Mecklenburg_Well Abandonment_20230109

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Con 71formation: WELL ABANDONMENT DETXI S
(�/ e �ev-1 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: I
NC Well Connactor 'fication Number 7b.Approximate volume of wati r remaining in well(s): 11114 (gal.)
Q FOR WATER SUPPLY WELLS ONLY:
J/
Compaq Name 7c.Type of disinfectant used: H 7�
2.Well Construction Permit#: P .�rn
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.)if1mown
7d.Amount of disinfectant used: Z
3.Well use(check well use):.
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Muni ' I/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) C3Kesidential Water Supply(single) ❑ ment Grout I ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S eConcrete Grout ❑Drill Cuttings
DIrrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well:
_ ❑Bentonite Slurry _ ,,.�,..g❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each alerial�selicted abov p ovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation I QN A
❑Aquifer Storage and Recovery ❑Salinity Barrier d l�
❑Aquifer Test ❑StormwaterDrainage
III+vi �v.�❑Experimental Technology ❑ ✓Subsidence Control %"J;C)j"1:�0u
7g.Provi a brief description of the abandonment procedure:
❑Geothermal(Closed Loop), ❑Tracer
❑ ��tJ t/�Ci
Geothermal(Heating/Cooling Return ❑Other(explain under 7 ) /
i
4.Date well(s)abandoned:
5a./Well location:
Facility/Owner Name / Facility M#(ifapplicable) 8.Certificatio;e:�
Physical Address City,and ip Si of Certified Well Contractor or Well Owner Date
i
G 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
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:
(ifwell field,one Wong is sufficient)
,. 9.Site diagram.or additional well details: ,
N W You may use ttie 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 Aitach well construction records)tfavailable.Formu/ttple injection ornon-watersupply wells SUBMITTAL INSTRUCTIONS
ONLY with the same construction/aband
o
nment,you can submit one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: ?t 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 Injection 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: A-44 (ft) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) lOc.For Water Supply&Ini fiction 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.
• i -
6g.Screen length(if known): / 1/B/t (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i

WELL ABANDONMENT RECORD For Internal Use ONLY:
l �
1.Well Contrac.Infor' ► lion: n WELL ABANDONMENT DETAILS
C �jj// n f I(/P, 7a.For Geoprobe/DPT or Clos Id-I oop 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
r ^ wells abandoned:
J I
NC Well Contractor fication Number 7b.Approximate volume of water,remaining in well(s): (gal.)
s FOR WATER SUPPLY WELLS ONLY: J
Company Name ) �/ 7c.Type of disinfectant used: &r /7
2.Well Construction Permit#:
List all applicable well construction permits 0.e.UIC,County,State,Variance.etc.)iflwown
7d.Amount of disinfectant used:
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mun paUPublic ❑Neat Cement Grrout + c ❑ Bentonite Chips or Pellets
❑Geothermal g Supply) Supply( ) Gl`� (t_
(Heating/Cooling Su 1 esrdential Water Su 1 (single ;�onc'.te
and ement Tout l —',ag a �� �"O Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout JAN 0 9 202311 Gravel
Non-Water Supply Well: -❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery Una
Injection Well: 7£For each material select d`�a1 b44 provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage I
❑Experimental Technology ❑Subsidence Control E
❑Geothermal(Closed Loop), ❑Tracer
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) tell
��A a l�
'i•
4.Date well(s)abandoned: /70 ?
5a.Well location:
/J e,
F tty/Owner Name Facility ID#(ifappplicable) 8.Certification1-2
Physical Address,City,and Zip Signature of Certified Well Contractor o r Well Owner ate
G By signing this form, I hereby e;,*that the well(s) was (were)abandoned in
Countyr 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/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 9.Site diagram or additional welt 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.Formulaple injection ornon-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#: 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
M 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:
I
6d.Water level below ground surface: (ft) Division of Water Resources,iUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fL) 10c.For Water Sunoly&Injei ti n Wells: In addition to sending the form to the
address(es)above,also submit o'ne 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): D/L (ft) abandoned.
