Scotland_Well Abandonment_20230315

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WELL ABANDONMENT RECORD Forintemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
S R&R Environmental, Inc. 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
Patrick Beccaria wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 6 gal (gal.)
N C-4543 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:' lGdN 1 IOC InritP
2.Well Construction Permit#: ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown .2 o u n CeS
7d.Amount of disinfectant used: • C1)'��
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement.Gr uo t.,^' :„
( g g PP Y) PP Y( g ) -..�Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ' `,'f!�. _❑�Drill Cuttings
0 Irrigation ❑specialtyGr"MAR 1 5 2023 ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
(Monitoring ❑Recovery ins,;,-,-;:.,%,-.,;-) r,,..,.,
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Injection Well: . 7f.For each materidL elected-apove,pioVide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation betonite chips half bag
0 Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage neat cement 6" plug
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Disinfected the well,then applies betonite chips until last 6 inches of well
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Then mixed neat cement plug for the last 6".
4.Date well(s)abandoned: 1/26/2023
5a.Well location:
James Partnership
Facility/Owner Name Facility ID#(if applicable) 8.Certification(—
at the corner of business 74 and S Main St i21, ,, 1/26/2023
Physical Address,City,and Zip Signature of Certified We I Contractor or Well Owner Date
Scotland 01000104'005
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'Wel1 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 Iat/long is sufficient) 9.Site diagram or additional well details: '
34.774362 N -79.462863 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 records)ifavailable.For multiple injection or non-water supply wells .
ONLY with the same construction/abandonment,you can submit one fonn.
1329 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: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
2" 10b.For Injection Wells: In addition to sending the form to the address in l0a t
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
r n
5-6 (ft.) Division of Water Resources,,Underground Injection Control Program,
6d.Water level below ground surface
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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
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C1
6g.Screen length(if known): 1`� (ft.)
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
S R&R Environmental, Inc. 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 GW1 30 is needed. Indicate TOTAL NUMBER of
Patrick Beccaria wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 5 gal (gal.)
N C-4543 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: C -
2.Well Construction Permit#: 1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known ,2 -u nccs F.+
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 I Neat Cement Grout-, ,_ _ ®Bentonite Chips or Pellets
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❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grouter 2: ,i ❑Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete GrodQ 0 Drill Cuttings
❑Irrigation 0 Specialty Grdlit R, 1 5 2023 0 Gravel
Non-Water Supply Well: ❑Bento te_Sl. -
t,�•�rti:.� r ,: r ti ❑ Other(explain under 7g)
•Monitoring 0 Recovery r,tr•:;_}; ;'�
Injection Well: 7f.For each material'sefecledabove,provide amount of materials used:
DAquifer Recharge ❑Groundwater Remediation betonite chips half bag
❑Aquifer Storage and Recovery 0 Salinity Barrier tt
❑Aquifer Test ❑StormwaterDrainage neat cement 6 plug
,0 Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Disinfected the well,then applies betonite chips until last 6 inches of well
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Then mixed neat cement plug for the last 6".
4.Date well(s)abandoned: 1/26/2023 •
5a.-Well location:
James Partnership
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
at the corner of business 74 and S Main St r / l 1/26/2023
Physical Address,City,and Zip Sign de re of Certified Well tractor or Well Owner Date
Scotland 01000104005
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.
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:
34.774362 N -79.462863 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 the same construction/abandonment,you can submit one farm.
p A 10a. For All Wells: Submit this form within 30 days of completion of well
V'6a.Well ID#: I W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 ft (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
�� 10b.For Injection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
-4"
6d.Water level below'ground surface: 5 (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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4.4 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016