Durham_Well Abandonment_20221118

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well ntractor InformaPon: I WELL ABANDONMENT DETAILS
t
�f 7a.Number of wells being abandoned:
Well Contractor ame(or well owner personally abandoning well on his/ber property) For multiple injection or non-water;, supply wells ONLY with the same
Q constrictionlabandonment,you can subndione form.
3 1 7b.Approximate volume of water remaining in well(s):_:e-(gal.)
X
nN;a
1n6 � FOR WATER SUPPLY WELLS ONLY:Company Name 7c.Type of disinfectant used: jlwp I
2.Well Construction Permit#:
List all applicable well permits(i.e.Couno,State,Variance,Injection,etc.)ii(known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that p ).
Water Supply Well: 1eat Cement GroutBentonite Chips or Pellets
OAgricultuml ❑Municipal/Public
(single) ❑Sand Cement Grout ❑Dry Clay
DGeothermal(Heating/Cooling Supply) OResidential Water Supply ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) D Concrete Grout Ss
D.Specialty Grout ❑Gravel
Dlrri tion ❑Other(explain under 7
i)ection
r Supply Well: D Bentonite Sluny ( p g)
❑Recovery p D ' o etch material selected above,provide amount of materials used:
Well: , // /9) s P��04/�fL
OAquifer Recharge ❑Groundwater Remediation y ,�,f�,As• k e'n-/J,41tt//c kle ro/u A�
❑Aquifer Storage and Recovery ❑Salinity Barrier NOV 1 g /
❑Stormwater Drainage
y�
DAquiferTest
1r, g. �'.,^.:;.�•y
❑Experimental Technology ❑Subsidence COMNO t&d Q 3Q 37g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer !� 0tll� 4"'f'A 4/e
OGeothermal(Heating/Cooling Returnrn) ❑••O0�ther(explain under 7g) I't°' �1 f (y G L t' I /dt
4.Date well(s)abandoned: , ` � &,L rT�-- ^ 7//c11���/NL� /rN
5a ell location: [�
I'l
u
G/+� r S.Cf Facility ID#(if applicable) 8 erti ion:
Facility/Owner Name
. Sig. of Ce 'fied Well Convector or Well Owner Date
Physi I Address,City,and Zip
By signing this form, I hereby certh?that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with/SA NCAC 02C.0100 or 2C.0100 Well Construction Standards
and that a copy of this record has bee'provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(ifwe115e((1j�dQonte lat/l(o�njg is sufficient) ,( pp
_3 S -1 1 L�b� N l pp t O?.� dd 2 You may use the back of this page to provide additional well site details or well
©�b O 3 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)tf available. For multiple injection or non-water supply
wells ONLY with the same constructionlabandonment,you can submit one form. lea. For All Wells: Submit this form within 30 days of completion of well
�/)/a►_ abandonment to the following:
6a.Well ID#: /� (1/V
I Division of Water Resources,Information Processing Unit,
Q 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth:
10b.For Infection Wells: In addition to sending the form to the address in 10a
ii above,also submit one copy of this foim within 30 days of completion of well
6c.Borehole diameter: (in•) abandonment to the following: k
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: �' (ft.) 1636 Mail Service Ce i teir,Raleigh,NC 27699.1636
�14 Kok+
10c.For Water Suualy&Iniection Wells. In addition to sending 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.
6L Inner casing/tubing length(if known): ' (ft.)
i�
UtN��nokh f
6g.Screen length(if known): (ft.)
b
Form OW-30 North Carolina Department of Environment and Natural Resources-Division of Water Res urces Revised August 2013
ti

S ;
WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.We ontractor nfor n: WELLABANDONMENTDETAILS
r n 7a.Number of wells being abandon jd:� f
Well Contracto am"(or well owner personally abandoning well on his/her property) For multiple injection or non-water : supply wells ONLY with the some
constructiordabandonment,you can submit one firm.
