Onslow_Well Abandonment_20230227

WELL ABANDONMENT RECORD For internal Use ONLY:
1.We f/Contractor,Information: . , WELL ABANDONMENT DETAILIS i
G1trQr 1 •
op
7a.For Geoprobe/DPT or Closed-Lo Geothermal Wells having the same
Well Contractot Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: P I
NC Well ContraistoFCbrtidcetioh Numb'et !?' 7b.Approximate volume of water remaining in well(s): (gal.)
61!,'/ ,t to_' /• FOR WATER SUPPLY WELLS ONLY:
• Company Name 7c.Type of disinfectant used: .2 ';,B "`�g." s �°nfry1"'L.:
1.
2.Well Construction Permit#: • FEBD 2 7 2023
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
J.Well use(check well use): 'r'"`"" '^'1 7\ "" "'"'j Ll""
7e.Sealingmaterials used(check all that apply):
y�C:'fi't)is3rJt�
Water Supply Well:' :.
OAgricultural. ` ❑Municipal/Public 24 Neat Cement Grout X,Bentonite Chips or Pellets
❑Geothermal(Healing/Cooling Supply) ❑Residential Water Supply(single) .❑ Sand Cement Grout 0 Dry Clay
thlndustrial/Commercial • ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
I
0hrigation 0 Specialty Grout 1 0 Gravel
Non-Water Supply.Well: . • ❑Bentonite Slurry 0 Other(explain under 7g)
[]Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge • ❑Groundwater Remediation N iea.t Onl e n'�' 110 A/t9t't s
[]Aquifer Storage and Recovery ❑Salinity Bather �/"1/
t7Aquifer Test. - ❑Stormwater Drainage (i N I S / gi94)
OExperimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
. 0 Geothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) lipther(explain under 7g) // ►►'► fl't I e A Howl 4?,
t�o(e o te� • %p 0 Fic as Pun (e4sr
4.Date well(s)•abandoned: fl 11s 1 aJ
( ft'u/Gf s /t kr afl' ,4k W.
1 1 5a.Well location: Fiore—re- •I-o(e— - YM 0 1 t?1 k
,� � ono Nc-cr.Facility/Owner Name S "iipL Facility 1D#(if applicable) S,Certification:
/b 8 7 t)ut. ?yes k ";tct' �C Af5gle of l IS l�3
Physical Address,City, d Zip Signature of Certified Well Contractor or,Well Owner Date
O/n 61 • By signing this form,I 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
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 WELLS)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
fa.Well ID#: \ t-.(Ori` • abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: 't'a• (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: C� (m.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
J
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
I' j
6e.Outer casing length(if known): (ft.)
i 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
• I 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.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
. . r A S;n�er►�r a,

WELL.ABANDONMENT RECORD... -- Forinternal use'ONLY: • i • '
1' ;
II •
• I,We Contractfri;Wormatlom . WELL ABANDONMENT DETAILS
. 1 I
GM/ &0ar1( . - . .... ' 7a.For Geoprobe/DPT or Closed-Loop Geothermal.Wells having the same
Well Contracto!Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 130 is needed. Indicate TOTAL NUMBER of
wells abandoned: ( -
; a ? 3 3 .4 . . .
NC Well Co :1 I • " ..7b.Approximate volume of wa m ter reaining in well(s). - (gal)
nt�to�!C6rt1 ticanoh 1�urhbet'
•
i •.fin,a..564i/,_ 1,,)%Ii,t q .. FOR WATER SUPPLYWELLSNI;Y: '� � Viz °of
Company Name ✓ • _ [! _.,
7c.Type of disinfectant used:
•
. . 2.Well Construction Permit#: • ... . . .. ••• •_ rL �t �1 G 3
Llst all applicable well construction permits(1.e.(TIC,County,State,Variance,etc.)if known • - . • -
7d.Amount of disinfectant used:+ �n;''��'"� � ?� ^�^.�. (�r;1
5.Well use(cheek well use): • ,.t,.3G.
: Water Supplyl Well:' :. ! . . :7e.Sealing materials used(check all that.apply): .
•CDAgricultural•• " `❑Municipal/Public Neat Cement_Grout Bentonite Chips or Pellets.
• COGeothern al(Heating/Cooling Supply) • ❑Residential Water Supply(single) C Sand Cement Grout •• • • 0 Dry Clay
IIIlndustrial/Commercial ['Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
•CII'rrigation • ❑Specialty Grout
1 ❑Gravel-
Non-Water Supply Well: . • • . : . ❑Bentonite Slurry•_ CI Other(explain under:7g)
Injection Well: 7f.For each:material selected above,provide amount of materials used:
17AquiferRecharge ❑GroundwaterRemediation , ]ea4- a eni- //0 7it/ldns
• [Aquifer Storage and Recovery •:DSalinity Barrier //�i
[Aquifer Test. '❑Stormwater Drainage • (::4 0 s Xol •
CIExperimental Technology • ['Subsidence Control
7g.Provide a brief description of the abandonment procedure:
[OGeothernaal(Closed Loop) .['Tracer . . . . p
l7 Geothermal(Heating/Cooling Return) thei(explain under.7g) •. . //I to nil( /J A/*ON1 (19
-; • 13ofe ��. • /bp Oh its putt (Iv, ..
44.Date well(s)abandoned:' Cl I)4 la i '
• _/API/Gf' }n 4i 0A/1 ,Sf{)/p. _
Sa.Well location: - . . - . .
