Lee_Well Abandonment_20230118

WELL ABANDONMENT RECORD For Internal Use ONLY:
0"4(1 ER' 1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sew = - 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�o�,.i ,�,,,t wells abandoned:
r
NC Well Contractor Certification Number i �' `'t IVED 7b.Approximate volume ofwater remaining in well(s): (gal,)
JA N 1 S 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name
? 1 `Cr �r=7 r�D^� o'KT3^
g UrlM 7c.Type of disinfectant used: /Jlh
2.Well Construction Permit#:J 3®� � :tr'1Q'EL30G
List all applicable well construction permits(i.e.UIC,Count),,State, Variance,etc.)ifknown
3.Well use(check well use): I
7d.Amount of disinfectant used: 'T 9 L
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑A cultural pp y)'
❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 9IFesidential Water Supply(single) ❑ Sand Cement Grout 206ry Clay
❑Industrial/Cormnercial ❑Residential Water Supply(shared) Potoncrete Grout ❑Drill Cuttings
❑hri anon ❑ Specialty Grout rravel
Non-Wate_pply_Su -Well:__ -- __— __ _ __ _ ____ _
`❑ Bentonite Slu '-- -
❑Monitoring ❑Recovery ❑ Other(explain under 7g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation❑Aquifer Storage and Recovery f912Vr1" ZQ S�af6bfS�G❑SaliniBarri
��yy t/❑Aquifer Test ❑StormwaterDrainage Of CIP.0 r o( ' b�; 'ilp�, �:'1Lrt�
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:Qym n4 5®x c+-F
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ,116 i ��jll1
f lJeo/ rvm 9� fd , } ky1 �2i1
4.Date well(s)abandoned:/-4 -a2 0-2
Sa.Well location:
rs:"Ec/y�Tic- OIL
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Physical Address,City,and Zip �7} D
Signature of Certified Well Contractor or Well Owner Date
Zee
County � J0 "J—Ay signing this form,I hereby certify that the well(s) was (were) abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record hits been provided to the well owner.
(if well field,one lat/long is sufficient)
1 � � � �y/� 9.Site diagram or additional well details:
4 �j� N. C)7 r W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach addidu al pages if necessary:-
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record(s)efavailable.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
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:
6b.Total well depth: I/ ! Division of Water Resources,Information Processing Unit,
(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
`/ G l abandonment to the following:
6d.Water level below ground surface: /6, (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Suoaly&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
6f.Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): (ft.)
Forst GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016

Well Abandonment Fol Office Use Only
Lee County *CDP File Numb r: 3130888-2
115 Chatham Street
P.O Box 1528 County ID Numb r: 9631-81-8871-00
Sanford,NC 27331-1528 Evaluated F r: WELLABANDONMENT
(91 9)718-4641
PERMIT VALID UN IL:
I
Property Owner: SECURE, Inc Applicant: SECURE,linc
Address: Address:
City: City:
State/Zip: NC/ State/Zip: NC/
Phone#: [phone] Phone#: [phone]
---{ --'D-illmg Contractor: -_ -- ------ - —Location: - - - _ --_--_--
Latitude:
Driller Registration: Longitude: T
I
I
i
1 Well:
Type: DRILLED Nearest Struc lure: 7 Ft
Fill Material Material: Method:
'Total Depth: 110 Ft From: Ft To Ft NIA I N/A
Diameter. 6 In. From: Ft To Ft N/A N/A
Static Water: 16 Ft From: Ft To Ft N/A N/A
j Water Removed: NO Date of Issue: 12/19/2022
Plumbing: YES
Well Grouted: NIA Cement Plug At:
Casing Removed: Ft From: Ft To 0 Ft
i
i
— , —--Comments--
Well must be abandoned according to nc well construction standards.
Issued By: Eubanks,Aaron Applicant/Legal Signature:
Total Time: