WI0700535_Well Abandonment Record(s) (GW-30)_20230414

WELL CONSTRUCTION RECORD (GW-b
For Internal Use Only:
1. Well Cont rRetor Information: RECEIVED
, /
Well Contractor Name y P R 1 a M.'i
_3 4? 7t%
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #: _
List all applicable well construction permits (i.e. UIC Comity, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agriculttual
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > 100.000 GPD
Non -Water Supply Well:
OitlClonitoring ❑Recovery
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Groundwater Remediation
❑Salinity Barrier
❑Stonnwater Drainage
❑Subsidence Control
❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #.21 Remarks
4. Date Well(s) Completed: -3 - 9 L Well ID# 6y) al
5a. Well Lrocatio/n�: / AI/ Q
Facility/Owner Name Facility lD# (if applicable)
l! 2 l] Sfree-fit. r,*41ff
Physical Address, City, and Zip r
CreL-veti 2-
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one ]at/long is sufficient)
3-S- 117 5r6N -77. 62 1616 ^W
6. is(are) the well(s): 4Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or �fio
If this is a repair, fill out known well construction itl%rrnation and explain the nature ofthe
repair under #21 remarks section or on the back of this fon n.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
9. Total well depth below land surface: _ ,L K _ ,(ft.)
For anrhiple wells list all depths ((diifftrent (erarnple- 3@200' and 1@100)
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: Y (in.)
12. Well construction method: A tJi9 e,—
(ix, auger, rotary, cable, direct push, etc.) If
14. WATER ZONES
FROM
TO
DESCRIPTION
it.
rt.
22. Certification:
�
Signature ofCcrtified Well Contractor //�,.)4, Date
By signing lhisforon, I hereby certify that the welh. was (were) constructed in accordance with
1 SA NCAC 02C .0100 or ISA NCAC 02C .0100 Well Construction Standards and that a color
of this record has been provided to the well outer.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBM]T`TAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Iniecttoon Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where costa led
FOR WATER SUPPLY WELLS ONLY: 24d, For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
13a. Yield (gpm) Method of test: _ Permit Program, 1611 MSC, Raleigh, NC 27699-161 l
13b. Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6.6-2018

WELL CONSTRUCTION RECORD (GW-1
For Internal Use Only:
1. Well Contractor Information:
/�%AEI �nhPt- RECEIVED
Well Contractor Name W �"
39 7G 4 APR 10 2023
NC Well Contractor Certification Number
X,vvt. `� DEQ/DWI
- Central offiGF
Company Name
I
2. Well Construction Permit #:
List all applicable well construction pertntr.s (l.e. UIC Cbon!)t State. Variance, etc.)
3. Well Use (check well rise):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (i-leating/Cooling Supply) ❑Residential Water Supply (single)
01ndustriaUCormnercial ❑Residential Water Supply (shared)
❑ Irrigation ❑Wells > 100,000 GPD
Non -Water Supply Well:
❑Aquifer Recharge ❑Groundwater Rennediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Rettim) ❑Other (ex Clain under
#21 Remarks)
4, Date Well(s) Completed: � o - �- `!I Well ID#-
5a. Well Location:
lei Al c j oo.3Zo18.3
Fafciliry/Owner Name p Facility 1D# (ifapplicabte)
/+/Zo %rulef1 [�/''ci
Physical Address, City, and Zip
C z -v�i DCI
County Parcel Identification No. (PiN)
5b. Latitude and longitude in degrees/tninutes/seconds or decimal degrees:
(if well field, one IaVlong is sufficient)
3S.ILq-'"o6 N-77029eJ6 W
6. Is(are) the well(s): *1 rmanent or ❑Temporary
7. Is this a repair to an existing well: GYes or &N-0
1f thly is• a repair/ill and knonm well Construction in/or•nrruion and caplain the manta of :he
repair under Ifll remarks seclion ar on the back ofthis /arm.
8. For Geoprobe/Dill' or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For rnulliple webs list all depths iI tgyerent te-va iple- 3@200' and 2L;100)
10. Static water level below top of casing: ^� _ (ft.)
ifwater level is above casing, use "+"
11. Borehole diameter: _ 157
12. Well construction method: cJ e o—
(i.e. auger, rotary, cable, direct push,
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ Method of test: _
13b. Disinfection type: Amount:
�FROM TO DFSCRIF-75I r
. G ft. / S- 5 ft. FI L 1 Cl r- 1 r'+
ft. ft.