• . t• L` re Me- - UJf) • t)e.1( ..
iRBGtB^o,) x�_S4rap�tn�l S�
Facility/Owner Name' Facility ID#(if applicable) • 8.Certification:
• off.\A7 .tG..):.tr% Bj v2, t 45,9Au:j to 1,0(_ diBSY(, . . .
• ofhgla3
*skid Address,City,and Zip . Signature of Certified Well Contractor or Well Owner Date--
By signing this form,I hereby cert(6,'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.
sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one:lat/long is sufficient) . . 9.Siteldiagram or additional well details:
You may use the back of this page to provide additional well site details or well
N, .• �i' 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-_water supply wells
•ONLY with the same construction/abandonment,you can submit one form. • 10a. For Alit Wells: Submit this form within 30 days of completion of well
t a.Well ID#: .\ j : • abandonment to the following:• ,
• i e . . - - Division of Water Resources,Information Processing Unit,
•(b,Total well depth: • go (ft) - • .1617 Mail Service Center,Raleigh,NC 27699-1617
i/ 10b.For-Injection Wells:-In addition to sending the form to the.address in 10a - •
Cc.Borehole diameter: (in.) above,also submit one copy of this:form within 30 days of completion of well
• • abandonment to the following: • .
(IId.Water level below ground surface: - (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: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
-
hi:Inner casing/tubing length(if known): abandoned
(ft.) I.
•
6g.Screen length(if known):• - (ft.) ' • -
I
Form GW-30 ' North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
•

•
WELL ABANDONMENT RECORD :- . •not Internal Use ONLY:
' • '
].We Contractor,I ormation: WELL ABANDONMENT DETAILS
•
` • e./ f •(/*an - ' - 7a.For Geoprobc/DPT or Closed-I:olop 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
.23 wells abandoned: i�
NC Well ConuatiteCkrt(dcadoh gtithbel :^,!• s-.7b.Approximate volume of.water;'remaining in well(s): (gal.)
4�R.sresrlc?. `�r�jY/.itj
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Typo of disinfectant used: ' .,, ��" r (�f�"+
•
2.Well Construction Permit#: • - 'FEB23
Lst all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if Fv :� ; c 0
7d.Amount of disinfectant used:
Well use(check well use): :n`".,�, -
Water Supply)Well:I :. ! . 7e.Sealing materials used(check all that apply): ' `Jt'`�Q 30G
•
ClAgricultural• .• • ❑Municipal/Piiblic . • .Neat Cement.Grout . .Bentonite Chips or Pellets
GIGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout '' • ❑Dry Clay ' .
LTllndustrial/Commercial ❑Residential Water.Supply(shared) 0 Concrete Grout 0 Drill Cuttings
•DIrrigation .• 0 Specialty Grout 0 Gravel:
Hon-Water Supply Well: . . ' . - ❑Bentonite Slurry : ' 0 Other(explain under:7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each.material selected above,provide amount of materials used:
OAquiferReoharge -❑GroundwaterRemediation 'deal /t e - PO /t)f1Bns. -
oAquifer Storage and Recovery ❑Salinity Barrier • //vi (i (1
bAquifer Test. '❑Stotmwater Drainage • (;4 i?S / •go.)
C4Experimental Technology ❑Subsidence Control . 7g.Provide a brief description of the abandonment procedure:
oGeothermal(Closed Loop) OTracer •
Cl Geothermal(Heating/Cooling Retuin) 'tiZOther(explain tinder.7g) . . f/l ni!C SO f-tom 4
Bore ho l� % - 45u(1 e s: •
-44.Date well(s)'abandoned:. 01 114 I St3 •
•
•
Sa.Well location: : _ J�P//e ed fn 0A, Aye.
•
A-c3C temp 1.4,etc srF ttpe .t,,� �r.st .. .
Facility/Owner Name Facility Wit(if applicable) 8.Certification:
4la1 1e-ji.cne 1'�lvA.1,aack.5ohvitic .1 put 0bb5't/( ril/l4/RI
Physical Address,City,and Zip .. .- • . - . Signature of Certified Well Contractor or Well Owner • Date -
By signing this form,I hereby certify that the well(s)was(were)abandoned in
county Parcel Identification No.(PIN) .accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has.been provided to the well owner.
Sb.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:
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.
' • &INSTRUCTION DETAILS OF WELL(S)BEING ABANDONED ,SUBMIT I AL INSTRUCTIONS
• Attach well construction record(s)ifavailable.For multiple injection or non-water supply weils •• • _ ' • -
U11 LY with the same construction/abandonment,you can submit one form. .10a. For All.Wells: Submit this form within 30 days of completion of well
da.Well ID#: n PT I abandonment to the following: -
i . r _ Division of Water Resources,Information Processing Unit, .
•Or.Total well depth: : g(..7• (ft.) - • • -1617 Mall Service Center,Raleigh,NC 27699-1617
•
. // i/ . 10b.For Infection Wells: In addition to sending the form to the;address in 10a
Etc.Borehole diameter: CO' (in,): :, •- .above,also submit one copy of this form within.30 days of completion of well
. abandonment to the following: . •11 I -
(id.Water level below ground surface: • (ft.) • Division of Water Resources,'Underground'Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
p ! '
6e.Outer casing length'(if known): _ • . - (ft.) . - • 10c.-For Water Supply&Injection'Wells: hi 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 •
if.Inner casing/tubing length(if known): (ft.) abandoned
6g.Screen length(if known):- (ft.)
