Wake_Well Abandonment_20221021

SELL.asa�lnorTMEN RECORD
•Pot Intenul Use ONLY:
1.Well Coutrsctor Information:
1- W ABANDONMENT DETAILS
eao e' ELL U.For Geoprobe/DPT or closed-Lei OP Geothernml Wells having the same
Well Contractor Name(or well owner personally abandoning well on hMer property) well construction/d ,oaly I GW-30 is needed. indicate TOTAL NUMBER of
4 wells abandoned
:
1( '�%�•��. can=maanoa tv—onus—et—. d 7b.Appr6xlmEite v(iluum of water reinditoiog an ssell(5):
P (9A)
D
PWell
Compatry Name VM FOR WATER SUPPLY WE ONLY:
//. t
2.Wdi Construction permit#: V 1 d$�-`-�,(�`�,�, 7c:Type of disinfectaut used:
Lisl all oppifcohlN nr0 ruarrrucilon pannlls(J e.(ll(,Counly,5rare,Narhrnce,elc)ijkem,va
3.Well an it heck well uce): 7d.Amount of disinfectant teed: LL i J7
Water Supply Well: K..c-.aa -•-• - -
":;�'"`"�•"", C3Munii:ipal/Public
17Geothetmal(Heating/CoolingSupply) O Neat Cement Grout. irBentonite Chips or Pellets
pP Y) i(Residential Water Supply(single) ❑Sand Cement Grout 0 pry Clay
01ndustrial/CommencM 131tesidential Water Supply(shared) 17 Concrete Grout
Dlyd ation 0 Drill Cuttings
Non-Water Supply WeU: 0 Specialty Grout O Gravel
Monitoring ORecovery 0 Bentonite Slurry ❑Other(explain under 7g)
e WeU:
OAquifer 7E For each material reel above,provide amount of materials and:
Recharge OGroundwater Remediation I G 04� �` � ,.t
OAn ufw Rtnnnnu.. t n.....__. — -.
13AgasferTest OStormwater Drainage
❑Experimentai Technology pSubsidenceControl
MeotherFRO(ClosedLoop) qTraccr 7g,Provide a brief d ptioaofthe abu#ounwatprocedure:
QGeothemr8) i iEatin oolin Ream bother lain under 7 ) ! I r °` IN E D
4.Datewell(s)abandoned:
Set.Well location
F 'liry/Owner N� a Facility[DO(if applicable) &Cerdlication:
5 K Ault 6 �.. .7-75q'
Physical Add'"'.City,and IL 10 a z
q It G Signanae o er it well tmnactor or well owner Date
Couroy By signing this form,!hem by ideadfieatian No.(Pirq by arl{/y rlrar the rve!!(s)was(were)obo►rdonad fir acgordorree with IsA NCAC 02C.0100 or 2C.0200 Well Cot bTellen.av,,,,c..%J=1a➢oawegrees: - vccr,p,wncra,00tz well 01rd8r_
(ifwett�eld.one:iaUlongissuti{uiei�tj" - --`-
9. to diagram or additional well detailb:
N W You may use the back of this page to provide additional well site details or well
abartdoomem details. You may also attach additional pages if necessary,
CONSTRUCTION DETAIL OF ylltd'i tlCl IIQily eg�titL1*tcn
Aaoclrmrpconvarcrlonrrcord(aJ ymnyablr.itotmuhlpleinjeciionormn-rvmrrsupplymeilr B� At.INCtRIi[TrnNa
UNLYwhh the acme cnnsrrucllonabandanmenl,you can Submit om fern..
62.Wtll IW#: 108,.For AU W 1.• Submit this form within 30 days of completion of well
abandonment to the following:
1 / ___.v:...yr::aia r'PXMU
.tiv.i oral well depth: 1° (g,) r..t617 li9ail Service Certerj�.merlon-ProeMitrg unit,
+ leigli,NC 27699-1617
6c.Borehole diameter.r _�- � 10b,For Iniecrton w 1Cet In addition to sending the form to the address in l0a
a.) 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: (fL) Division of Water Recourses Underground Injection Control PRogtmn,
1636 Mail Service Center,Raleigh,NC 27699.1636
6e,Outereadaa length(if known): 30c: W
t •)' • in addition to sending thn fn. n..t...
