Johnston_Well Abandonment_20221122

WELL ABANDONMENT RECORD For Internal Usc ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
R IC I( -9 CCCq�t
.� � 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
wells abandoned: I
�J LU C k4 5-k 3—B
NC Well Contractor Certification Number 7b.Approximate volume of water!remaining in well(s): �y 4 (gal.)
4(Z $2�'Ml ma mo^el'"LI.la1 C, FOR WATER SUPPLY WELLS ONLY:
Company Name Cj01LCeM�"� 1j�OCr OL W,��1(,OfiliJe
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ffknown
7d.Amount of disinfectant used:', y•
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that a ly):
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❑Agricultural ❑M_/unicipal/Public 54at Cemen o t� n!t 4 entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) �estdential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) R"Concrete Grout NOV 2 2 2022 ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite ?x?'5,:a Una
�� r., ,,, ❑Other(explain under 7g)
❑Monitoring ❑Recovery �' x
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 1JEiltr Co'V-q- 6-Jto-l--A-y t(LIT
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of ithe abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 'Pow`K cunrar__1- "t tit-/ f µ U•l;rD P�� o7-t", 6
4.Date well(s)abandoned: (I q' to�'Z r W�(
W r-M CyNCnG7'iL � ' ,,-JWW ew a)(Ftli
5a.Well location: 1J OTF CeMGM( "-I-
Facility/Owner Name Facility ID#(if applicable) 8.Certificatiioopp;e
301-9 tJc- ' HWr 1 y`S'awiu►(�a+M- 0mrl NcZ3Szy (/
Physical Address,City,and Zip / 1 Si 'cure of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I SA 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: I
(if well field,one lotllong is sufficient) 9.Site diagram or additional well details:
35', N W You may use the back of this page to provide additional well site details or well
l abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well conshwetion record(s)ifavailable. For multiple h jection or non-watersupply Welty
ONLY with the same construction/abandonment,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: �Z g abandonment to the following:
n t t Division of Water Resources,Information Processing Unit,
6b.Total well depth: !/ J (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
t 1 10b.For Iniection Wells: In addition to sending the form to the address in 10a
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6c.Borehole diameter. 6114 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
t I
g 6d.Water level below ground surface: (ft.) Division of Water Resources;Underground Injection Control Program,
1
1636 Mail ServiceCenter,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): O (ft.) 10c.For Water Suaaly&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
1 of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): Z 0 (ft.) abandoned.
6g.Screen length(if known): ri 1A (ft.) E
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

JOHNSTON COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
309 East Market Street, Smithfield,NC 27577
Phone: [phone] Permit No: 190578
Fax:[phone]
Email: septicwellapplicationeiohnstonnc.com pate: 10126122
-- ' WELL ABANDONMENT PERMIT
Name: Stanley Thomas Address: 3029 NC Hwy 96 S Four Oaks,NC 27524
Location: NC 96S/Property on L on Corner of Thompson Rd
S/D&Lot#:
Construction Type of Well: Bored Type of Facility: SFD Number of Original Connections: 1.2
Well Contractor. Phone Number: F .
Owl" Jacob Squires f
Permit Issued By::
,
Location of existing well to be abandoned is shown in sketch below.This permit is valid for 5 years from date of issue.
***PER STATE AND LOCAL.WELL REGULATIONS,ONLY THE OWNER OF THE PROPERTY OR'A CERTIFIED
WELL DRILLER CAN LEGALLY ABANDON A WELL***
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Inspections(by Environmental Health Staff}:
Sitting/Location: GPS Coordinate: Lat- Lon
Plumbing Fixtures Removed: Concrete Pad Removed: Well Head Removed:
All Debris Removed: Well Chlorinated: Fill Material Approved:
***To be filled out,signed by well contractor and returned to the Johnston County Environmental Health Office***
I hereby certify that this well was abandoned in accordance An on-site inspection has concluded that this well was
with regulations set forth by the State of North Carolina and abandoned in accordance with regulations set forth by the
the Johnston County Environmental Health Department. State of North Carolina and the Johnston. County
Environmental Health Department.
(Stganture of Property Owmt/tegal Represomative)
(Certirirate ofCampiatinni (Date)
(Signatumffrceffxra cam) (Date) *Note to Well Contract 'r or Owner of Property-Attach a
copy of GIN-30"Well Abandonment Record"and Return
(Weil Company) (:erWication 4) with this form.*The GW-30 must be received prior to the
issuance of the Certificate of Completion.
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