15, OUTER CASING for multi -cased wells OR LINER I if a licable
FROM I 'TO DIAMFTER THICKNESS MATEI
ft. ft. in.
FROM
'r0
vnna, eotnermal
ll1AMETF,R
erased -too
1'HICtNNESS
MATERIAL
FROM "
ft.
10. GROUT
S ft.
o ft.
l� ft.
1ft. in. ,
.c/0
ft. in. —
MATERIAL, ilEMPLACEMENNT METHOD & AMOUN
f'- -ae 1..*.,.,•}e! L'/<<f.S "" 4-r61 J: �`y r—�✓'i.J
ft. pitrCref
ft.
n,A r eRwL I F,MPLACEM ENT METHOD
rt. /Sc ft. _ ���._t��1 151�:v nor c�•�rlrl
rt. rc.
20. DRILLING LOG attach additional sheets if necessa
FROM TO DFSCRIPTION (color, hardness solt/rock _Lyric, Rraln size, cic) —
(� 6J- fill.- t? t �.vr't iL -- -
et. fL /W h �j
=I�6�' fC 1.�JA/ j
ft. ft. — — —�
ft. ft.
22. Certification: ------------
13
Signature of Certified Well Connector
it r signing this for•nt, I hereby ceri fir that lite well (s) was (werel u�'s uvrterl iu •t, c or da ,, e n n k
I SA NCA C 01C .0100 at- iSA NCAC 02C.0100 Well. ConsO•uctro+ sAmdards anri char a r"i r
o/7his record has been provided to tire well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR
information Processing Unit, 1617 MSC', Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground injection Controi (I(jC')
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Sur 1 and Open -Loop Geothermal Return Wells: Copy to the
countyenvironmental tealth department of the county where installed
24d. For Water Wells producine over 100.000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-161 1
G..nn rW_I A�....1. f`....,.I:.... rt........... e... ..r r.....: _.. _..........1 n....l:... n:..:�:.... „r=V...e. D....�..�,..,.. Rn..i c..rl (.. (,_lnll2

WELL CONSTRUCTION RECORD 1 Gt iVED
I. Well Contractor Information:
APR 10 2023
Well Contractor Name
3 NG DEQIDWR
Central office
NC Well Contractor Certification Number
©[
Company Name
2. Well Construction Permit #:
List all applicable ivell colhstraction 1,_ns (t.e. UI(_. Cnantp, Stare, Variance, etc.)
3. Well Usc (check well use):
Water Supply Well; --
❑Agricultural OMunicipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑IndustoaUCominercial ❑Residential Water Su 1
❑hri ation PP Y (shared)
Non -Water Supply Well; — — Wells > 100,000 GPD
- — -- ❑
❑Aquifer Recharge
pGroundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
otema(Closed Loop)
LO(GeOtl'lel�-.J'
[]Tracer
(Heating,'('ooling Rettuurn)
❑Other (explain under #2] Remarks)
4. Date Well(s) Completed v f ~L JY/ J�•—
WellID#�`
So. Well Location:
-c�c-
sued oo3
2-o/(U7Facility
Facility/Owner Name
IDII (ifapplicable)
12-o D sb-ee t-
Physical Address. City, and Zip
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/Iniuutes/seconds or decimal degrees:
(ifwcll field, one latlong is suf-Icicnt)
3 s if 2' O t N,->7, o z-`t pig
� ._ W
6. Is(are) the well(s): @Permanent or ❑Temporary
7. is this a repair to an existing well: ❑Yes or S4611,
0birePai is a repair, fifl ohrt knoon 11,
11 constraeliw[ infohnmtiou and explain me nature ofthe
repair tinder 821 ren[arke.section ar an the bark of this %rot,
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled:. _
9. Total well depth below land surface: _
par multiple wells list all depths irdierent (example- 3@200' and : t@100) (ff.)