-.w-v auv,nn vuc copy Or nnS Turn VAM11130 days 0' Completion:.
of'well abandonment to the county health department of the cowry where
6E Inner casing/tubing length(if known): + (g•) abandoned,
69.Screen length(if known):
Form Mao North Carolina ikpnrtmem of Environmental Quality-Division of Warr Resources Revised 2 22 201d

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well ntractor Inform . n: WELL ABANDONMENT OE74AILS I
Y S 7a.Number ofwells being abandoned:
Well Contractor ame or well owner personally abandoning well on his/her property) For multiple doinjnmen!ction or non-water supply wells ONLY with the srmre
Qconstrircilon/abandonment,you can submit one form. h A�
3 1 7b.Approximate volume of wafer remaining in well(s): "t"� (gel.)
NC well Co tint rtifieation Number
6` a e C `�b(, FOR WATER SUPPLY WELLS ONLY:
Company Name J 7c.Type ofdisinfectant used:
2.Well Construction Permit N:
List all applicable well permits(t.e.Corm04 Stare,Variance,Injection,etc.)ifknoun 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that appl ).
Water Supply Well: entonite Chipsor Pellets
❑Ivlunici aUPublic ,Neat Cement Grout
[]Agricultural P
❑Sand Cement Grout ❑Dry Clay
❑Geothermal(Heating(Cooling Supply) ❑Residential Water,Supply(single) ❑ Drill Cuttings
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout g
❑Specialty Grout ❑Gravel
❑Irri ation a Other lain under 7
n-Water Supply well: ❑Bentonite Slurry ❑ (explain g)
Monitoring ❑_Recovery 7E For each material selected above,provide amount of materials used: L L
I` 'Infection Well: r D �1i3� bete 6lc�s /5 G �6 � ©OtT�G'l� Gtr�i
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier E f(1�. PD Ly�81/j( �?zA4,,
3 5 9� sr
❑Aquifer Test ❑Stormwater Drainage ---.
❑Experimental Technology ❑Subsidence Control 7g.Provide,a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer f�� �e %iiy e Adg-,duty d ;✓at g
❑Geothermal(Heating/Cooling Return) Other(explain under 7g) / Z t L
i­4 ex
4.Date well(s)abandoned:. /0 I' Or� Ita ceotextLg
�trx �nn Ntt Duj�
5a.Well location:
ZI
It�I G PS S c `ps ttv erezr� r v pl /7G f1L� � keih/u+t de&,-K
Facility/OwnerName Facility lDN(ifapplicable) _ 4ta�3 <(b�,A4,L , P 14 4, A(,(-
Contractor or Well Owner Date
Physical Add res,City,and Zip
�q) e By signing this form,!hereby cenifj that the.weli{s1 Iffs (ve�mb� i�ni
County p, Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.020�`�C'�(.0 f D>p Spnkdrds
and that a copy of this record has been provided to the well owner. y �022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well de'tails: C•11 1
(ifwell field,one lattiong is sufficient) �teplgj i u�UrA
__ f�� / rp You may use the back of this page to provide additional w}JI s'
Sr N 0 � �`J / 3 -' W abandonment details. You may also attach additiopfttTAPV* �
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS U�
Anach well construction record(s)y available, For muluple injection or non-water supply
wells ONLY with the same construction/ahandonment,you can submit one jorne• 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well I,,: Ll y�r
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 2 7 69 9-16 1 7
6b.Total well depth: �� (ft.)
