Ashe_Well Abandonment_20220909

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
k
Jon Pfohl 7a.For Geoprobe/DPT or ClosedLoop 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
3301-A wells abandoned:r
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
Antler Env. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
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 ❑Neat Cement Grout is 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)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediatior. Bentonite Chips-3/8" 925 pounds
❑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) Temporary boring for water level measurement.
Sounded boring and slowly dropped bentonite chips w/constant
4.Date well(s)abandoned: 8/10/22 tagging. Hydrated with' potable water after each bag.
5a.Well location: Compacted at surf—e r.
'r r_. �U.P.o ttr�.n..
Ashe Co..LCID Landfill � I I
Facility/Owner Name Facility ID#(ifapplicable) S.C,ertirirN*
739 Fred Pugh Road, Crumpler, 28617 i !`j SEP b 3 2022 9/2/22
Physical Address,City,and Zip Signa f rtifie&Well C11146J flS�,"Ta pnNUZ �,� Date
Ashe By signing t is form, I hereby certify that theivell(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.5250393 N -81.369427 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(s)ifavailable. For multiple injection or non-watersuppiy wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• OW-4 abandonment to the following:
Division-of Water Resources,Information Processing Unit,
6b.Total well depth: 54 (ft) 1617-Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above, also-submit one copy of this form within 30 days of completion of well
abandonment to the following:
36.22 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
6r Outer casing length(if known): (ft)
none 10c.For Water Sanaly&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
611 Inner casing/tubing length(if known): none (ft) abandoned.
6g.Screen length(if known): none (ft)
Form GW-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
Jon Pfohl 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 130'is needed. Indicate TOTAL NUMBER of
wells abandoned:-'
3301-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Antler Env. FOR WATER SUPPLY WELLS'ONLY:
Company Name
7e.Type of disinfectant used:
2.Well Construction Permit#:
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 ❑ Neat Cement Grout in 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
DIrrigation ❑ 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 Bentonite Chips 3/8" 850 pounds
❑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 7 ) Temporary boring for water level measurement.
Sounded boring and slowly dropped bentonite chips w/constant
4.Date well(s)abandoned: 8/10/22 tagging. Hydrated with potable water after each bag.
Sa.Well location: Compacted at s
Ashe Co. LCID Landfill f n° a' 'gn-4
.,
Facility/Owner Name Facility 1D9(if applicable) 8.Certific i
739 Fred Pugh Road, Crumpler, 28617 � � SF N 0 2022 9/2/22
Physical Address,City,and Zip Signa '-of ertified Wel c .or. l Date
Ashe i U.[�r;�(X
By signing this form, I hereby ceni�y 11tat t�well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long-is sufficient) 9.Site diagram or additional wellidetails:
36.5257159 N -81.368862 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
A Hach we/l construction record(s)ifavoilable.For multiple injection or non-water supply wells
ONLY with the same consiructioniabandonment,you can submit one form.
102. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: OW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth- 50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6 (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: 39.01 (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
tie.Outer casing length(if known):
none (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
none abandoned.
6E Inner casing/tubing length(if known): (ft.)
i
I
6g.Screen length(if known): none (ft.)
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
Jon NON 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
3301-A wells abandoned:-' 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Antler Env. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
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 ❑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
DIrrigation ❑ 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 Bentonite Chips 3/8" 925 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description oft he abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Temporary open boring for water level measurement.
Sounded boring and slowly dropped bentonite chips w/constant
4.Date welt(s)abandoned: 8/1 0/22 tagging. Hydrated with,potable water after each bag.
5a.Well location: Compacted at su RE t�:'
Ashe.Co. LCID Landfill
Facility/Owner Name Facility ID#(ifapplicable) 8.Certifiea n: S E P 0 9 2022
739 Fred Pugh Road, Crumpler, 28617 \\ r{. J r h L 9/2/22
Physical Address,City,and Zip Signa of Celtifified ell M Mor Orr, � 1O4 Date
Ashe uJ
By sign rg this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.5243839 N -81.368688 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
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this;form within 30 days of completion of well
6a.Well ID#• OW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 55 (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. 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
10.75 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): none (ft.) 10c.For Water Suoaly&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): none (ft-) abandoned. y
I
6g.Screen length(if known): none (ft-)
f
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jon Pfohl
7a.For Geoprobe/DPT or Closed-hoop 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
wells abandoned:
3301-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Antler Env. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.IJIC,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 ❑ 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
oirrigation ❑ Specialty Grout D Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
e Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips 3/8" 650 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description oft he abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Temporary boring for water level measurement.
Sounded boring and slowly dropped bentonite chips w/constant
a.Date well(s)abandoned: 8/10/22 tagging. Hydrated with potable water after each bag.
5a.Well location: Compacted at
Ashe Co. LCID Landfill
�� `�
'
r .ati
Facility/Owner Name Facility IDit(ifapplicable) 8.Certir, tip
739 Fred Pugh Road, Crumpler, 28617 - 1 SE P Q � 2022 9/2/22
W
Physical Address,City,and Zip Signa fC ified a Date
�"�+o "+ iIli. tq Ural
Ashe By signing this form, I hereby c`eerri?Ra tTte well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.5239241 N -81.3676751 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
Attach wellconstructionrecord(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: OW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (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: 6 (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: 24.3 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): none (ft.) loc.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
611 Inner casing/tubing length(if known): none (ft) abandoned.
6g.Screen length(if known): none (ft.)
4
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016