Orange_Well Abandonment_20230315

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
()°k( C 0 CTril-h ., 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning welllon.his/her property)_, well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
1157 Z _ ^ It >;:., :r."7,'—wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Za CAS MAR 1 5 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name t'''''''''''' rt(; ,:-"^ .0 r ' 1 DI
toki �� y �i�,✓,:_�� '7i:`Type of disinfectant used: /—
2.Well Construction Permit#: co 3�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known -�
7d.Amount of disinfectant used: 307—
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public /Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑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 \�eei-jV
Cervical- COO lb S
❑Aquifer Storage and Recovery ❑Salinity Barrier d�
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer PEAPei
., al,/I_(-e�/ Ci/J 4— r ran pe�,/)� 1�U (ui-o&4
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Vv 1 CIA (�i �l
2� 0/1ftrji d -
4.Date well(s)abandoned: 2 — I to- f-�'t,- en�l e idle �t ti CA bU1 `erirej�
5a.Well location: 1 66
RAW)Cia. Nadi
Facility/Owner Name Facility 1D#(if applicable) 8.Certification:
' O I C -be q)(d LA. °ilib1 N'� 2 25
Physical Address,City,and Zip Si a of Certified Well Contractor or Well Date
t/1A/Ige By signing this form,I hereby certify
_ t 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:
. t` r 60�/� N — 3' on Q A a f(Q W You may use the back of this page to provide additional well site details or well
11�f 4� ` Uc 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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 62 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: I9 (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: 2/l� (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): All a (ft.) 10c.For Water Sunnly&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): 'V/14- (ft.) abandoned.
6g.Screen length(if known): / 4. (ft.)
Form GW-30 Ail/
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
Thomas Will 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:
NC Well Contractor Certification Number CT :. !j ? ° 7b.Approximate volume of water remaining in well(s): (gal.)
East Coast Environmental PAtAo 1 5 2Q23 FOR WATER SUPPLYWELLS.ONLY:
Company Name Chlorox pool shock
kin:,7c.Type of disinfectant used:
2.Well Construction Permit#: na } {
List all applicable well construction permits(i.e.UIC,County,State, &Nee,etc.)(known 12 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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) lResidential Water Supply(single) ❑ Sand Cement Grout IN Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑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 Clay placed from 60'to 2' bls Poured in top of well
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Cap from 2'to land surface Poured in top of well
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer 12 oz of pool shock poured in well followed by filling
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
with clay to 2' bls. Final 2' of well
4.Date well(s)abandoned: 2-27-23 was filled with concrete to land surface
5a.Well location:
National Spiritual Assembly of the Bahais of the US na
Facility/Owner Name Facility ID#(if applicable) S.Certifre '
1700 Mount Carmel Church Road, Chapel Hill NC 27517 2-28-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Orange 9797013402
By signing this form, I hereby certibi 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 52' 08.89" N -78 02' 00.22" 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/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 60 (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: 36 (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: 47 (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) IOc.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): 1 t�'V/A (ft) abandoned.
6g.Screen length(if known): N/A/A (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
• II