6g.Screen length(if known): 69 A e ft)
' � I
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Conror In ormation• WELL ABANDONMENT DETAILS
1 < �ti 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
I�/e� wells abandoned:
NC Well Co � [Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
/f f FOR WATER SUPPLY WELLS ONLY:
Company Name i G/
7c.Type of disinfectant used: .,
2.Well Construction Permit#: D 7
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.)i lmown
7d.Amount of disinfectant used: y0
3.Well use(check well use):.
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M al/Public ❑Neat Cement Grout_ I I _❑ Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) [?Residential Water Supply(single) ❑ S ement'C�r.rout-•a' pl'1y ary Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Concrete Grout 1. ❑Drill Cuttings
Oh-rigation ❑ Specialty Grout JAN p 9 2023 ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry I Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material eprovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
El Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop). ❑Tracer
❑Geothermal(Heating(Coolin Return) ❑Other(explain under 7 ) _ �U`
4.Date well(s)abandoned: Id ?O
5a.Well location: j
FaAhysical
cility/�OwnerName Fact7ityID#(if applicable) 8.Certification
/ :
� r t — �r owi�s�^-
Address,City n
,aan/d Zip Signatu a of Certified Well Contractor of Well Owner Dat�f
c, 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has Teen provided to the well owner.
(if well field one laUlong is sufficient) 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 records)ifavailable.Formultiple injection ornon-watersupply wells
ONLY with 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#: / "// abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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,lUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (D•) 10c.For Water Supply&InieI tiI n 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 Icoimty health department of the county where
6L Inner casing/tubing length(if known): ( ) abandoned.
6g.Screen length(if known): (ft.)
i
Fort GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Co7irmat-ion-t WELL ABANDONMENT DETAILS
f e w� 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:
NC Well Contractor C 'fication Number 7b.Approximate volume of water remaining in well(s): (gal.)
R y FOR WATER SUPPLY WELLS ONLY:
Compaq Name 7c.Type of disinfectant used: �T
2.Well Construction Permit#: zoo s
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown y,7
7d.Amount of disinfectant used:
3.Well use(check well use):: i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M�allPublic ❑Neat Cement Grout , ; >: 1 i F t BentWd7e`.Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CResidential Water SuPP1Y(single) ❑ San ement Grout ❑` ryr"C"l`aay
oncre❑Industrial/Commercial ❑Residential Water Supply(sha �te `
Grout J A v 0 9 &t�31 Cuttings
OIrrigation ❑ Specialty Grout ❑ Gravel
Non-Viater Supply Well:
❑Bentonite Slurry (Ihvi��%+=W� {"�i�'�-=p'p'thlrt(ezplain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage I
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description if the abandonment procedure:
❑Geothermal(Closed Loop), ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) A
i
11
4.Date wells)abandoned: ! co i 2
5a.Well location:
e
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
ZL-11-3 //0 AV
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
B signing this form I hereby I erti that the wells was were abandoned in
Y S S .f Y, ,,h' �)
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 bieen provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient)
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 SUBMTTTAI,INSTRUCTIONS
Attach wellconstructionrecord(s)ifavailable.For multiple injection ornon-watersupplywells
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!#• /V rl abandonment to the following: .
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1111d 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: r
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): A) 10c.For Water Suoaiv&In, I til n 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 couunty health department of the county where
6£Inner casing/tubing length(if known):'/V (it) abandoned.
i
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY: I
II
1.Well Co ct r Information: WELL ABANDONMENT DETAILS
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 constructiom/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
�7D Y wells abandoned:
J
NC Well Contract o fication Number 7b.Approximate volume of water remaining in well(s): (gal.)
ac y J FOR WATER SUPPLY WELIS ONLY:
Company Name 7c.Type of disinfectant used: 1.
