Wake_Well Abandonment_20230213

1 !
WELL ABANDONMENT RECORD For Internal Use ONLY: ,
1.Well Contractor Information:n, WELL ABANDONMENT DETAIILS
��'� /io
�� +`/I>1"�J` r—,, "'r.` , $7A,f or Geoprobe/DPT or Closed I L o Geothermal Wells havingthe same •
Well ContractorName(or well owner personally abandoning well�n Itiither propetiy'j' ` 3 o well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4 FEB 1,
J 71 - 1. ` 2023 wells abandoned: 1 I
NC Well Contractor Certification Number 7b.tntt Approximate volume of water,r Imaining in well(s): -I, 6 (gal.)
V'CAeiti- ( 2—Cir .y )41' : r--;:cwr);11043 FOR WATER SUPPLY WELLS•ONLY:
Company Name t1
( 1W/ (� 1...:'
L(31.1
O��•
7c.Type of disinfectant used:
2.Well Construction Permit#: `T —69 1 33 'd•
List all applicable well construction permits(i.e.WC,Como,.State,Variance,etc.)iflatown [� �� ���
7d.Amount of disinfectant used: —1
" 3.Well use(check well use): ,
Water Supply Well: 7e. eating materials used(check all that apply):
DAgg/ricultural ❑Municipal/Public Neat Cement Grout 0 Bentonite Chips or Pellets
0 othermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout
d ❑Dry Clay
ndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slu
❑Monitoring rr 0 Other(explain under 7g)
❑Recovery
. Injection Well: 7f.For ea fit material selected bove,,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation • (erA: %ft it ()
`('1_s
❑Aquifer Storage and Recovery ❑Sal inity Barrier l (� bJ `►�VJ
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a b ief description of the abandonment( cit
roce ure:
❑Geothermal(Closed Loop) ❑Tracer {J c k.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Nit elm " J`JV\�� I \ j�S'��1 it (�� 1I° , .-
lt ��.4 vtie s"C,t.`t& *t3t , -0p
4.Datewell(s)a6andoned: LoiV4/r W 1 l J ai rk d u 'I� l,,` -
5a.Well location: I j'� I'd V
I e,Vd
(C. S+tt ii C_ta,A pvs
Facility/Owner Name Facility m(ifapplicable) S.Certification:
1 )\6 ‘)Ct)r.01 (3r. V\Cilia.V\ f\;0 krAp-f~1, _
Physical Address.City,and Zip Signature of Certified Well Contractor or,Wel 'ner Date
CountyParcel Identification No.(PIN) By signing this form. I hereby cer(r�that the well(s) was (were)abandoned in
accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beenlprovided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwo)(field,o "latllong irs�sufFicicm�� 9.Site diagram or additional well details:
AL[(,� 5ti't W t�ld N /7 41 1 to. L,1�gd 1' 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 WELLJS)BEING ABANDONED
Attach well construction recorl(s)ijarailable.For multiple injection or non-eater supplyvells SUBMITTAL INSTRUCTIONS
ONLY with the.same conunhction•ahardonment.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:
I '1 Division of Water Resources,Information Processing Unit,
6b.Total well depth: v U (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
ti I 10b.For Iniection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: IO � (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: V O (ft,) Division of Water Resources,Ulnderground Injection Control Program,
C
1636 Mail Service Inter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): ' A (ft.) 10c.For Water Supply&Infection W
4 ells: 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 1 health department of the county where
61.Inner casing/tubing length(if known): A A (ft.) abandoned. I'
6g.Screen length(if known): (A (ft.) - '
Form GW-30 'North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
U
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will I'
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
2700b wells abandoned: 1 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY: E"' R,r: - , J.
. b ;i-t
m
Company Name 7c.Type of disinfectant used: None FEB2.Well Construction Permit#: na J 1013
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known N/A Ini i r3:3;�
7d.Amount of disinfectant used: r.-`3-,.•�'r3 l;i ii1
tmlah-N,V,r,.-.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ' I9 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) IResidential Water Supply(single) 0 Sand Cement Grout t 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings • .
