Alamance_Well Abandonment_20221222

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS,
Frank Beecher 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: f
3225-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):3.0 (gal.)
Aecom FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.U1C,Conn(v,State,Variance.etc.)ifhnowvt
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 ❑Neat Cement Grout -Bentonite Chips or Pellets
❑Geothermal(HeatinglCooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
—-❑Industrial/Commercial DResidential Water Supply(shared) @ Concrete Grout ❑Drill Cuttings
❑Iri gation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Shury ❑Other(explain under 7g)
@Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete 10 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Holeplug 561bs
❑Aquifer Test ❑Stonnwater Drainage
I
❑Experimental Technology ❑Subsidence Control !
7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer
Slowly add Holeplug and verify no bridging is taking place and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
add water when needed.
4.Date well(s)abandoned: 11.21.22 Top of with concrete
5a.Well location: " td�e �-�- -�
Cintas Corporation NA ff11 2
Facility/Owner Name Facility lD#(if applicable)
8.Certification: Li L 1. 2�22
610 Woody Drive, graham, NC 27253 1tt 'Pro
zZ
�,j
Physical Address,City,and Zip Signature of Certified Well Contractor o il r Well Owner -� Date
Alamance 147218
By signing this form,I hereby cent fy that the rvell(s) 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 been provided to the well owner.
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees: !`
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
_3.6__3'32.50.74" N -79 23'6.612" 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atiachwellconsu•tuctionrecord(s)ifavailable.rormultiple hyection ornon-watersupply wells
ONLY with the same construction/abandoin ent,von can submit one forn.
]Oa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-59 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (tt.)
37 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above, also subunit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 19.79 (ft.) Division of Water Resources;Underground injection Control Program,
163611']ail Service, Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Sua"ly&Iniectlion 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): 27 (ft.) abandoned
i
i
6g.Screen length(if known): 10 (ft.) +I
I
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resou ies Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Frank Beecher 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
3225-A wells abandoned:
`;
NC Well Contractor Certification Number 7b.Approximate volume of water rl maining in well(s): '3
(gal.)
Aecom FOR WATER SUPPLY WELLS ONLY:
Company Name j•
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable uvtll construction permits(i.e.UIC,Couniv,State,f'rriance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndustriaUCom mercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
IlMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete i 10IbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
Holeplug 61 Its
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothemtal(Closed Loop) ❑Tracer
Slowly add Holeplug and verify no bridging is taking place and
11
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
add water when needed.
4.Date well(s)abandoned: 11.21.22 Top of with concrete! E_C; i E
5a.Well location:
ncr 2 2 nn
Cintas Corporation NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1rg0 an Prccwoing I.lrA
610 Woody Drive, graham, NC 27253WM02.20.2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Alamance 147218
By signing this fornt. 1 hereby certify that 11te well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 3'31.8234 N -79 237.6554" W You may use the back of this page to provide additional well site details or well
aba dbnmcnt details. Yoti may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS.
Attachwellconsn•actiourecord(s)ifavailable.For multiple injection or non-watersupplywells
ONLY with the same comsh•uctiat/abaedomment,you can submit are foirn.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-57 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:40 (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.)
2 above, also submit one copy of this form within 30 days of completion of well abandonment to the following: 1 i
6d.Water level below ground surface• 20.03 (ft•) Division of Water Resources,UInderground Injection Control Program,
1636 Allail Service CcInter,Raleigh,NC 27699-1636
NA 10c.For Water Suaoly&Iniectiori Wells: In addition to sending the form to the
6e.Outer casing length(if known): (fL) 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): 30 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I