McDowell_Well Abandonment_20221208 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
8re,f+ gurne.4+ei 7a.For Geoprobe/DPT or Closed!L I op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Li L Gill
- A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water!r i maining in well(s): (gal.)
�rrg�vn Gd/f S✓ ( I kA�S /��'/. FOR WATER SUPPLY WELLS ONLY:
Company Name
lc.Type of disinfectant used:
2.Well Construction Permit#: !
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:'
3.Well use(check well use):
Water Supply Well: 7-el,Sealing materials used(check all that apply):
❑Agricultural ❑ /Pu Municipalblic eat Cement Grout.,F. ❑B}entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grobt� ,Zoo '� 5jT1 D Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑DEC 0 S 202 23 Drill Cuttings
'
❑Irri ation ❑ Specialty Grout Gravel
No Water Supply Well: ❑Bentonite Slur Iher(explain under 7g)
onitoring ❑Recovery Dl,t Q,s,�L,
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation l Ll W 1 f0n.5 QCou
❑Aquifer Storage and Recovery ❑Salinity Barrier_• .-•- "
❑Aquifer Test ❑Storniwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer NC4. Camel,+ Al"Y� JA e/l py:�'lp�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
AL- T'roM bd�n�l �� �,J'ell
4.Date well(s)abandoned: 1�&V 2, r Zd�i '
5a.Well location; /y►�lhd)� Cp+'J� 1nJl�n L©nGf eT °�
Rainbow Pct/4 *2- .T^G*
Facility/Owner Name Facility ID#(if applicable) 8.Cc ation:
III-11-1 Vs 2- 9 AloOk
1 ZZ�ZZ
Physical Address,City,and Zip S' ature of Certified Well ontrector or Well Owner Date
M��loaye i
By signing this form,I hereby certify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C:0100 or 2C.0200 Well Construction Standards
and that a copy of this record has i e In provided to the well owner.
56.Latitude and longitude in degrees/minutes/secon s or decimal degrees:
(if well field,one lat/lon is sufficient) 11 9.Site diagram or additional well details:
$i�G N1A� I/1GItJ�it
N 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well construction records)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
/ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: /'[�/►k/' ' abandonment to the following:
!' Division of Water Resources,Information Processing Unit,
6b.Total well depth: V (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I�
10b.For Infection Wells: In addition to sending the form to the address in 10a
above also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
6d.Water level below ground surface: (ft.)
Division of Water Resources,I Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&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
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
I .
I '
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcos Revised 2-22-2016

WELL AliANVOINAlE VT RECORD For Internal Use ONLY.
1.Well Contractor Information: J WELL ABANDONMENTL DETAIL,
D re4 8 V r/)P,4e 7a.For Geoprobe/DPT or Closed I Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number ++ 7b.Approximate volume of water i remaining in well(s): (gal.)
TearrAo;i ['pn SU)4-cn .r .�LnPi FOR WATER SUPPLY WELL$ NLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoum 1,
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e. aling materials used(check all that apply):
❑Agricultural ❑Municipal/Public beat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Ileating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout L
R. F" Drill Cuttings
❑Irri tion ❑ Specialty Grout _ �t ❑Gravel
Non-Water Supply Well: / ❑Bentonite Slurry D r C V 8 2022❑ Other(explain under 7g)
❑Monitoring 117Recovery
Injection Well: 7E For each mateiWa-el&ed�bdV tptdW6'hmtount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 105w1 c(aro•`�MVWQ�30G
❑Aquifer Storage and Recovery ❑Salinity Barrier !b
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ^� 1
❑Geothermal eating/Cooling Return) ❑Other(explain under 7g) /►pc4+
4.Date well(s)abandoned: JVfly 21 20 2 Z 1 j. , ,
W 9 �c;Mm, e N 1 to e,
5a.Well location:
Karl 66w '&Jru V 2 Xn&t* ?760
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1y1'Y VS 221 A/brit, 11 2%A2
Physical Address,City,and Zip Signature of Certified Well ontractor,or Well Owner Date
/r'G Dow eJ By signing this form,1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C;.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has Ibeen provided to the well owner.
I �
(if well field,one lat/long is suffr ieqt)
t"h, M4P ;nL Ind 9.Site diagram or additional well details:
N 1 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formuhiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: W abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of Phis form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (fW Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fL) 10c.For Water SDDDIV&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
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL "ANDUN1VlEN1 RECORD For Internal Use ONLY: � I
i
1.Well ContractorInformation: WELL ABANDONMENT DETAILS
D f F.4 13 v rn e.4e 7a.For Geoprobe/DPT or Closed, Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Tra rcion 'LOn SV 14"cn r Xn ri FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e. aling materials used(check all that apply):
❑Agricultural ❑Municipal/Public [ eat Cement Grout ❑Bentonite Chips or Pellets
is
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) ❑ Sand Cemen ou z"'�T `�• .4 D Clay
� P>/ g PP Y) uPP Y( g ) �.. �:-_-..u • .. � Dry Y
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout"�"� �s""'I �—'-d Drill Cuttings
❑hri ation ❑ Specialty Grout DE C 0 8 '2022 ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry
❑Monitoring Wkecovery ❑ Other(explain under 7g)
�� a�Ur-.
