Burke_Well Abandonment_20230112 (2)

1
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAiLSI
DAVID HALL 7a.Number of wells being abandoled- 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
constructionlabandonment,you can subut!one form.
A-4459
NC Well Contractor Certification Number 7b.Approximate volume of water re wining in well(s): 3'0 (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
r_
2.Well Construction Permit#: y e.-I , §
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all ttRat;A1fp1k).;i '!'�.�?. �� ialYl
❑Agricultural ❑Municipal/Public
❑Neat Cement Grout ❑Bentoitile`eBio or Pellets
❑Geothermal'(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.75 GALLONS
❑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) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 12/21/22
Sa.Well location:
KNOB SERVICE CENTER
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1145 US - 70 CONNELLY SPRINGS 28612 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
BURKE 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 a•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 lat/long is sufficient) 9.Site diagram or additional well details:
35e 11 a 44 21.23 81 29 1�54.97 You may use the back of this page to provide additional well site details or well
N ` W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
welts 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#. M W-5 R abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 29.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the forth to the address in 10a
2.0 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 11.0 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
10c. For Water Supply&Iniection Wells: In addition to sending the form to
6c.Outer casing length(if known): (ft.) 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 abandoned.
611 Inner casing/tubing length(if known):
i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETA`IILS
DAVID HALL 7a.Number of wells being abandonel: 1
Well Contractor Name or well owner personally abandoning well on his/her roe For multiple injection or non-water supply ivells ONLY with the same
( P Y g property)rtY)
conslrucrion/abandonnrent,you can subnnt one form.
A -4459
7b.Approximate volume of water remaining in well(s): 3'0 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS,.ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: et `•_'m r "
List all applicable well construction permits(i.e.County,Slate,Variance,etc.)ifknowrr 7d.Amount of disinfectant used
3.Well use(check well use): " Lut J
Water Supply Well: 7e.Sealing materials used(check fill that apply�7lit;ir r';!W 1 �C „^i^n P��rr,l
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Closear P�I`{et `
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: IZI Bentonite Slurry " ❑Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 5.0 GALLONS
❑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) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 12/21/22 k
5a.Well location:
f �
KNOB SERVICE CENTER
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification:
1145 US - 70 CONNELLY SPRINGS 28612 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
BURKE By signing this fonn, 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 lat/long is sufficient) 9.Site diagram or additional well details:
350 44 21.23 810 29' 54.97 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if arailable. For multiple injection or non-water supply
wells ONLY wish the same construction/abandonment,you can submit one form 10a. For All Wells: Submit this forth within 30 days of completion of well
6a.Well lD#: MW-6R abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 30.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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: 2•0 (in.) abandonment to the following:
I
6d.Water level below ground surface 1 1.0 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Envirortrnent and Natural Resources-Division of Water Qua',
ua ty Revised March 2013

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply ire!/s ONLY with !!re same
A -4459
construction/abandonmeni,you can submit one form.
f
NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): 2.25 (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: F--aL. ,.
Company Name 7c.Type of disinfectant used: � ,��
2.Well Construction Permit#: JA N 1 2 2023
List all applicable well construction permits(i.e.County,Stare,Variance,etc.)ifknou'n 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(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout' ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.0 GALLONS
❑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) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 12/21/22
Sa.Well location: _
KNOB SERVICE CENTER
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1145 US - 70 CONNELLY SPRINGS 28612 01/09/23
Physical Address,City,and Zip Signature ofCertified Well Contractor or Well Owner Date
BURKE By signing this form, I hereby certify that the ivell(s)ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constriction Standards
and that a copy of this record has been provided to the ivell 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:
350 44' 21.23" 810 29' 54.97" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if orailable. For multiple injection or non-haler supply
wells ONLY with line same construction/abandomnent,you cam submit one form. 10a. For All Wells: Submit this:form within 30 days of completion of well
6a.Well ID#:
MW-7R abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth 25•0 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2•0 (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 1 1.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I;
10c.For Water Supply&infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Q lal I Revised March 2013

f
WELL ABANDONMENT RECORD For Internal Use ONLY: !
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL oned� 1
7a.Number of wells being aband :
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction abandonment,you can su6nttt one f
A - 4459 orm.
NC Well Contractor Certification Number 7b.Approximate volume of water{remaining in well(s): 3.0 gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS'ONLY: h� .
Company Name '�`� �, '�• s (�tc �;: ',I
7e.Type of disinfectant used: A 3
2.Well Construction Permit#: JAN V 9n93
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
Llt L
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
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: [71 Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.75 GALLONS
❑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) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 12/21/22
Sa.Well location:
KNOB SERVICE CENTER
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
1145 US - 70 CONNELLY SPRINGS 28612 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
BURKE By signing this form, I hereby certify that the wells)was (were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 44' 21.23" 810 29' 54.97 You may use the back of this page'to provide additional well site details or well
N W abandonment details. You may also+attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonmeni,you can submit one form. 10a. For All Wells: Submit this!form within 30 days of completion of well
6a.Well ID#: MW-8R abandonment tothefollowing:
it
Division of Water Quality,Information Processing Unit,
29.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) !i
10b.For Iniectioti Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
,i
11.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
r
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
6f.Inner casing/tubing length(if known):
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013