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Co tracto Cc i13 do Number
�SS� FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: n
List all applicable well permits(i.e.County,State,Variance.injection,etc.)if known 7d.Amount of disinfectant used: �V
3.Well use(check well use):
Water Supply Well: 7 Sealing materials used(check all hot app :
❑Munici al/Public Neat Cement Grout entonite Chips or Pellets
❑A icuItural p Dr y
1F ❑ and Cement Grout Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidentiaaSlv`p'�fsfiajr �' p�ialty Grout ❑Gravel
Oirri tion 5� Other(explain under 7
N n-Water Supply Well: NOV 1 o 2022 O BentoniteSluny O ( p g)
Monitoring ❑Recovery
7f.For each material selected above,provide amount of materials used:
ction Well: Irt(ictx ta;aa� r^ R, ^3 U I� r/QI /fc� 6g
OAquifer Recharge ❑GroundwaterReme#-ft>30GB2 6 NI�e 'I
OAquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description ofthe!,abandonment procedure: �I�
❑Geothermal(Closed Loop) ❑Tracer su( t ppat he►`7'D+,,lZ `j y�a P��q �uw� Well
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) t i
1 I Larne o.
�/�
4.Datewell(s)abandoned: n� Ceytrl�� �CwYt -1"' lk C�l krtt �Ir fit" �fi
5a. location- StAt
� tr'c'� 8.Certif Lion:
Facility/Owner Name Facility ID#(if applicable)
Physical Address,City,and Zip Signature of rtified Well Contactor or Well Owner Date
4JyzA___ By signing this forni, I hereby cerito,Ithat the well(s)was fiver¢)abandoned in
County — Parcel Identification No.(PIN) accordance with l SA NCAC 02C.0/00 or 2C.0200 Well Construction Standards'
and that a copy of this record has beeni p ovided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one tat/long is sufficient)
( �1? N You may use the back of this page to'provide additional well site details or well
Q
t -1 ! W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)lavadable. For multiple injection or non-water supply
wells ONLY with the same constructionlabandomnent,you can submit one form. 109. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#: V1J
I Division of Water Resources,Information Processing Unit,
(� 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: r- (ft•)
10b.For Infection Wells: In additioh to sending the form to the address in 10a
h above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in•) abandonment to the following:
Division of Water Resources,U f derground Injection Control Program,
6d.Water level below ground surface: I ' (ft•) 1636 Mail Service Center,Raleigh,NC 27699.1636
�� 10c. For Water Supply&Infection Wells: In addition to sending the form to
C
6e.Outer casing length(if known): ��h (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 casingltubing length(if known): (ft•)
6g.Screen length(it known): r��nD wh (ft.)
i
Form OW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Co actor Infor at'o / WELL ABANDONMENT DETAIL S
Q/y SGI�Cy- 7a.Number of wells being abandoae'd
EE For multiple injection or non-water supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) construction/abandonntent,you can submit lone form.
-5q 7b.Approximate volume of water remaining in well(s):
NC Well Con et rti 9�Ce 6o Num r
��,/ ^ ���� FOR WATER SUPPLY WELLS ONLY: �
Company Name 7c.Type of disinfectant used: / l
2.Well Construction Permit#:
/t/ A
List all applicable well permits r.e.Cauno,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7 Sealing materials used(check alli that
❑Munici aVPublic Neat Cement Grout I r Bentonite Chips or Pellets
❑Agricultural P
❑Geothermal(Heating)Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
Supply( ❑Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Su (shared) ❑(',ravel
❑Irri Lion �� IC tatty out
n-Water Supply Well: rW`1% o "Cl.
