Burke_Well Abandonment_20230112 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For nrulliple injection or non-wdie supply wells ONLY with the same
construction/abandonment,you can submit one form.
A -4459
3'0
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: i' `c Gam, =!I" L ;�• '
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Slate,Variance,etc.)ifknoivn Inform--"
_� -
7d.Amount of disinfectant used: '�::•?• l�Pill
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑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: IZI Bentonite Slurry ❑Other(explain under 7g)
RlMonitoring ❑Recovery
Injection Well: 7E 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
5a.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 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 with 15A NCAC 02C.0/00 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 rat/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 tb 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 itltection or non-water supply
wells ONLY with lite same construclion/abandonntent,you can submil one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-9R 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 Injection 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
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&Iniectio '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
611 Inner casing/tubing length(if known): (ft.) where abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Qual'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 DETAi�LS
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-wale" supply ive//s ONLY wilh the same
A-4459
construclion/abandonment,you can submit one form.
7b.Approximate volume of water I emaimng in well(s): 2.0 (gal.)
NC Well Contractor Certification Number I
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: f
6`'` 1' ",Company Name 7e.Type of disinfectant used: L _T-x 2.Well Construction Permit#: _
List all applicable we//construction permits(i.e.County,State,iVariance,etc.)ifknown JA N
7d.Amount of disinfectant used: j 2 2023
3.Well use(check well use): jfiuV 3i i „^�M
7e.Sealing materials used check all that apply): C%a
Water Supply Well: g ( PP Y)� ,�,, L
❑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)
RIMonitoring ❑Recovery
Injection Well: 7E 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 lD#(if applicable) $•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 ivell(s)ivas(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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' S4.97a 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach hell construction record(s)if available. For multiple injection or non-water supply
hells ONLY with the sane construction✓abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
24.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For infection Wells: In addition to sending the form to the address in I Oa
20 above,also submit one copy of this'form within 30 days of completion of well
.
6c.Borehole diameter: (in.) abandonment to the following: 11
I
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 Sunnly& Iniectio I Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit 'onb copy of this form within 30 days of
completion of well abandonment to the'county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
i�
f
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality' Revised March 2013
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