Form OW-30 North Caroling Department of Environmental Quality-Division of Water Resources 1i : '_ Revised 2-22-2016
.

.WELL ABANDONMENT RECORD-1... -' For Internal Use ONLY: . .- • ..
•
1.W.e135ontractri Wormationt . , . WELL ABANDONMENT DETAILS • • ' . ,
j
•
G/// i iiran( . - 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 GWI30 is needed. Indicate TOTAL NUMBER of
�� walls abandoned:
Arc Well Connai tortOrt{6c4ttoh is/Staid :1! -.lb.Approximate volume of.water;remaining in well(s):.- (gal.)
/a SGLS/t(P_i .P✓14 jl • FOR WATER SUPPLY WELLS:ONLY: �' =., '�—a.
company Name L . .- ,
• - 7c.Typo of disinfectant used: ! - P' tit, ,,i
•E� 2�23
2.Well Construction,Permit#: • •• - • . - '(
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.)if known- , _ '
7d.Auiount of disinfectant used:'• +RiCffi:,t%-..
.Well use(check well use): btr;'oj ir'r f
Water Supply)Well:' :: ! . . 7e.Sealing materials used(check all that apply):
•
ClAgricultural. :. . --❑Municipal/Public . Neat Cement Grout • XBentonite Chips or Pellets
'ClGeothernial(Heating/Cooling Supply) ❑Residential Water Supply(single) .O Sand Cement Grout ' ' : 0 Dry Clay • ' .
Dlndustrial/Commereial - • ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
•£Ilrrigation •• 0 Specialty,Grout 0 Gravel'
• Non-Water Supply Well: 0 Bentonite Slurry: 0 Other(explain under 7g)
OMonitoring ❑Recovery ,
. Injection Well: 7f.For each material selected above,provide amount of materials used:
C1Aquifer Recharge - - ❑Groundwater Remediation �J
• elAquifer Storage and Recovery • ❑Salinity Barrier !/"ieQ� Crn�n�- //Q(:r ��Ons
OAquifer Test.- ❑Stormwater Drainage (.,4 l'p s /. a0l ,
•
QExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the:abandonment procedure: •
[Geothermal(Closed Loop) ❑Tracer ..
0 Geothermal(Heating/Cooling Return) ISTOther(explain Under.7g) //I►''f't(( o7FfON1 AO.
tsofe.4w I 7Op oft As pull r24,7.p pl
4.Date well(s)abandoned: o la3 fa3 ?Par s fp "nP oA`, 'live
• Se.Well location: +• • :-
�) It ' graCt- hole-. 7.V1O ;semi : ..
111:7BC..bY . Iftaxr Sut?ei-atid 5 kt. .
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
a1 lAila3
- etto.1 '/�.3tArte Vtiel,, act vo\e:i vie_ tAfPSY� . . . �: . - ,
Physical Address,City,and Zip .. . •- Signature of Certified Well Contractor or,Well Owner - Date
' By signing this form,I hereby certify,that the well(s)was(were)abandoned in
qo arty - 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.
Sb,Latitude and longitude in degrees/mintites/seconds or decimal degrees: •-
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N '• abandonment details. You may also attach additional pages if necessary.
. CONSTRUCTION DETAILS OF-WELL(S)BEING ABANDONED sUg pp- 1,INSTRUCTIONS
.1ti,wh well construction record(s)ifavailable.For multiple injection or non-watersupplywells -
O AbYwith the same construction/abandonment,you can submit one form. • 10a. For All-Wells: Submit this'form within 30 days of completion of well
-6IIa.Well ID#: 19'Ii- 35.5 • . •" abandonment to the following::.
• - . Division of Water Resources,Information Processing Unit,
• r(tib,Total well depth:. : t 'O (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
- // i.' 10b.For-Injection Wells: In addition to sending the form to the.address in l0a
6.c.Borehole diameter: CO: (m,), above,-also submit one copy of this form within 30 days of completion of well
abandonment to the following. . .
-Gad.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636 ,
•
, I
.6e.Outer casing length'(lf known): (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
(/1.Inner casing/tubing length(if known): (ft.) abandoned.
eg.Screen length(if known):• (ft.) .
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 .

•
•
WELL ABANDONMENT RECORD ' .FeiInternal Use ONLY,
1.We Contractor ormat(on: :• . . WELL ABANDONMENT DETAILS.
/ty (Aran -. .'-.• •
: ..:. 7a.For.Geoprobe/DPT or Closed-Loop Geothermal Wells having the same .
,, V/ell Contractot Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of'
wells abandoned: I 1
27 , 0.4- . -
NC Well Contral#toedgod atioh Dtwbbel !I!- • .7b.Approximate volume of.waterlrel ainingin well(s):.• (gal.)
• � i
(�gJG4/It° �t�JYIi h� FOR WATER SUPPLY WELLS; m
Com an Name Typec %„ a ,, {,,
pomp any • 7c. of disinfectant used: ,
2.Well-Construction Permit it: i' } >y -,-, -
Lst all applicable well construction permits(l.e.UIC,County,Stale,Variance,etc.)jluzown - : • FEB 9
7d.Amount of disinfectant used:'• : '-' . /073
3.Well use(cheek well use): .r w,,.;
�Vater Supplyl Well:' ". • 7e.Sealing materials used(check all'that apply): �f.'�'u� '' i✓tr,;
rlAgricultural:":. . " ❑Municipal/Public :: . -. .XtNeat Cement:Grout . Bentonite Chips or Pellets
CIGeothermal(Heating/Cooling Supply) • ❑Residential Water Supply(single) .0 Sand Cement Grout • l7 Dry Clay • • .
LTllndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete.Grout ❑Drill Cuttings
•
•Elation - - • . . ❑ Specialty.Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ; : 0 Other,(explain under.7g)
Moriitoring ❑Recovery
D 1.
injection Well: 7f.For each material selected above,'provide amount of materials used:
0Aquifer Recharge • ❑Groundwater Remediation J /
DAquifer Storage and Recovery •:❑Salinity Barrier • :Neal- �''rn��l f �(�t+t`}�lOns
•
tAquifer Test. -- • • ❑Stormwater Drainage • (;�N I12$ / .g1 • . :
L?F.xperimental Technology ❑Subsidence Control '7g,Provide a brief description of the abandonment procedure:
C]Geothermal(Closed Loop) . ❑Tracer .. +f�
.. CIGeotheimal(Heating/Cooling Return) �Dther(explain under.7g) //►1r►nl f IO HOM GI . •
QOcCHo to
4.Date well(s)abandoned:0 I I A41/ -
• PP/( J . h) ''pi bA ' 'kV . •
\' -.Sa..-Well location:
I BL eAk. Nduw ,5,treA.v8 5i-IG ! r 6P _�f)(� - �Jj� t 1Q�1
Facility/Owner Name Facility ID#(if applicable) 8.Certification: -
. YI? 7 Le3ww . Blvet i ck.sovq/me. IA) : As.s'(6. ". ... 0/bell.23
Physical Address,City,and Zip - . Signature of Certified Well Contractor oi•,Well Owner . Date '"
By signing this for" I hereby certiikthat 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.
Sb,Latitude and longitude in degrees/minutes/seconds or.decimal degrees: .
(if well field,one lit/long is sufficient) . . 9.Site diagram or additional well details:
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.
•• C(INSTRUCTION DETAILS OF WELL(S)BEING ABANDONED ,SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supplywells :
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
tea.Well Mil: A•13 —IV 51.5-• • abandonment to the following: , - .
Q • Division ofWater Resources,Information Processing Unit,
Gb,Total well depth: t• Y (ft.) • -1617 Mall Service Center,Raleigh,NC 27699-1617 -
. / 10b.For-Infection Wells:•In addition to sending the form to the address in l0a
Cc.Borehole diameter: (O • (in.), -above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
•
d.d.Water level below ground surface: (ft.) Division of Water Resources,-Un derground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
•
Ge.Outer casing length•(if.kaown): (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
, Of.Inner casiug/tobing length(if known): (ft.) abandoned. i
6g.Screen length(if known):• (ft.)-
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources ,, Revised 2-22-2016
•
•
..

WELL.ABANDONMENT RECORD . . :• ,For Internal use ONLY.
•
1.We Contractor ormation: . I . . WELL ABANDONMENT DETAILS ' : ' .••
,e6 ./fv (J 1(an• 7a.For GeoprobelDPT or Closed II:I op Geothermal Wells having the same
Well Contracta Name(or well owner personally abandoning well on-his/her property) .well construction/depth,only 1 GW=30 is needed. Indicate TOTAL NUMBER of
O wells abandoned:
NC Well ConnalitorlClrtidica'tioh Nnrhberi :1"• . .7b.Approximate volume of-water remaining in well(s):_-_ (gal.)
•
4 •
• ci.5 Qih o' . .it+t. .. . . FO SUPPLY Y.R WATERUPPL WELLS.O.
•
Company Name• _�
7c. used:
• . . e ,
of disinfectant as -'�.
2.Well Construction Permit#: •c '� °' .4 f� v
4'Ist all applicable well construction permits(i.e.UIC,:County",State,Variance,etc.)ifldaown•
7d.Amount of disinfectant used:' FER 9� n •• -
•3.Well use(check well use):
inform:,s � Pr-,.,
Water Supply!Well:• .:7e.Sealing materials used(check all-that apply): r„„ ."5�- 7 Llr;,•',
•
ElAgricultural .: • . . .' :❑Municipal/Public - - .Neat Cement Grout -,K.Bentonite Glittps`di 'e11ets
GKGeothermal(Heating/Cooling Supply)- -OResidential Water Supply(single) .0 Sand Cement Grout - ' : 0 Dry Clay ' .
LTllndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings ,
•
El ation - - - . ... - - . 0 Specialty.Grout 0 Gravel'
Neu-Water Supply Well: ❑Bentonite Slurry: 0 Other(explain under 7g)
• l7Monitoring ❑Recovery
l aijection Well: 7f.For each material selected above,provide amount of materials used: .
OAquifer Recharge ❑Groundwater Remediation y1 f '
- -
I:Aquifer Storage and Recovery - ❑Salinity Barrier r/►/PQ� �t rn��+ l�p"" �l�n S .
bAquifer Test: ❑Stormwater Drainage : n o S / "e0. .
