Lee_Well Abandonment_20230113

WELL ABANDONMENT RECO" 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 f ned:
Well Contractor Name(or well owner personally abandoning well on Iris/her property) For multiple injection or non-wateir supply wells ONLY with the saute
construction/abandonnnent,you can subnnt one form.
A-4459
7b.Approximate volume of water remaining in well(s): 2'0
NC Well Contractor Certification:Number (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS'ONLY:
Company Name '"`-
t,
7c.Type of disinfectant used: �-' :4....
a�
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Stale,Variance,etc.)ifknown
7d.Amount of disinfectant used: n
x
3.Well use(check well use):
• 'Water Supply Well: 7e.Scaling materials used(check all that apply
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ BeYttdnite! It'tp�or PelleEst
❑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)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater 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: 12/07/22
5a.Well location:
f I -
CIRCLE K- 2720355 ! '
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
429 EAST WEATHERSPOON STREET SANFORD 27330 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
LEE By signing this form, 1 hereby certify that the ivell(s)was (were) abandoned it?
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 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:
350 29' 17.32" 790 10' 05.17" 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
Allach well construction record(s)if available. For muUiple injection or non-waler supply
wells ONLY wilh the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
MW-5 abandonment to the following:
Division of Water Quality,Information Processing Unit,
20.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
lob.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'
I �
S.0 Division of Water Quality,Und,'erground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
I0c. For Water Sunnly&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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
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

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
t
1.Well Contractor Information: WELL ABANDONMENT DETAILS
t
DAVID HALL I 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-u6cr supply hells ONLY with the same
construction✓abandonment,you can submit one form.
A - 4459 I
NC well Contractor Certification Number 7b.Approximate volume of waters remaining in well(s): 2'0 (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLSi3ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: '
List all applicable well construction perm (i its .e.County,State,Variance,etc.)ifknown 1 V
7d.Amount of disinfectant used: Jq A' ..• 209,
3.Well use(check well use):
7e.Sealing materials used check all that apply): �h(,? �t3ii
Water Supply Well: g ( pP y): >chi�0' " t
❑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
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 21 Bentonite Slurry ❑Other(explain under 7g)
IDMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 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: 12/07/22
5a.Well location: i
CIRCLE K- 2720355 I.
Facility/Owner Name Facility ID#(ifapplicable) $•Certification:
429 EAST WEATHERSPOON STREET SANFORD 27330 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or,Well Owner Date
LEE 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 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 29' 17.32" N 790 10' 05.17" 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 injection or non-water supply
wells ONLY will?the same construclion/abandonment,you cat?submit one fornn. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
20.0 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 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: 5.0 (ft•) Division of Water Quality,Uhd'crground Injection Control Program,
1636 Mail Service Geriter,Raleigh,NC 27699-1636
� I
6e.Outer casing length(if known): (ft.) 10c. For Water Supply&Infection 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 ib 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

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 abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-crater supply hells ONLY frith the saute
A -4459
construction/abandontnent,you can submit one form.
7b.Approximate volume of water're i aining in well(s): 2'0 (gal.)
NC Well Contractor Certification Number I _
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: _ `Y�,�`f, }
Company Name 7c.Type of disinfectant used: ryn
2.Well Construction Permit#: 1 2 223
List all applicable well construction perntils(i.e.County,Stale,Pariance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use): ` '4.tic, "' M.4
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: 91 Bentonite Slurry ❑ Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 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: 12/07/22
5a.Well location:
CIRCLE K- 2720355
Facility/Owner Name , Facility ID#(if applicable) 3.Certification:
429 EAST WEATHERSPOON STREET SANFORD 27330 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
LEE By signing this form, I hereby certify that the ivell(s)ivas (were) abandoned it?
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 01C.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:
350 29' 17.32" 790 10' 05.17" 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 j
Attach well construction record(s)if available. For multiple injection or non-wa[er supply
wells ONLYwith 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-7 abandonment to the following:
Division of Water Quality,Information Processing Unit,
bb.Total well depth: 20.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
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.
6d.Water level below ground surface 5•0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunnly&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
611 Inner casing/tubing length(if known): (ft.) Where abandoned.
6g.Screen length(if known):
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 20I3
I

WELL ABANDONMENT RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells 1
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-ii+erj supply ivells ONLY with the same
construction/abandonntent,you can submit one form.
A -4459 11 7b.Approximate volume of water remaining in well(s): 2'0 (gal.)
NC Well Contractor Certification Number I
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: z
Company Name 7e.Type of disinfectant used:
v
2.Well Construction Permit#: JA N r
List all applicable well construction permits(i.e.County,State,variance,etc.)ifknown 7d.Amount of disinfectant used: 1 ` 2023
3.Well use(check well use):
7e.Sealing materials used check all that apply):
v�`•" i � �tt'1
Water Supply Well: g (
❑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) 0 Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 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: 12/07/22
5a.Well location: k I -
CIRCLE K- 2720355
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
429 EAST WEATHERSPOON STREET SANFORD 27330 � 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
LEE By signing this form, I hereby certify that the ivell(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance ivith I5A NCAC 02C.0100 or 2C.0200 Well Construction 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:
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
350 29' 17.32" 790 10' 05.17" 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 ivell construction record(s)if available. For multiple injection or non-water supply
hells ONLY with the same construction/abandontnent,you can submit one form. 10a. For All Wells- Submit this form within 30 days of completion of well
Ga.Well ID#:
MW-8 abandonment to the following:
Division of Water Quality,Information Processing Unit,
20.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
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
6e.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface: 5.0 (ft,) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1.
10c.For Water Sunaly&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 Ito the county health department of the county
6E Inner casing/tubing length(if known): ( ) where abandoned.
ft
i
I 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
I
WELL ABANDONMENT RECORD For internal Use ONLY: j
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-irate supply ivells ONLY with the same
constructiotdabandonntent,you can subndt one form.
A -4459 11 5.75
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: "~_•' " ,
Company Name 7c.Type of disinfectant used: �''
2.Well Construction Permit#:
jAN i = 2023
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use): --> % OL W
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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 9.0 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: 12/07/22
5a.Well location:
CIRCLE K- 2720355
Facility/Owner Name Facility lD#(ifapplicable) $•Certification:
429 EAST WEATHERSPOON STREET SANFORD 27330 � 'e 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
LEE By signing this form, I hereby certify that the ivell(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:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
35 29 17.32 790 10 05.17 You may use the back of this page to provide additional well site details or well
o " 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 constructionlabandonn+ent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: MW_9 abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth: 55.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: 2'0 (in.) abandonment to the following: i
i
1
20.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc.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): (ft.)
6g.Screen length(if known):
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Q I4 ty Revised March 2013
I '
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