T
2.Well Construction Permit#: 0 y�d j
List all applicable well construction permits(i.e.U1C,Counry,State,Variance•eta)if known
7d.Amount of disinfectant used: d2
3.Well use(check well use):: ;
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grou�;(: F > ('d fl?Berl Rite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) San .Cement Grou`�"i v ^�❑1tDry Clay
m ❑ _
❑Industrial/Comercial ❑Residential Water Supply(shared) Concrete Grout JA N-o C, 2Kbrill Cuttings
[]Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: -t- " � er !
❑Monitoring ❑Recovery ❑Bentonite Slurry 4t1iv�T yy='t='� "'`'�"'``"©'Other(/explain under 7g)
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provt e a brief description of the ban onment procedure:
❑Geothermal(Closed Loop). ❑Traced ri /� (/
❑Geothermal(Heating/CoolingReturn ❑Other(explain under 7 ) //� (f s!�� �J��(� 4 e n
I
4.Date well(s)abandoned: )L36
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
/Z 31.5- ����cv��rr i�r .1 2419
Physical Address,City,and Zip Signature of CertifIed Well Contractor or Well Owner Date
e G/' By signing this form, 1 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
and that a copy of this record has ieen provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat4ong is sufficient) 11
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
Atmchwellconstructionrecord(s)ifavaifable.Formaltipfelnjectionornon-warersupplywells
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 IDf#• 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 Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) above,also submit one copy of i is 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
I'
6e.Outer casing length(if known): �_(ft.) 10c.For Water Supply&Injection Wells: In addition to sending the foam to the
address(es)above,also submit bne copy of this form within 30 days of completion
of well abandonment to the i,county health department of the county where
6E Inner casing/tubing length(if known): --eY (ft) abandoned. l
,
. I
6g.Screen length(if known): Aoe_%c (ft)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

I '
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Con or Information: WELL ABANDONMENT DETAILS
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
3 y�
wells abandoned:
NC Well Contractor C ticanon Numit tr 7b.Approximate volume of water remaining in well(s): /y/J' (gal.)
A FOR WATER SUPPLY WELLS ONLY:
Company Naife / 7c.Type of disinfectant used: 1- T d
2.Well Construction Permit#: 0 / �y�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)tf Imown �
7d.Amount of disinfectant used: : /`7
3..Well use(check well use):: �, I
Water Supply Well: 7e.Sealing materials used(check ill that apply):
❑Agricultural ❑Mont blic ❑Neat Cement Grou i��. 0 8entonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) esidential Water Supply(single) 7oncrete
Cement Grou F'❑?Dry Dry-"Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Grout ll Cuttings
JAN 0 9 20�
❑Irri tion ❑ Specialty Grout ravel
Non-Water Supply Well:,
❑ Bentorrite Slury`Dwf.��Ds��� ^r�YTi�.L?:JO-t�ier��explain under 7g)
❑Monitoring ❑Recovery UV"a.Qi�-OG
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test , . ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 7g provide a brief description I f the aba7dent proce ore:
❑Geothermal(Closed Loop). ❑Tracer
le-
❑Geothermal(HeatineCoolin Return ❑Other(explain under 7 ) �/ e n o
4.Date well(s)abandoned: .2
52./ry�W�en location:
/J 1
` ef// r Ili 1
Facility/Owner Natne Facility ID#(if applicable) 8.Certificatio
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
GA 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
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient)
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 records)ifavatlable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
lOs. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (g,) 1617 Mail Service'enter,Raleigh,NC 27699-1617
f
10b.For Iniection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: (in.) above,also submit one copy of this
is form within 30 days of completion of well
abandonment to the following:j
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 easing 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 f county health department of the county where
�
6f.Inner casing/tubing length(if known): d" (ft) abandoned.
