJ loc.For Water Supply&Infection Wells: hi additiotn to sending the form to the
address(es)above,also submit onejcopy of this form within 30 days of completion
of well abandonment to the county- health department of the county inhere
6C Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
i
Form GIV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD L7=LY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan Y 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contactor Name(or well owner personally abandoning well on hislher property) well construction/depth,only 1 GW f 30 is needed. indicate TOTAL NUMBER of
2725-A wells abandoned: iI
7b.Approximate volume ofwaterfre'maimn mwell s �1 al.)
NC Well Contractor Certification Number E PP g O'
I ET FOR WATER SUPPLY A'ELLS ONLY:
Company Name (.
P.J� � � 7c.Type of disinfectant used:
2.Well Construction Permit#: .r 10 Uri
List all applicable well constructors permits(i.e.J s;' a 1St biu(r ee,etc.)if known
iJ 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check till that apply):
❑Agricultural ❑Municipali'Public IN Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑hndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri 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 ❑GroundwaterRemediation 94 Ibs portland cement -6.5 gallons water
❑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
❑Geotheral(Heat in Return) ❑Other(explain under 7g) Filled M W completely with neat cement through
m
tremie pipe.
4.Date well(s)abandoned: 8/17/22
53.Well location:
Franklinton Landfill
Facility/Owner Name Facility ID#(if applicable) R.Certification:
737 Main St, Franklinton 27525 lee�- 8/18/22
Physical Address,City,and Zip Swmanue ofCer ' ed Well Contractor or Well Owner Dale
Franklin
By signing this form. I herebI y cer;;hf'that the well(s) was (were) abandoned in
County Parcel identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 lVell Construction Standards
and that a cony of this record has b�en provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 05 23.786 N 78 27 52.927 `r, 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
.3ttachrvellconstnrctionrecord(s)ifm-ailable. For multiple injection or non-water supply wells
ONLI'with the same consbractionlabandonment,you can submit one,%s-m.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (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 (PVC) (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: -29 (ft.) Division ofWater 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: hi addition to sending the form to the
address(es)above,also submit onejcopy 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): (g•) abandoned.
6g.Screen length(if known):
i
Form GIV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
i
Mike Tynan 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Conuactor Natne(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW!30 is needed. Indicate TOTAL NUMBER of
2725-A wells abandoned:
NC Well Contractor Certification Number f'a `E j F 7b.Approximate volume of water:remaining in well(s): 1 (gal.)
FOR WATER SUPPLY WELLS'ONLY:
Company Name AUG ! 'IT NZY_
7c.Type of disinfectant used:
2.Well Construction Permit#: �?a.R+��L lnii
List all applicable well constniction permits(i.e.UI(1 N) N. 6,je 'i4gi VlJBtC.)ij'known
J 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check till that apply):
❑Agricultural ❑Municipal/Public R Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heat ing/Coolin e Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommereial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry I ❑Other(explain under 7e)
19monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 100 Ibs portland cement ^-7 gallons water
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothemral(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled M W completely with neat cement through
tremie pipe.
4.Date well(s)abandoned: 8/17/22
5a.Well location:
Franklinton Landfill
Facility/Owner Name Facility ID#(if applicable) S.Certification:
737 Main St, Franklinton 27525 / 8/18/22
Physical Address,City,and Zip Si•,namre ot•Cer ed Well Contractor dr Well Owner Date
Franklin
By signing this form. I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0/00 or 2C.0200 Well Construction Standards
and that o cop} c fthis record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 05 22.410 N 78 27 49.632 fir, 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 VVELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.41tac1nvellconstnictionrecor-d(s)ifavailable. For multiple injection or non-water supply wells
ONLI-Wth the saute construction.labandomnent you can submit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 34 (R) 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 (PVC) (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: -31 (B) 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 onelcopy 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): (B,) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016
l
l

i
I
WELL ABANDONMENT RECORD For internal Use ONLY.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan 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 GW i 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
J �..i Y ,.�.P `
NC Well Contractor Certification Number ���-� '• J 7b.Approximate volume of water',remaining in well(s): 1 (gal.)
ET 411r, '( '/ 2022 FOR WATER SUPPLY WELLS ONLY:
Company Name
Wivm&f C-n !�r(`YWi R9 UMA 7c.Type of disinfectant used:
2.Well Construction Permit#: r-y%m 3i3OG
List all applicable well construction permits(i.e.UIC,Count.State. Y'ariance.etc.)if k--nonzt
7d.Amount of disinfectant used:.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check sill that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑hndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry I ❑Other(explain under 7g)
mmonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 85 Ibs portland cement ~6 gallons water
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief descri ption of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heat in /Cooling Return) ❑Other(explain under 7g) Filled M W completely with neat cement through
tremie pipe.
4.Date well(s)abandoned: 8/17/22
5a.Well location:
Franklinton Landfill
Facility/Oamer Name Facility ID#(if applicable) 8.Certification:
737 Main St, Franklinton 27525 8/18/22
/N1ZCLiL
Physical Address,City,and Zip Signature orCe( ed Well Contractor or Well Owner Date
Franklin
By signing this form. I her•ebi•certify that the well(s) was livere) abandoned in
Count% Parcel Identification No.(PIN) accordance with 1 S.4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that o cops'of this record has been provided to the icell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 190ong is sufficient) 9.Site diagram or additional well details:
36 05 24.277 N 78 27 51.628 `r, 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 R ELL('S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
3ttachwellconstnrcdonrecord(s)ifm-ailable. For multiple injection or non-water supplvwelis
ONLY with the same consbvction/abandonment,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W 2 B abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.)
25 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 (PVC) (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: -23 (ft) Division of Water Resources,iUnderground 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
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GIV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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