McDowell_Well Abandonment_20221208

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: ,, (, 'WELL ABANDONMENT DETAILS
'Bre-i Q.urf%e 1 fi 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 1 G
Liu cy L ' j30 is needed. Indicate TOTAL NUMBER of
A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wati r'remaining in well(s): (gal.)
erS gGOn 60/L SO ( P CAA 4"s -TAO, FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(r.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.dealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public eat Cement Grout ❑Bentonite Chips or Pellets.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
No Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
Zonitoring _ PRecpvv .
Injection Well: 7E For each material selected above,provide amount of materials used:
"L• a a
❑Aquifer Recharge Q❑Groundwater Remediation � ^,lions ro u'4
❑Aquifer Storage and Recover F C 81 Ngly Barrier
❑Aquifer Test a ^� I�❑ Vuw&FPrainage
❑Experimental TechnoldW'-)"' Q bsidence Control
�ljn � 7g.Provide a brief description of the abandonment procedure:❑Geothermal(Closed Loop) ❑Tracer A 64 Cat)l efl+ A4.'YCJ A, - cn'V A''t P&/
❑Geothermal(Heating/Cooling Return ❑Other(explain under 7g) �t'
AL- I 6M bd6nr'1I0�
4.Date well(s)abandoned:1 fPV 2 20 2 t+ " ,
5a.Well location: /hcti hole• CQ� LJI�n LDr+GTe.T °`
Ram6w Pan�'r *2• -7740 i-1
Facility/Owner Name Facility ID#(if applicable) 8.Cer' ation:
14-1"11 VS 2-StNos}�11 I ZZ�ZZ
Physical Address,City,and Zip. S' ture of Certified Wel ntractor or Well Owner Date
Mt;Dol,y.c 1 I By signing 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
5b.Latitude and longitude in degrees/minutes/secon s or decimal degrees: and that a copy of this record has,been provided to the well owner.
(if well field,one laUlopp sufficient)_ 9.Site diagram or additional will(
ll details:
fc7
`SI 6 .Acj N You may use the back of this pagelto provide additional well site details or well W
abandonment details. You may also attach additional pages ifnecessary.
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 samegcogns�truction/abandonment,you can submit onejorm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well Eft ow— abandonment to the following:
�� Division of Water Resources,Information Processing Unit,
66.Total well depth: ��/ (ft.) 1617 Mail Service;Center,Raleigh,NC 276994617
I'
1 t 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above, also submit one copy of ibis form within 30 days of completion of well
abandonment to the following:
• 1i
6d.Water level below ground surface (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,nter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft•) 10c.For Water: &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 ecourity health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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LEGEND.
SUBJECT SITE
" "'RECOVERY WELL LOCATION
MONITORING WELL LOCATION
DEEP MONITORING WELL LOCATION
:SUP.,PLY WELL LOCATION.. j 0 60
♦ SAMPLED MONITORING WELL
SAMPLED RECOVERY WELL I Approximate Scale
THIS WAGRAY IS FOR GENtRAL LOCATION ONLY.AN IS NOT INTENDED FOR CONS7RUC110N PURPOSES I (Feet)
r,�'eal CMP a"� 86179004E MONITORING.WELL LOCATION MAP EXHIBIT
is s AS SHOWN an GROUNDWATER ASSESSMENT
mcladBy. RA. RAINBOW PANTRY 6INCIDENT NO.7760
CMP 14M Uls.? 1 NORTH
Apoveaer Dade: I �>�
72 Pdnte Grde Greerm9e.SC�615
CMP AUGUST 202211 18641292-2901 664 2U-Ml NORTH COVE,NORTH CAROLINA