• [aExporimental Technology ❑Subsidence Control •
- 7g.Provide a brief description of the abandonment procedure:
•
DGeothermal(Closed Loop) ❑Tracer : - -
LI Geothermal(Heating/Cooling Retina) 'Other(explain under:7g) • : '. // i►n rn(C ,f O fiO►r1 (t f
I
t3of�ho f?..- /Dp a►Fi 45 pfn (^Gs.
4.Date •well(s)abandoned: O 1 1 aN I al •
' -Sa.,Well location:
• :It & e_ 4'0(e_ —./Ali') t).t_t(
. 6..PL.Ovui.. F ltr Su?erwt 54 . . -
Facility/Owner Name ' Facility ID#(if applicable) 8.Certification:
•
R_Aa7 -`e-3.L`� Diva ,,jtack&i„tii I vi the Arc'ef
o l/ayla.3
Physical Address,City,and Zip - • Signature of Certified Well Contractor oriWell Owner • ..Date: .
•
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) -accordance with:5A NCAC 02C.0100 or 2C.0200 Well Construction Standards -
and that a copy.of this record has been provided to the well owner.
vb.-Latitude and longitude in degrees/minntes/seconds or decimal degrees: . . .
(if well field,onelat/long is sufficient) - .. 9.Site diagram or additional well details: . •
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 WELLS)BEING ABANDONED -. .:,SUBMI7'I ALINSTRiJCTION5
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells• •
ONLY with the same conyhvction/abandonment,you can submit one form. .10a.•For All:Wells: Submit this form within 30 days of completion of well
6a.Well D?#: Pr 13- abandonment to the following:g. .
t - - Division of Water Resources,Information Processing Unit,- •
'61b,Total well depth: i; 70 ((t.) 1617 Mall Service Center,Raleigh,NC 27699-1617 • '
- // i r . lob.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: l0 - (in.)- . - .above,also submit one copy of thjs;form within-_30 days of completion of well
. .abandonment to the following: . '' - -
.
(Id.Water level below ground surface: (ft.) - Division of Water Resources;Underground Injection Control Program,
• - - .- 1636 Mail Service Center,Raleigh,NC 2,7699-1636 .
I; 1
6e.Outer casing length'(if known): . . (ft.) . 10c.For Water'Supply&InjectlonVells: In addition to sending the form-to the
addresses)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
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):• • . • (ft.)
•
Form OW-30 - ' North Caroline Department of Environmental Quality-Division of Water Resources • , -_•- _ Revised 2-22-2016
• -

•
WELL ABANDONMENT RECORD. .For Internal Use ONLY: �'
-
•
1.We Contractpr,Information: WELL ABANDONMENT DETAILS • ..
4/4 (Afoot' 7a.For Geoprobe/DPT or ClosedkI:oop Geothermal Wells havingthe same
j Well Contractot Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: 1 I !
2730 I '
' NC Well ContraljtorgCbrtitcalttoh Nuihbe' 'R l ;lb.Approximate volume of wate I remaining in well(s):-- (gal.) •
. FOR WATER SUPPLY WELLS ONLY: '$"•r j T--,e
Company Name ✓ �p .1 j4�,y ' d//.•.r
•
7c. a of disinfectant used: _l�
2.Well-Construction Permit#: - . •. 'F t p 9 j Z�z3
a L'st all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if blown i; - ' ll
7d.Amount of disinfectant used: iC,. --
3.Well use(check well use): - , .�i�;: iU0c2.=;/Linti
Water Supply]Well:' :. ! .. . .7e.Sealing materials used(check all:that.apply):
EIAgriculttiral' ❑Municipal/Pablic .Neat Cement Grout ,hl Bentonite Chips or Pellets
CIGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout " O Dry Clay .
IIlndustrial/Commemial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
•Edrrigation '0 Specialty.Grout • 0 Gravel '
Non-Water Supply Well: . . b Bentonite Slurry: 0 Other,(explain under.7g)
DMonitoring ❑Recovery
Injection Well: 7f.For each-material selected above,provide amount of materials used:
[]Aquifer Recharge - ❑Groundwater Remediation /eQ-t
OAquifer Storage and Recovery :❑Salinity Barrier CmEI1 ft' PO�r?��ens
(]Aquifer Test. ❑Stormwater Drainage e4 f?S / 3�
[]Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
0Geothermal(Closed Loop) ❑Tracer
O Geothermal(Heating/Cooling Return) 1KOther(explain under-7g) %livirmie SO lei (�/f
fSofe-ho le-- ? Oft As Pull rSsr,
4.Date well(s)abandoned: -D I Ie5k1.)
• f oNel i /n i,p af^ ' may.
'Sa.Weil location: •
'
j l� Fioie� , {�, A LIc Ce •hf)(� - i'NC7 t?ie..it
Siff. ;
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
. of - te(jurte: RIvd ,,)ackgp,vole .wc-pjssY& • --7 - I - of lay!/ate
Physical Address,City,and Zip . .. . . Signattire of Certified Well Contractor or Well Owner ' Date
' By signing this form,I hereby certify,that the well(s)was(were)abandoned in
•County Parcel IdentificationNo.(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.
Sb.Latitude and longitude in degrees/mimites/seconds or decimal degrees:
(if well field,one lat/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.
•
•
CONSTRUCTION DETAILS OF•WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Atdreh well construction record(s)tfavalable.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
da,Well BM: 1.2A -IV.`3.01 • abandonment to the following::
„/ • Division of Water Resources,Information Processing Unit,
6b,Total well depth: �' �'�1 �y,/V (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
! ., e 7 10b.For•Infection Wells: In addition to sending the form to the address in 10a •
Etc.Borehole diameter: CO (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: . I, '
-
Gd.Water level below ground surface: (ft.) - - Division of Water Resources,Underground•InJection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
• i .
