Davie_Well Abandonment_20230120

WELL ABAND0NME T RECOIRD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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
2957-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#: 385444-2
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta)ifknmvn 6.5 oz.
7d.Amount of disinfectant used:
3.Well use(check well use): l
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation- ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete grout 2.5 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subs*nce�G trw%\/
i ,,` �
r cer„4t
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑
❑Geothermal(Heating/Cooling Return) ❑Other ex 1 'n ll 73 Placed concrete mix into well casing to depth
1/18/23 Wen�� of 3 feet below surface and then poured 6"
4.Date wells abandoned. ��'-."PI""
O r - a .� thick concrete plug as cap on top.
5a.Well location:
Robert Cornelius Estate N/A
Facility/Owner Name FacilitylD#(if applicable) 8.Certification•
162 Redland Road 'e 6-e-, ►�`�d,rL'( 710�5'7 A 1/19/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Advance, NC 27006 5861481452 By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
County e 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 indegrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.989771 N 80.473222 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)ifavailable.For multiple injection ornon-tvater supply wells
ONLY with the same constructioniabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ED#• SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 29 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
24 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- 13 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 10e.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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): N/A (ft) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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
2957-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit it: 385445-1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 6.5 oz.
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 j ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ❑Drill Cuttings
❑Irri ation• ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete grout 2 cubic yards
❑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 Placed concrete mix into well casing to depth
❑Geothermal(Heating/Cooling Return) 00ther(explain under 7g)
1/18/23 -- �"1'", I'� t�'-
of 3 feet below surface and then poured 6"
4.Date well(s)abandoned: 4-`ice` ,r l thick concrete plug as cap on top.
5a.Well location: N
Robert Cornelius Estate N/�►�` b
Facility/Owner Name ; FarlityWks f � -0 8.Certification:
162 Redland Road Fi ��' � ,,/✓Io�.t O zq:57-4 1119/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Advance, NC 27006 5861481452
By signing this form,I hereby certify that the well(s) was(were)abandoned in
County C(//,l_(� j Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Y 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:
35.989855 N 80.473183 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)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonmeni,you can submit one form.
Z loa. For All Wells: Submit this farm within 30 days of completion of well
6a.Well MY: SW abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth- 19 (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: 24 (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: 8 (ft.) Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (fk) loc.For Water Supply&Injecton 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): N/A (ft.) abandoned.
6g.Screen length(if known): NIA (fL)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016