Harnett_Well Abandonment_20230213

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: -�, p`..., WELL ABANDONMENT DETAILS
_ # gy
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 hie/h j� well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
1 2957-A wells abandoned:
•NC Well Contractor Certification Number IntGirc,l a Pt�" r'� 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental ConsultantsniC.✓ FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Calcium Hypochlorite
2.Well Construction Permit#: Harnett Co. app# EH2211-002
List all applicable well construction permits(i.e.WC,County,Stale,Variance,etc.)if known 7 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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) s Concrete Grout 0 Drill Cuttings
❑Irrigation' 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 6 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:
OGeothermal(Closed Loop) OTracer Filled well void completely with concrete to
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
within 3 feet of land surface where a 18"
4.Date well(s)abandoned: 2/1/23 thick concrete plug was installed on top.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4936 NC Highway 55 "f a/L. ,v-vf #z97-,Q 2/2/23
Physical Address,City,and Zip ure of Certified Well Contractor or Well Owner Date
Angier, NC 27501 0682-57-8765
By signing this form, 1 hereby certify that the well(s) was(were) abandoned in
County .gyp/,41 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 lat/long is sufficient) 9.Site diagram or additional well details:
35.474611 N 79.711828 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 with ihe same constructtom abandonment,jon can submit one form. loa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 41 (ft)
10b.For Injection 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: 25 (fE) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): N/A (ft) 10c.For Water Sunoly&Injection 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): N/A (fL)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore - 5 r°: 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally al andoning oreO'oe his/her`property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2957-Awells abandoned:
NC Well Contractor Certification Number FEB D 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Cocsultants, Inc.:.'"'"3(rl FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#: Harnett Co. app# EH23O1-0025
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known '7 oz.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑ Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) PIResidential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial 0 Residential Water Supply(shared) Ill Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete grout 4 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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled well void completely with concrete to
wellhead at land surface and installed an
4.Date well(s)abandoned: 2/7/23 18-inch thick concrete plug on top.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certificatio
n: �J
4798 NC Highway 55 �K �1101A fZ9'57-A 2/7/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Angier, NC 27501 0682-67-3277
By signing this form, 1 hereby certib,that the well(s) was (were)abandoned in
County f/V"nilT 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 lat/long is sufficient) 9.Site diagram or additional well details:
35.473045 N 78.709893 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)ijavailable. For multiple injection 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 ma: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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 17 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft) 10c.For Water Suuoly&Injection 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): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016