Union_Well Abandonment_20221114

WE L ABANDONMENT MCORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Will Contractor I�inf�orma/lion: WELL ABANDONMENT DETA1-I,S
—L/✓iar� �CX�J��I ✓1GPi ' /
Well ContractorName(or well owner personally abandoni on his/her property) For
Number ofwells being abandoned:
abandoning well For nnihi le in ecuon or nwt;trater supply welTc ONLY with die sonic
constnzctionlabandanmew,ynn cmz submit one form.
NC,Well 7Contractor Certification Number 7b_Approximate volume of water remaining in well(s):
f,J(�l� FOR WATER SUPPLY WELLS ONLY:
Company Name
_ 2 2.Well Construction Permit 7c.Type of disinfectant used:
#: � 7i Z� `J/�
List all applicable lcell pernzils ft.e.Coano,,State,i'ariance.Bzlectionz,etc)tflnzawn r
7d.Amount of disinfectant used:_�'OZ
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural
❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothemtal(Heating/Cooling Supply) MRV'5—dential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
,�/� Y
❑Industrial/Commercial ❑Residential Water Supply(shared) L'I'Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slu
❑Monitoring �' ❑ Other(explain under 7g)
❑Recovery
Injection Well: 7f.For each material selected above,provide
p amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and ReeoveR, ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ,
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
r 1[]Geothermal(Heating/Cooling Return) ❑Other(explain under7g) 1 (� /J�`y� �' 3 'L�e-/G'—) 6rct�C.
•" CcHriC� •t-//�[� l�Jv%lj C.otn G�'G��
4.Date well(s)abandoned:
Sa.Well location:
LLB
t tr L
F ciligdOwner Name acility iDR(ifa plicable) $.Certification:
S j `✓�
OVYQ`3OG Z Z
I'l ic I Address,City,and Zip Signature of Certified Well Contractor or Well Owner
Date
` 1 By signing This form, I hereby cettif that the mell(s)was 6vere)abandoned in
County Parcel Identification No.(PrN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sh.Latitude and longitude in degrees/minutes/seconds or decimal deg and that a copy=of this record has been provided io the hell owner.
(if well field,one ladlang is sufficicn[)e Drees:
9.Site diagram or additional well details:
��5 �.6 N ��� G/f ) You Wray use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLIS)BEING ABANDONED SUBMITTAL,INSTRUCTIONS
.attach well construction record(s)if mailable. For multiple injection or non-water supply
u•ellr 011IY With the.came constzvzctiozz/zthatidoiznzent,you can submit one form.
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: {ft) 1617 Mail Service Center,Raleigh,NC 2769 9-1 61 7
10b.For infection Ya'ells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: /o {in_) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
r 6d.Water level below ground surface: �7 {fC) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A) the
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
6f.Inner casing/tubing length(if known): (ft) where abandoned.
6g.Screen length(if known): (ft)
Form Gw-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources
Revised August 20I3

[ENT RECORD --
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information: WELL ABAND 3NI LATENT DEVILS
_ �✓ice•-•� �•et�li �rc�G
For multi Number
iu eefi
Well Contractor Name(or well owner personally abandoning well on his/her property) Fpr oft being abandoned:
Fotimr or non-water supple hells ONLY with the same
3 -7—/ consimclionlabandonmem,you cmr submit one form. r NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): J
_(gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name L>
7c.Type of disinfectant used:
2.Well Construction Permit
List all applicable irell permits(i.e.Cnnnly,Slate,Yarimicr.h jection,ere.)iflnrouat
7d.Amount of disinfectant used: �oz.'
3.Well use(check well use):
1Vater Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural
❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) E?1foncreteGrout
❑ Drill Cuttings
Non-Water Supply Well: ❑ Specialty Grout ❑ Gravel
❑Monitoring ❑Recovery ❑Bentonite Slurry ❑ Other(explain under 7g)
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation G Q
❑Aquifer Storage and Reeoven' ❑Salinity Barrier C�k� " 4k
❑Aquifer Test ` ❑Stormwater-Drainase
❑Experitnental Technology ❑Subsidence Control
7g.Provide a brief descriptionof the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ��'��°�s+7/ 3 //�C�/p1,J y ZI
L A oFF
4.Date well(s)abandoned: 2Z
fig.}61locatflion: A.
�►n LAG A, .
Facility/Owner N rue Facil'ty iDm('{applicable $•Certification:
l" S InfOrMatiUll Uru� 9
C -C�_ rtOe�JVfK1j'�� �Z Plnsi aJ Address,City,and Zip Signature ofCemficd Well Contractor or Well Owner J
^ +� ^ _ Date
1 1 ' 1 By siowritrg this fora:, I hereby certrfi_1 drat the wells)u'as(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A ArCAC 02C.0100 or 2C.0200 idrell Constntclion Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has been provided to the well owner.
(ifivell field,one fat/long is sufficient)
9.Site diagram or additional well details:
O(7 G Lf� �S 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 SUBNIITTAL INSTRUCTIONS
anach well construction recorel(s)f ai•ailable. For muhiple injection or non-u•mer supply
u'clls IhYIY with the same co»smuclioulahmidatmrcny yort cal;submit oneforni.
10a. For All Wells: Submit this form vrithin 30 days of completion of well
6.4.Well IDR: abandonment to the following:
p Division of Water Resources,Information Processing Unit,
6b.Total well depth: / (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Iniection Wells. In addition to sending the form to the address in I Oa
6c.Borehole diameter:_- (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the foilonrine:
r 6d.Water level below ground surface �� (ft) Division of Water Resources,Underground Injection Control Program,
1636 ilfail Service Center,Raleigh,NC 27699-1636
(ft) 1Oc. For Water Supply& Injection wells: hr addition to sending the form to
6e.Outer casing length(if known):
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 corm"
6f.Inner casing/tubing length(if known): ) where abandoned.
6g.Screen length(if known): (ft.)
Fonn G%V-30 North Carolina Department ofEnvironmcat and Natural Resources-Division of Water Resources
Revised August 2013