❑Irrigation ❑ Specialty Grout I. 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 Wash Stone 1.5 yards
❑Aquifer Storage and Recovery 0 Salinity Barrier
DAquifer Test ❑StormwaterDrainage Bentonite Chips 500 pounds
❑Experimental Technology 0 Subsidence Control l'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well was chlorinated followed by adding wash stone from
225 feet bls (well bottom)to 45 feet BLS
4.Date well(s)abandoned: 2-3-23 From 45 Feet BLS bentonite chips were poured
5a.Well location: in the well to land surface
Doris Hicks na
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 10
301 Jones Street Zebulon 27597 / 2-3-23
Physical Address,City,and Zip Signature of Certified Well Contractor or:Well Owner Date
Wake 2706015099 6
By signing this form, I hereby certi!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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.8395611" -78.3234361" You may use the back of this page Ito 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 record(s)ifavailable.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 ID#: W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth Unknown (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 $r (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: l
Unknown Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 35 (ft) 10c.For Water Supply&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): 225 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

!I
WELL ABANDONMENT RECORD For internal Use ONLY: II • .
1.Well Contractor Information:
/y,�/f Ali WELL ABANDONMENT DETAILS
CC" !-1"""""°'" 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor flame(or w iI owner personally abandoning well on his/her property) well conskuction/depth,only l GW-30 is needed. indicate TOTAL NUMBER of
J S 0 O wells abandoned: ` i
NC Well Contract Certifica'n N bar ,, ( ( 7b.Approximate volume of water remaining in well(s): (gal.)
Gra, D0 f✓ `W Q d l i pu W� , LI,, FOR WATER SUPPLY WELLS O LY:
Company Name
1,' a 1 7e.Type of disinfectant used:
2.Well Construction Permit#: W Q U J e( ?"d 7.Z ,"'L �6 �,
List ail applicable well construcilon permits(i.e.111(',County,State,Variance,etc.)ifknomn ►► I E •
(_., -� `c�C ; ',3.:,.�
7d.Amount of disinfectant used: t' i ` ,
3.Well use(check well use): li r t d 1 5L 0J
Water Supply Well: 7e.Sealing materials used(check all that apply).
❑Agricultural ❑Municipal/Public ❑'Neat Cement Grout I' 0 Bea:11111KttipsarTel}els, :rg Unit
❑Geotherrnal(Heating/Cooling Supply) l4rResidential Water Supply(single) 0 Sand Cement Grout I' 0 Dry Clay '�5° "'' '
❑lndusttial/Commeroial ❑Residentiai Water Supply(shared) 0 Concrete Grout ' 0 Drill Cuttings
❑Irrigation. . 0 Specialty Grout 14 Gravel
Non-Water Supply-Well: . • .
❑Monitoring ❑Recov 0 Bentonite Slurry ❑Other(explain under 7g) -
�y .......__::. •
Injection Well: 7E For each material set ted above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 6 a- I_ mil_
°Aquifer Storage and Recovery ❑Salinity Barrier ID ` II
• °Aquifer Test ❑StomtwaterDrainage b °LS' C)K l •Qi ;j
❑Experimental Technology ❑Subsidence Control i; •
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:_
❑Geothermal pleating/Cooling Return) ❑Other(explain under 7g) vl ra.1 r(+4 - i t 1
b L. V1 /
4.Datewell(s)abandoned: _ 3 6 -b 1
• i;
5a.WeII l tt m: r r n ! •
C a P r let 1 U' raft l h9
Facility Owner Name Facility IDS(if applicable) & lication:
1 -3t 0160, Mt-114,01(v ..
Physical Address.City.and Zip d i
i tine Certified Well Contractor or Well owner Date
rc ke, I•, 1
County Parcel identification No. By signing this form.I hereby certify that the well(s)was(were)abandoned in
(� 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 has been piovtded to the well owner.