In us�r:�„spa � r...�a•,.:�
Injection Well: 7f.For each material soli l:leyT6oYe,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier ,� w1 It U,+� g
❑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) 1 r�/eC4 CAetieX -P�P
4.Date well(s)abandoned: /V�y 21 � 20 2'Z
5a.Well location:
Rare bow Pb 3ru 1k 2 xn&* 7760
Facility/Owner Name IJ Facility ID#(if applicable) 8.Ce 'fication:
IL "f I-7 VS 221 /Var� t) Za 22
Physical Address,City,and Zip Signature of Certified Well 64mractorlor Well Owner Date
MG poW�� By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02t:�.0100 or 2C.0200 Well Construction Standards
and that a copy of this record hasb ien provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/second`s or decimal degrees:
(if well field one latJlong is suffiie>at) M�� nL 1Vp1� 9.Site diagram or additional Well details:
t N W You may use the back of this page Ito provide additional well site details or well
abandonment details. You may also-attach additional pages if necessary.
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 same cpon_st'ructkon/ab fo andonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
L
1D 6a.Well #: R W V abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: '✓`� (ft) 1617 Mail Service Center,Raleigh,NC 276994617
h
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) 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: (g,) 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 Supply&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
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft,) abandoned.
i
i
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL AKAADUN1 IEN 1 RECORD IFor Internal Use ONLY: I
l
1.Well Contractor Information: WELL ABANDONMENT DETAIL'S
D rG 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: If�
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
TeS J'C4 ton S 1) Lqt1 TS" n Pi FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit M
List all applicable well construction permits(r.e.UIC,County,State,Variance,etc.)ifknawn i
7d.Amount of disinfectant used:
3.Well use check well use):
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public M/Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Ceme aqur ems'R� 7 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Gr6ut� �`'U. a�' ❑Drill Cuttings
❑Irri tion ❑ Specialty Grout 2 ❑Gravel
Non-Water Supply Well: D� '2�22
pP y ❑Bentonite Slurry F]-OOther(explain under 7g)
❑Monitoring m'Recoveryl..r
Injection Well: 7f.For each 'iai s t�eletjed aLoiie;provide amount of materials used:
OAquiferRecharge ❑Groundwater Remediation 3 C 5c 1, 6-fow+
❑Aquifer Storage and Recovery ❑Salinity Barrier �'Sx vJ '
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description oY'the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer n/ �1—J
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1►-5 4� C en� �1 tl x �im ;PLA t e
NovRM W4om off' >„Io11 io �Cp p
4.Date well(s)abandoned:_N V 20 22 r 1 I
Sa.Well location:
Rare 6w Pr,,�ru V 2 XA&* ?760
Facility/Owner Name Q Facility ID#(if applicable) 8.Ce 'tication:
114-11-1 VS 221 //arit,
Physical Address,City,and Zip Signature of Certified Well ontractor;or Well Owner Date
/► C.DOW ell l
By signing this form, I hereby cert fy that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02Ci:0100 or 2C.0200 Well Construction Standards
�Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(,£well field one lat/long is suffii%qt) ��� nG IVd 9.Site diagram or additional well details:
N W You may use the back of this page Ito provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY"h the same construction/abandonment,you can submit one form.
S 10a. For All Webs: Submit this form within 30 days of completion of well
6a.Well ID#• .� abandonment to the following:
I�
QDivision of Water Resources,Information Processing Unit,
66.Total well depth: w "`� (ft.) 1617 Mail Service,Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1.
6d.Water level below ground surface: (ft.)
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service,C iI nter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 00 10c.For Water Suooly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit orie copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.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
I

WELL Al3AN DUN MEIN 1 KLi l ORD For Internal Use ONLY: ( I
1.Well ContractorInformation: 1 J WELL ABANDONMENT DETAIL'SD re4 B V rn e,+ a 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 GW-30 is needed. Indicate TOTAL NUMBER of
Q wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
TeUVA60rl (O�S V I�t� S n Pi FOR WATER SUPPLY WELLS ONLY:
CompanyName 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sling materials used(check all that apply):
❑Agricultural ❑Municipal/Public Xt'Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gr uri' 'r. j F•, �E13 Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout IL L- -,,1-Ls 5 1a8 thrill Cuttings
❑hri anon ❑ Specialty Grout DEC 0 18 20220 Gravel
No Supply Well: / ❑Bentonite Slung ❑ Other(explain under 7g)
❑Monitoring 67Recovery
Injection Well: 7E For each material seleEtk11t!W j�,-rovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation (� p, • Caiyw4
❑Aquifer Storage and Recovery ❑Salinity Barrier-
❑Aquifer Test ❑Stormwater Drainage �•7 D( -I ��
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
A'
❑Geothermal eating/Cooling Return ❑Other(explain under 7g) Neg+ Cents eni /h ti XJ +�En puwpej
hb4t7M Db
/YI OT:Qsl) ic, L O p
4.Date well(s)abandoned: JVO V 21 0 1s o1,9
5a.Well location:
RaLeA haw pa.,N 2 nG 1 ?7(c0
Facility/Owner Name Q Facility ID#(if applicable) 8.K:;��
ty1'11 VS 221 Nor
Physical Address,City,and Zip Signature of Certified Well 8rntractor..or Well Owner Date
/V1�poUJ�11
By signing this form,I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C,.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record hasbfen provided to the well owner.
(if well field one lat/long is suffii has'
been
•,nG 1Vd 9.Site diagram or additional well details:
N 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLYwith the same constructionlabandonment,you can submit one form.
}� 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: R� -1 abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service"Center,Raleigh,NC 27699-1617
i
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: I
I
6d.Water level below ground surface: (ft.) 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 Supply&Iniec I on Wells: In addition to sending the form to the
address(es)above,also submit orie copy of this form within 30 days of completion
of well abandonment to the cl unty health department of the county where
6f.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