yq erkonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery
Iniection Well: Zf.For each material selected above,provide amount of materials used:
� / r— p
FNI
❑Aquifer Recharge ❑Groundwater Remediation S e ak 41/1 w S(�S Ty�J� .10441
❑Aquifer Storage and Recovery ❑Salinity Baritt(iu
❑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) t
4.Date well(s)abandoned: CI ` dEt KPlr eAf- dO" keu P(tl/r
q C
5a. Il location: t,J/t /L G��Cntt SU
urn 8.Certifi on:
Facility/Owner Name Facility IDH(if applicable)
20� �rn 1 11��G„ JV �i �/
Signature of rtified Well Contractor or Well Owner Date
Physical ddress,City,and Zip
I ,
wr�Gyy, By signing this form, 1 hereby certh,jthat the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0100 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: 9.Site diagram or additional well detail s:
(if we field,one IaUlong is sufficient) / You may use the back of this page to provide additional well site details or well
3 5i q q I f 90 N ©'IFg•f f Sb-�3 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same consm�ran/a_bpidomnent,you can submit onejonn. 109. For All Wells: Submit this form within 30 days of completion of well
//�)�( if abandonment to the following:
69.Well ID#:
1 Division of Water Resources,Information Processing Unit,
Q 1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: V (ft.)
Jn 10b.For Iniection Wells: In addition to sending the form to the address in 10a
I/ above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: / Aft.) 1636 Mail Service Cent i r,Raleigh,NC 27699-1636
f 10c. For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): V h�Cn f)kIr (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.
6f.Inner casing/tubing length(if kno/wn):f (ft.)
6g.Screen length(if known): V N t��Uu-t.. (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resou I s Revised August 2013

II
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well ntractor In rmati WELL ABANDONMENT DETAIL`S j
7a.Number of wells being abandoned
Well Con me(or ell owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
`.Jj construction/abandonmenr,you can submit one form.
7b.Approximate volume of water remaining in well(s):
NC Well
C1 or tar Cc fica er
/U _ � onNNu
L S [ , FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: k
I
2.Well Construction Permit#: (V
List all applicable well permits f.e.County,State,variance,injection,etc.)if know-n 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that app y):
❑ (cultural OMunicipal/Public Neat Cement Grout Bentonite Chips or Pellets
❑ ry Clay
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) O Sand Cement Grout
❑ crete Grout ❑Drill Cuttings
Olndustrial/Commercial ❑Residential Waterer ("t}"ar1,� -� ❑(,,ravel
pi ialty Grout
❑Irri tion O Other(explain under 7 )
o -Water Supply Well: NOV Q �O Bentonite Slurry ( P g
onitoring ❑Recovery v
Infection Well: 7t for each aterial selected above,provide amount of materials used:
;7 ry.;-,:ey^.rs.c`.. ftit / /
❑Aquifer Recharge OGroundwatekl`tr941 �sq@.. �0 75 �en�pni�� �/li;(L �lL
„1.��3�v
❑Aquifer Storage and Recovery ❑Salinity Barrier / S N.
y f ��c �0`//y� lC f-# 1�dyd/ 14-41��
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abando eat procedure:
[]Geothermal(Closed Loop) ❑Tracer r l4- W✓� jps2Q (� U i�Y^
❑Geothermal(Heating/Cooling Return) ■other(explain under 7g) ,A f tI ' Iva/p f�i I /r^ t 6 / /i�` SfL/ t
4.Date wells)abandoned: ` 11�" pKrel 11el L e, �kr well
Sa ell zeaflon,Ae 1 11� i/
Facility ID#(if applicable) 8•Certifi on:
Facility/Own Name
go
Phy al Address,City,and Zip Si use of Ce fied Well Contractor or Well Owner Date
By signing this form, 1 hereby certify i that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 o'r 1C.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: 9.Site diagram or additional well detoil s:
(if well field,one tatllong is sufficient)
3 �����Z� N U t� �(��f �p You may use the back of this page to,provide additional well site details or well
l! ( W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one fonn 10a. j_or All Wells.• Submit this form within 30 days of completion of well
abandonment to the following:
69.Well ID#: i
Division of Water Resources,Information Processing Unit,
�( 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: I V (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
if above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
r
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Cent i er,Raleigh,NC 27699.1636
10c.For Water Supply&Infection Wells: In addition to sending the form to
6c.Outer casing length(if known): �n U� (ft•) the address(es) above, also submit one I copy of this fonn 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.)
CP117W y� (tt.) E
fig.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resou Ices Revised August 2013