6e.Outer casing length'(ff known): - . (ft.) . • 10c.For Water Supply&Injection Wells:'In addition to sending the form to the
address(es)above,also submitone copy of this form within 30 days of completion
.. . Of well abandonment to the county!health department of the county where
(If.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):• (ft.) I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources ', ' - , - Revised 2-22-2016 .

II
SWELL ABANDONMENT RECORD For Internal Use ONLY: ., i
y
1.Well Contra r Inforrtion: WELL ABANDONMENT DETAILS
,,�_ j x C//i 6 j2IF/l '(j 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
\., wells abandoned:
: .2 •7304
:lC Well Contmetbr Certification 'N�'um*l I III i 7b.Approximate volume of water remaining in well(s): (gal.)
C a 5 cad.e. b r,l r 1 I in, L 9 FOR WATER SUPPLY WELLS ONLY:
Company Name ;'., ,'"'e, -r. •
' 7c.Type of disinfectant used: s ,„::w r '-.y S.,f";
1
•
n 2.Well Construction Permit#: 1
Ttst all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known FEB 2
7d.Amount of disinfectant used: •� 7 209 3
?l.Well use(check well use): ;nit:in:1 `0n prz,7,..:�;•
f.., Uri':
7ater Supply Well: ; '11 '1' ; i I,'r!:' 7e.Sealing materials used(check all that apply):�� G o�
:7Agricultural . " ❑Municipal/Public 0 Neat Cement Grout [zrtientonite Chips or Pellets
]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
:]lndustrial/Commercial • ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
1
Dhrigation 0 Specialty Grout 0 Gravel
?ton-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
i3Monitoring , ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
l]Aquifer Recharge '❑Groundwater Remediation
[]Aquifer Storage and Recovery ❑Salinity Barrier
(Aquifer Test ❑Stormwater Drainage •
(1Experimental Technology ❑Subsidence Control I
7g.Provide a brief description of the abandonment procedure:
CIGeothermal(Closed Loop) ' OTracer
tGeothermal(Heating/Cooling Return) 0 Other(explain under 7g) 1
{ / 341.Date well(s)abandoned: I/I '//.Z ,
}f Sit.Well location:
PA 5L,Per P(l{hd S r‘ -P : '
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
•
_,1 12 7 L e3-euki Ply el r caciSejoilo re i/c i:_. I-20-p7?
Physical Address,City,and Zip Signature of Certified Well Contractor on Well Owner Date
1
Z.ClICK S Uh V I'1 l G By signing this form,I hereby certrfy that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(t'well field,one.lat/long is sufficient) 9.Site diagram or additional well details:
3 Lt t 7 ( I Li c79 6 . N• _71, 3 1-cR JFS 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.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED ,SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supply wells
QVLY with the same constructtor✓abandonment,.you can submitone form. 10a. For All Wells: Submit this form within 30 days of completion of well
ID&II.Well #: if Pt t(0 1 abandonment to the following:
' P Division of Water Resources,Information Processing Unit,
•&b.Total well depth: $0,' I J (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
I.1
10b.For Injection Wells: In addition to sending the form to the,address in 10a
&I:,Borehole diameter: (in.)
above,also submit one copy of this form within 30 days of completion of well
. abandonment to the following: 1
611.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c:.Outer casing length(if kn• own): (ft) 10c.For Water Supply&Injection Wells 1 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
•
, 6%Inner casing/tubing length(if known): (ft.) abandoned.
6l'l.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources!, Revised 2-22-2016
1 '

9 4 .
WELL ABANDONMENT RECORD For Internal Use ONLY:
11.Well Contraflor Inforrinaq n: I,.ill r WELL ABANDONMENT DETAILS
Kr f/5' (i?.1,�r Zit 7a.For Geoprobe/DPT or Closed-Loop p 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
.wells abandoned: I 1
.27)0 A
.,4C Well Contractbi•Certificafi'dn lVirebel•I(I!I I 7b.Approximate volume of water remaining in well(s): (gal.)
I G CAS c l5 a 0/'1l4((ii)j (—P FOR WATER SUPPLY WELLS ONLY: -- ' :
II 1
company Name 7c Type of disinfectant used: `'t�7 'ar''e" "e a
- sr''' k•,�, c (<y ,,,..Well Construction Permit#d • ; I y '1,,,,,,' v
list all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if!mown
7d.Amount of disinfectant used: FEBA 7 2823
3.Well use(check well use):
itliivfif,0.Itzm>7,-,-
WVater Supply Welk ; 1! 'I1 ; i I!I ,I 7e.'Sealing materials used(check all that apply): , `` a:4,
:]Agricultural ! ; ❑Municipal/Public 0 Neat Cement Grout tikirrnconite Chips or11eilb1•s
±Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ❑Sand Cement Grout '0 Dry Clay ,
']Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 1 0 Drill Cuttings
Dlnigation 0 Specialty Grout 1 0 Gravel
Non-Water Supply Well:, ❑Bentonite Slurry 0 Other;(explain under 7g)
1lMonitoring . ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
I QilAquiferRecharge ❑GroundwaterRemediation •- ',
!