10b.For Inlection Wells: In addition to sending the form to the address in 10a
tl above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Q Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: tt r (ft-) 1636 Mail Service Center,Raleigh,NC 27699.1636 '
e 10c.For Water Supply&Inlection Wells: In addition to sanding the form to
6e.Outer casing length(if known): (ft-) 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 abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT JIUARS
74.For GeoprobeJDPT or Closed-Loop Geothermal Wells having the same
Weil Con coon ame(or w 11 owner petsmuliy abandoning well on hu tter property) well construction/depth,only t GW-30 is needed. indicate TOTAL NUMBER of
14 5 6 v wells abandoned;.-
• •• pr.rvniatmse ter Tvsuurs us.rate:•eeutattent au b b' vast K F
r44 FOR WATBRSUPPLY WELLS O LY:
Compury Nurse
2.Well Construction Permit#I: L7 U e • Lo III 7�Type of disinfectant used:
l iv augo1evble moll tortttraerlun Partalra 0,e flit:(,aunv,State,Variance,efe)trkwwn +
74L Amount oidfstnfeclxnt used: 1 I
3.Well an(check well use):
Water Supply Well: 'A;.Starling matetiab used(check all that a®n(v).
X
utttdip417Public :13NeatCementGrout. tBentoniteChipsorPellets
OGeothelmal(HeatinglCoolina supply) eaidentiel Water Supply(single) '❑Sand Cement Grout 0 Dry Clay
❑lnduscrial/Commercial OResidential Water Supply(abared) ©Concrete Grout 17!Drill Cuttings
obvigation. ❑Specialty Grout. 14 Gravel
Non-Water.Supply Wdi: O.Bentonite S1
oMottitoring oi3ecov ' O 0dta(explainunder 7g)
It lectlen ell: 7£For each material W
above,provide amount of materiah used:
OAquifer Recharge OGrounduater Remediation ^
OArluiferTest ❑StomtwaterDminage
DExperimental Technolozy OSubsidence Control
OGeothemusl(Closed Loop) OTtacer 7g.Provide it brief description of the abandonment pr ocedum:
OGeothatmal Hearin ooli Retum OOther lain under 7 ' �'�
4.Date well(s)abandoned: b b Z 7.-
a
io Won ren�
T. -1 P� JrA
UVW
F201470wrier None 4 Newly W#(if liable) 8. flcatiaD: �. 1 pio'%
a
3a3t olc� M����'n��
Physical Address.City.and Zip nee Certified Well Contractor or Wen Owner Date
' — By slgrttng tits form,1 hereby cert�jj+that the well(s)was(were)abandoned in
�' Ccmtsy Parcel Identification No.(Pint) accordance with 15A NCAC 02C.6100 or 2C.02W Well Conme0on Slardardr
_ and that a cony ofdds record Ims been provided to the well owner.
� (�fpvell freed, 'k+tllong is suPiieier�i�---. 9.Site diagmin or additional well dieter.CAla—
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.
Atrt��cckurllcarurnrcitonrccaid(aJ(�aval/ably.l�'armultlplelyder(dvrornronicatersepptyxreifs
U Mf'ITAL iNC7 RLICTiONg
UiV�Pwlth the setae ctttulrxcllaa abaadanaeat,Jam cansvbmlt o»e form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 111g1 n-r abandonment to the following:
nlvklnn of WAMr Rwannmrs_infnrmofinn Fmemaina Tint,
6b:Total watt depth: tf1.) 1,617 MaiiService Center,.Ra1d9b,NC Z7699-1617
10b.Fnr InteetEon Weill: in addition to sending the fomt to the address in 10a
6c.Borehole diameter. ;n.) 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.• ® (fir) Division of Water Resourcfa,Underground Injection Control Program,
1636 Mail Service Centen Rake^NC 27M-1636
6e.Outer raft t ng*(If known): ►t OL (f) IOC.For Water Snili ft&Inifs:Non Welter In addition to sendingthe form to the
addreWecl abov&also submit one cony of this form within 30 dave of ommnletian
of well abandonment to the count), hwith department of'the county where
K inner eat Winbing length(if known): (L-) a�aitaonoa
6g.Screen length(if knownY. (R.)
Form OW-30 North Caroline Deparmunt of Environmental duality-Division of Water Reso um Revised 2 2,2-2016