(if ell field,one let/long is sufficient)
9.Site diagram or additional well details:
N 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.
C NSTRUCTiON DETAILS OF WELIASI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Angell well constractionreand(s)((available.Fornnililpie infection or non-water supply Wens
ONLY with the sane conrtrucdon abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well Ili#: n 1 abandonment to the following:
5 Division of Water Resources,Information Processing Unit,
6b,Total well depth: )" b (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617 t
r,, 10b.Far inie ction Wells: In addition t I'sending the form to the address in 10a
6c.Borehole diameter. ([J (In.) above,also submit one copy of this forth within 30 days of completion of well
[� I� abandonment to the following:
6d.Water level below ground surface: 2 o 1` (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,'Raleigh,NC 27699-1636
6e.Outer casing length(if known): r 1/1 I 1
l(a (f ) 10c.For WatetSunnly&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
'I of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): t"t (fL) abandoned
6g.Screen length(if known I a-
Font 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
To V` Poole, 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 consttuction/d th,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
-a� (�I wells abandoned:
NC Weil Contractor Ceniticatiionn Number li 4 7b.Approximate volume of water remaining in well(s): 0 (gal.)
��1 p I,
-I r4 T U ` o o I e kki El Pu,t1 FOR WATER SUPPLY WELLS ONLY:
Company Name I f I,
2.Well Construction Permit#.
d ` ta� 7o Type of disinfectant used: �1
List all applicable well construction permits 0.e.(/)f',County.State,Variance.etc.)if known I 1 . r _
•
7d.Amount of disinfectant used: 4j 1 ! d7 - ' y °Cea
3.Well use(check well use):
�' a; ,
Water Supply Well: 7e.Sealing materials used(check all that apply): FEB1 2�23
DAgricultural ❑Municipal/Public O Neat Cement Grout I ' f/iBentonite Chips or Pellets
OGeothetmal(Heating/Cooling Supply) [Residential Water Supply(single) ❑Sand Cement Grout O Dry Clay irgo ri i-443a Pr r r'f ziF.9 Ur:i
0lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings D. �' '
0 irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ORecovery
injection Well: 7E For each material sel above,provide amount of materials used:
OAquifer Recharge OGroundwater Remediation 3 - &I 5 IL z s it
DAquifer Storage and Recovery OSalinity Barrier
°Aquifer Test OStomtwater Drainage r_. 11
OExperimentalTechnology 7SubsidenceControl
OGeothemmt(Closed Loop). •:. °Tracer /►
7g.Provide a brief d ription of the I anent procedure:
, ` F1I
OGrlothermlal(Heating/Cooling Retum) O•ther(explain under 7g) J
I Q.0 I r ,
4.Date well(s)abandoned: ..�� :`
3a,Well location: •
F ility/Owner Na a Facility IMO(if applicable) 8.Certification:
\ii a it IN i I\I a-15T - 1 .
Physical Aa 19 t I/: i 6_ 7... .-2.z,
s.City.and , ' I
Signature o e»i9ed Well ratractor or Well Owner Date
VI a l`Z
By signing this form,I hereby cert(t I hal t the well(s)was County . Parcel Identification No.(PIN) (were)ion abandoned ins
accordance with 15A NCAC 02C.01001 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and tl7OJ a copy of this record has been provided to the well owner.
(if well.field.one lat/long.is sufficient) �i
9.Site diagram or addidonal well details:
N 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 WEL1411 BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction tecord(s)ifavallable.For multiple injection organ-watersupply 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 IDff: abandonment to the following: j
•
Division of Water Resour
ces,information Processing Unit,
6b.Total well depth: I (0 0 (ft.) : • 1617 Mail Service Center,Raleigh,NC 27699-1617
5/
G • 10b.For Infection Welts: in addition'to sending the form to the address in 10a
6c.Borehole diameter. 5 / 77 (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: e2-0 (it.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I? I 1
• 6e.Outer casing length(if known): ; )• - 10c.For Water Supply&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
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): I I a-- (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2,22-2016