[ilAquifer Storage and Recovery OSalinity Barrier
DAquifer Test • ❑StormwaterDrainage • '
[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)
I
4.Date well(s),abandoned: I/I D /2-3 '
t
�) 5a.Well location:
AI-% _E P A S uPe tr Ptlrid S t`f-e i•
Ficility/Owner Name Facility ID#(if applicable) S.Certification: .
Z121 t_et-Q E1(, 01Vd)YQCICSOnVI(le Nc -7r I. , ./-20-.21
Physical Address,City,and Zip Signature of Certified Well Contractor on Well Owner Date .
'.,Ta GI(SUyi V i lie- By signing this form,I hereby cerl&&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.
Si).• Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
?Li, 1 LI I e-I ff 7 Li • N. —7 7 e 3 (y 6(.(tj Z c W You may use the back of this page to provide additional well site details or well
Iabandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
GiVLP with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this,form within 30 days of completion of well
&i;.Well m#: et Pr I O rJ Z abandonment to the following:
(� Division of Water Resources,Information Processing Unit,
Gb.Total well depth: a q 4 7 J (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• 10b.For Iniection Wells: In addition to sending the form to the address in 10a
Co.Borehole diameter: (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1'
4• 1
G iL Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
r
6<°:.Outer casing length(if known): (ft.) 10c.For Water Supply&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
I of well abandonment to the county'health department'of the county where
6ia Inner casing/tubing length(if known): (ft.) abandoned l
t
. •
611.Screen length(if known): (ft.)
Farm GW-30 • North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
j
1

II
WELL ABANDONMENT RECORD . . For Internal Use ONLY:
:L.Well Contractor 1(nforr at}pn:, ill r WELL ABANDONMENT DETAILS
I I
f('t/. C/Z�,v7'- T/21. 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/depp ,only 1 GW•13 i is needed. Indicate TOTAL NUMBER of
wells abandoned:
i g'73 0 A .
. ?IC Well Contractor Certification 1 Vmibe}I HI!r 7b.Approximate volume of waterlrei aining in well(s): (gal.)
i c 03Cad e Ph' It tinyL P FOR WATER SUPPLY WFI.i S'ONLY:
1. .
c',ompanyName .E' er o? .g�.--t•.»..
7c.Type of disinfectant used: I '' t r t' F. E S""x
- •---...•
2.Well Construction Permit#: I: I FEB'
n
:lit all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)((known r t a 7 2l'2 3
7d.Amount of disinfectant used:,.
31.Well use(check well use): 1nscs a.37-1 PrC^.. c r.(Jr i
Water Supply Welk 1 II .11 I i I!hl • 7e.Sealing materials used(check all that apply): DINC030C4
:]Agricultural • : ❑Municipal/Public 0 Neat Cement Grout • [i"rite Chips or Pellets
:JGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
llndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout' CIDrill Cuttings
C°.lhrigation 0 Specialty Grout 0 Gravel
)'?ion-Water Supply Well: 0 Bentonite Slurry , 0 Other(explain under 7g)
E1Monitoring . ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
EilAquifer Recharge ❑Groundwater Remediation ,
E]Aquifer Storage and Recovery ❑Salinity Barrier .
L:IAquifer Test ,❑Stormwater Drainage • -
EilExperimental Technology ❑Subsidence Control
1 7g.Provide a brief description of the abandonment procedure:
G:IGeothermal(Closed Loop) ' OTracer
CIGeothermal(Heating/Cooling Return) pother(explain under 7g)
4.Date well(s)abandoned: 1/ 19/Z 3 .
,-----, 5s.Well location:
� 1 _Pei\ Suto.ei•Ftl rid Su� ° ,
Facility/Owner Name Facility ID#(if applicable) 8.Certification: !
BIZ 1 I-eTeunt313(vci)tiaGKSal i.1i Ue /✓ •-•7;, .----_— J—Z0-.21
Pl ysical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
_®CIS SUri ✓1 lie By signing this form,I hereby cerij;that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 154 NCAC 02C.0100 or 2C.0200 Well Construction Standards
•
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,onelat/long is sufficient) 9.Site diagram or additional well details:
34, .7111
q 6,6 7 • N. 7 7+3 G 4-3 g.SS `,;' 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)ifavailbble.For multiple injection or non-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
ds.Well ID#: ft ft 1013) tier i et73 ik) Ik PT i(03 Q abandonment to the following:
. i
1 C Division of Water Resources,Information Processing Unit,
O.Total well depth: 1✓ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
10b.For Infection Wells: In addition to sending the form to the address in l0a
1 2 above, also submit one copy of this form within 30 days of completion of well
fir.Borehole diameter: (in.)
• abandonment to the following: I; i
p
f 11.Water level below ground surface: (ft.)
Division of Water Resources,Underground Injection Control Program,
+ 1636 Mall Service Center,Raleigh,NC 27699-1636 •
6r.Outer casing length(if known): (ft.) lOc.For Water Supply&Injection Wells: In addition to sending the form to the
i address(es)above,also submit one copy of this form within 30 days of completion
I of well abandonment to the countyI. l health department of the county where
6i. Inner casing/tubing length(if known): (ft.) abandoned
1 •
6i.Screen length(if known): (ft.)
•
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources;' Revised 2-22-2016
I'
I'

•
a it i l: •H .
