Burke_Well Abandonment_20230112 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells `I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL 7a.Number of wells being abando I ed: 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 sauce
A -4459 constructim✓abandonment,you can subnrjt one form.
7b.Approximate volume of water rining in well(s): 6.25
ema (gal.)
NC Well Contractor Certification Number 1' I
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name
e,,
7c.Type of disinfectant used: r v n- v" ',n, t`= ��'1
2.Well Construction Permit#: JAN � nqq
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: ~ 20C3
3.Well use(check well use):
7e.Sealing materials used check all that apply):
r(`;'C�;,•, r Lire
Water Supply Well: I; ( ��Lu
❑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
I
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 9.5 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: C ' --
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 certij�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 been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 9.Site diagram or additional well details:
350 e 44' 21.23" 81 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 records)if available. For multiple byection or non-water supply
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#: MW-1 0 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 59.0 (11,) 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: 2.0 (in.) above,also submit one copy of this;form within 30 days of completion of well
abandonment to the following:
1'
20.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Centel,Raleigh,NC 27699-1636
i
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 OW-30 North Carolina Department of Environment and Natural Resources-Di i vision of Water Qualty Revised March 2013
1

I� I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I :
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL 7a.Number of wells being abandol ed: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For tnuhiple ityection or non-water supply hells ONLY with the same
construction/abandonment,you can subtntt one form.
A -4459 I'
NC Well Contractor Certification Number 7b.Approximate volume of water re I wining in well(s): 3'0 (gal.)
; I
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: :sr
List all applicable ire//construction permits(i.e.County,State,Variance,etc.)ifknown JA 1V � ?Z o
7d.Amount of disinfectant used:
VL
3.Well use(check well use): I�iOisli l:�„
Water Supply Well: 7e.Sealing materials used(check all that apply):
PPY
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or{'ellts
❑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: Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.75 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
53.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 ivell(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 io 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" N 810 29' 54.97" 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)if available. For multiple ityection or non-water supply
wells ONLY with the same construction/abandonment,you call submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 R abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 29.0 (ft.) 1617 Mail Service Ceaater,Raleigh,NC 27699-1617
10b. For Iniection 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
Gc.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 Ceiiter,Raleigh,NC 27699-1636
10c.For Water Sumnly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit j'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.)
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
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