�Ii ELF z 'ANIID0MMNT RE+C0
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor
Information: WELL ABANDONMENT DETAILS
Yt a•r. �P�l�/1 //G�
Well Contractor Name(or well owner personally abandoning well on his/her property) 7a.Number of tyactiells being abandoned:
For multiple in ectiwt or nett-water supply svelty ONLY with ilia same
constntctionlabandotnuent,you can submit one form.
NC WeIICJ Contractor
'CCartii�ficatioon Number 7b.Approximate volume of water remaining in well(s): ©� al
` l //✓!I�v! FOR WATER SUPPLY WELLS ONLY:
Company Name _/ /
/ 7c.Type of disinfectant used:�� 77
2.Well Construction.Permit ft: �� ` Cam!
List all applicable well permits(i.e.Connit:State,lrarlance.L jecria;etc)ifkmwn
7d.Amount of disinfectant used:�/®�
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
❑Agricultural
❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips orPellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout
❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) w6oncrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout
Non-Water Supply well: ❑ Gravel
❑Bentonite Slurry
❑Monitoring ❑ Other(explain under 7))
❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
ClAquifer Storage and Recovery ❑Salinity Barrier GG wGrG�G
❑Aquifer Test ❑Storm rater Drainage
[]Experimental TechnologY ❑Subsidence Control
7g.Provide a brief description o{the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
/
❑Geothermal(Heating/CoolinaReturn) ❑Other(explain under 7g) —�Xee�va Cd �j '6"►1GL-1 6✓a" GU7"
C� awl ��/�' wr-/•%�, ����re�� '
1.Date well(s)abandoned:
Sa. ell location: : , ,
rn 1 f't-Lp� L L�
F cility/Owner Name Facility ID;'(ifa plicable) S.Certification: `
G(,,C�� S �l� NOV 2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Ou ne
By signing this form, J hereby cer101 that the mvell(s)was(were)abandoned ill
County Parcel Identification No.(PIN) accordance with 15.4 NC.AC 02C.0100 or 2C.0200]Yell Constntclion Standards
5b.Latitude and longitude in degrees/minutes/seconds ot•decimal degrees: and that a copy of this record has beer:provided to t/te mrell owner.
(ifwelt field,one lar/long is sufficient) 9.Site diagram or additional well details:
35-" 3 1 q-11 N S/Q a° yZ 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.
COi!'STRUCTIOIlr DETAILS OF R'ELL(S)BEING ABANDONED7•
Attach well construction record(s)f m•ailable. For nuduple injection or Iron-water supply SUBMIT �,INSTRUCTION.
wells ON11'trith die saute catsn7tctioulahaiidaitnieitt,you can suhnih one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDM: abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb.Total well depth: ({t•) 1617 Mail Service Center,Raleigh,NC 27699-1 6 1 7
6 10b. For Injection Wells: In addition to sending the fort to the address in 10a
6c.Borehole diameter above, also submit one copy of this form within 30 days of completion of well
(in.)
abandonment to the following:
r 6d.Water level below ground surface: 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 Sunniv di rnjection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the counri,
bf..Inner casing/tubing length(if known): (ft) where abandoned.
6g.Screen length(if known): Yt.)
Form Gw-30 North Carolina Department of Environment aid Natural Resources-Division of Water Resources
Revised August 2013