•i,i i I •'a i i t it I'
W B ELL AB. RECORD '•For Internal Use ONLY: ';f . '
tt; I .: ;
1.,We Contractpr, ormatlon: tWELL ABANDONMENTIDETAILS !!' , .
, i, I ,i ,
G/f /�crart f a.For Geoprobe/DPT or to a I II�Ipop Geo'tlier�ialidWe I�rh�vim the same
/ ,1 ell construction/d ,, 'q I II r' • at
Well Contracts Name(or well owner personally abandoning well onhis/hor property) epth,onl,1 I;: rs rie���ii �idr� �TO�'�AI,.NUMDER of
ells abandoned: I I I , .Ii, i; ,I€{i LI d ,i!; ;j 1,I.
a-7,710 .4- • is Il 1 1 li�Ili!!1I ,1-{-p.p1, IIIII 9'-II .IiijI,!� !, .
NC Well Contrak{tor!Cbrtidelirioh)u hbei' :1! - - 'f'I b.Approximate volume of.water 4•eitudid'Ing;in well(s)':• .!',, . (gal.) •
/� II
III
jrlro�. �p•)% •fi, . ;FOR WATER SUPPLY WELLS,ONLY:
Com• pany Name y •' `, :r ;? , ,
7c.Type of disinfectant used: .�I:1. I, ' I .. . . .-.ia'_ ii 'i �,,,
.. • , Fill�;', III I I it PI 4' �,�I; i4 i' ;1
2,Wel-Construction-Permit#: -- •- : Fk,
a. 12021
Last all applicable well construction permits(Le.UIC,County,State,Ydr•tance,etc)tflmown ! e• I
17d.Amount of disinfectant used: ;n;. - `
•Well use(check well use): ivi ; ,,� �Q
Water Supply)Well:' ; • ! 7e.Sealing materials used(check'all that apply): :-'sty 'mot''•! ..
LlAgricultt mi: :. •• . . • .❑Municipal/Pdblic ,1.Neat Cement.Grout I I I I .Bentonite Chips or Pellets
CI Geothermal(Heating/Cooling Supply) ' ❑Residential Water Supply(single) O Sand Cement Grout ' • ! ❑Dry Clay
LTllndustrial/Commercial ❑Residential Water Supply(shared) ',O;Concrete Grout . . ;' I I j IjiR 1I ;), 'i,❑j Dri11ICuttmgs'!III;I !!
•
Oirrigation l7 Specialty,Grout - - • ❑Gravel •
Non-Water Supply Well: • I. ❑'Bentonite Slurry, • ! • • 0 Other(explain under;7g)
OMonitoring • ❑Recovery • r
• Injection Well: ,7f.•For each.material selected,above,provide amount'ofrmaterials used:
DAquifer Recharge -❑GroundwaterRemediation hII - //I'•II I�j1II I 1 :1'I ,'� 1 1I I
DAquifer Storage and Recovery DSalinity Barrier • f�leQ-� ��r�en F !l QI ` r�i 15 �� � I!�I. '�' •
DAquifer Test. li Stormwater Drainage (:4 t(9S I'•8 'I •
0Experimental Technology ,❑Subsidence Control I'
7g.Provide a brief description of the abandonment procedure:.
OGeothermal(Closed Loop) • •OTracer 4,p-
...
OGeotherinal(Heating/Cooling Return) 't[�Other(explain under-7g) // ovnite, JO7t'f0+r1
/op 0Ft cis pulr, r_...
^6sr,� - .
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4{.Date wells)abandoned:; �� 1,1 3 a J III i; ''I i ,
• : ii9//Gf s ,AQ iri ' F I -Noe, - .
Sa..Well location: i
" Aid(, n,%� ilpu,r•Surep.t4 5,}e- .. �tf :h0(�• —: 1� ta��'�
Facilrty/Owner Name . Facility RV(if applicable) 8.Certification:
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Physical Address,City,and Zip Signature of Certified Well Contractor or;Well Owner Date;
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-By signing this.form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No."(PIN) -accordance with 15ANCAC:02C,0100or2C,0200 Well ConstructionStandards
• and-that a copy of this record has-been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - Ii •
(if well field,one 1at/long is sufficient) '9.Site diagram or additional well details:: r r I.„ ..,i r
You may use the back of this page'tio provide additional'well site dI etails or well
— N W abandonment details..You may also Attach additional pages if necessary.
CONSTRUCTION DETAILS OF-WELL(S)BEING ABANDONED • 1
Attach well construction record s i i available:For mult le in ection or non-water ,SUBMYITAI'INSTRUCTIONS •
�I f P .l supplywells ONLY with the same construction/abandonment,you can submit one form. - j ,
I :10a. For All:Wells: Submit this form within 3Q days of completion of well
da,Well BM: 3)11- j I • abandonment to the following: - '
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- Division Of Water Resources,Information Processing Unit,
•6b,Total well depth: . I,IC.3• •(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
! // •• -10b.For-Iniection Wells: In addition to sending the farm to the:address in l0a •
Etc.Borehole diameter: CD (in,) • above,-also submit one copy of thi form within-30-days of completion of well
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-abandonment to the following: _
tld.Water level below ground surface: • (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 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
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• •,6f.Inner casing/tubing length(if known): (ft.) abandoned.
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' 6g.Screen length(if known):• • (ft.)- q' .
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Fairs GW-30 , -North Carolina Department of Environmental Quality-Division of Water Resourcos- - Revised 2-22.2016 .
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