6g.Screen length(if known): O !t C (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of W ater Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
f
1.Well Coct r Informatio WELL ABANDONMENT DETAILS
/1 O i 1fe 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:
NC Well Contractor ertifiration Number 7b.Approximate volume of water remaining in well(s): ,NA(gal.)
a y S FOR WATER SUPPLY WELL'S ONLY:
Compaq Name p 7c.Type of disinfectant used:
2.Well Construction Permit#: V �O
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: %0'1
3.Well use(check well use):.
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MM pal/Public ❑Neat Cement Grout I^ ❑Bentonite Chips or Pellets
�•n•.,.~:_�, '"^ "grDyOlay[]Geothermal(Heating/Cooling Supply) �Residential Water Supply(single) ❑ S ement Grout
❑Industrial/Commercial ❑Residential Water Supply(shared) Cnce Grout y Drill'Cuttings
olffigation ❑ Specialty Grout JAN ® 9 ZR7)-vel
Non-Water Supply Well: El Bentonite Slurry ll�l❑ her(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected-Al q%, 3!Eovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop). ❑TracerCl Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) �
4.Date well(s)abandoned: td 6d 1.2)
5a.Well location:
ce ChQ/
Facility/Owner bame Facility ID#(ifapplicable) 8.Certification-
OIL,
Physical Address,City,and Zip Signature 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 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record hds teen provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one laUlong is sufficient) 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
Anach well construction record(s)ifavatlable.For multiple injection ornon-watersupply wells
ONLY with the same construc
ti
on
/a
b
andonment,you can submit one form. 10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: / " / abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Servi6'e Center,Raleigh,NC 27699-1617
/ 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 17 (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: O Division of Water Resources„Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A) 10c.For Water Suooiv&Ini Iction 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 IcoIunty health department of the county where
6E Inner casing/tubing length(if known): abandoned.
6g.Screen length(if known): d n of (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
l
1.Well Con ryif�rmation: WELL ABANDONMENT DETAILS
w 1 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:
i
NC Well Conuactor Certi on Number 7b.Approximate volume of watt r remaining in well(s): (gal.)
�.� FOR WATER SUPPLY WELLS ONLY:
°� 7�
Company Name c 7c.Type of disinfectant used: i
2.Well Construction Permit#: 0 V 1.7-7 O l
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifktown /�Z 7d.Amount of disinfectant used: `7 a
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(che Ik Ill that apply):
❑Agricultural ❑M pal/Public ❑Neat Cement Grout-- f _ ❑Bentonite Chips or Pellets
❑Geothermal(Heating/CoolingSupply) l�Residential Water Su 1 �'
pp y) pp y(single) ❑ S ement Grotit'<«� i, '�,;' Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Concrete Grout nn ❑ Drill Cuttings
❑Irri lion ❑ Specialty Grout JA I�t 202a Gravel g
Non-Water Supply Well: ❑ Bentonite Sl ❑ Other(explain under 7g)
❑Monitoring ❑Recovery ui`R"` "'"'Df�=7
Injection Well: 7E For each material selected ide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage r
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description�Of the abandonment procedure:
❑Geothermal(Closed Loop), ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) t re e'dn e.,Pe le,
4.Date well(s)abandoned: 1.2120 42
5a.We ocation:
I,
Facility/Owner Name acility ID#(ifapplicable) 8.Certification:
'Y1_3 A
Physical Address,City,and Zip Signature of Certified Well Contracto or Well Owner Date
/ By signing this form, I hereby'certtfy 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
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.
,
(ifwell field one Wong is sufficient) 9.Site diagram or additional I well details:
N W You may use the back of this page to provide additional well site details or we]I
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION-DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.Formu/tiple injection ornon-watersupply wells
ONLY with the same constructio abandonment,you can submit one form.
Q 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• (! 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: Inladdition to sending the form to the address in IOa
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: Division of Water Resources,Underground Injection Control Program,
1636 Mail Servicel 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): d/t'r (ft.) abandoned.
6g.Screen length(if known): �dA ed (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016