10, Static water level below top of casing: - G
lf•svater level i.s above casing, rise
11. Borehole diameter: (in.)
12• Well construction method: LJ C e r--
(i.e. anger, rotary, cable, direct push, e[cJ
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: ADiount:
For Internal Use Only:
ft.
ft.
ft.
L o , r -
IS. OUTER CASING For multi -cased wells OR LINER Ff a
'ROM
Ileable
TO
fL
DI ETER TNICKNESS
MATERIAL
ft. Fa.
6. INNER CASING OR TUBING eothermal closed-loo
N011t TO
It.
DIAMETER
n. Z in.
TIiICKNESS
^
MATERIAL
c � `) 0
'A V L
fir.
it.
I.SCREEN
ROM TO
5 ft.
DIAMETER SLOT SIZE THICKNESS atATER1AL
v C7 / 0
ft. ft,
in.
.GROUT
tom TO
3 ft.
MATERIAL EMPLACEMENT METHOD d AMOUY7
fit.
Prr�l.�.vs�P i�P%�t7t3-6�r'a✓:t�
1vw
O ft. -3
fL l'V( r4 G�rcLUi1
r
fir.
fir.
_
ft. ft•....",. mn mcsnuu
�S• .
ft. ft. t
ILLING LOG attach adJFHoas! sheets if necessa
TO DFSCkIPt•IIaV (color, hardness solOrock
fL t)'Pe, grain size_ etc.)
ire oLT-o ov�d! aNtc rr'e{t
ft. g, > Q
ft.
ft• ft.
ft. ft. -
ft. ft. --
ft. fr. —
IARKS
22. Certification-
Signature ofCenined Well Contractor � —
t Date
Ily signing thisform, I hereby ce,•gfj• !)fiat lire uell(.t9 "'as (were) coast [a'ted in accordance with
ISA NCAC OIC .0J00 or ISA NCAC 02C' .0200 lVell Consn•nction Standards and that a cope
oflhis record has been provided to the well mwher.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add'Sce Over in Remarks Box). You may also attach additional pages ifttecessaly.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
249. For All Wells: Oli4inal form to Division of Water Resources (DWR),
Information- Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For IDiection Wells: Copy to DWR, Underground Injection Control (JUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and O en-LOD Geothermal Return Wells: Copy to il)c
county environmental health department ot'the county where install
24d, For Water Wells r•oducin over 100 000 GPD: Copy to DWR, CCPCIJA
Perru C Program, 161 I MSC, Ralcigh, N27699-161 I
i
V.,— nw-1

WELL CONSTRUCTION RECORD GW-1
1, Well Contractor Information:
RECEIVED
Well Conlrrctor Name
3 G APR 10 2023
NC Well Contrnctor Certification Number
f e - -S- riPit i�� NC DEQ/DWR
�v,'raw CentralOffrce
Company Name
2• Well Construction Permit #:
List all applicable well canetrxrction permits (i.e. UfC. Cornrt)" State, Vuriurrcc, etc.)
3. Well Use (check well use):
OGeothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
OAquifer Storage and Recovery
❑Experimental Technology
OResidential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > 100,000 GPD
OStonmvater Drainage
OSubsidence Control
4. Date Well(s) Completed `eL ` Z yye111D# M 60
'isv-c C-E� Ck'M.G t� �Q�`,
Facility/Owner Name
/l/t-•D o 0 � z a 92
Facility ID# (ifapplicable)
Z0. Q sl'ee t Are d
Physical Address. City, and Zip
ro-veo..
County �.._.-_.,, -- --
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is slimcicot)
S 12
9 _'>O b - 22. Certification:
N �% 6ZY�1�_ W
6. 19(are) the well(s): ClPermanent or OTemporary Signature of Certified well Contractor -----
�-- Dntc
For internal Use Only:
7. Is this a repair to an existing well: lJYes Or t�tSVp Bysigning tbisfornr, !hereby ce"10'that lire uvil(s) cans (were) constructed in accordnnre with
15A NCAC 02C .0100 or 154 NCAC 02C .o200 {Yell Construction .Standards and that a c•opr
lflhis is a repair, 'll oat known Well consnuction hr/ornration and explain the nature ofllie g0his record has beenprovided to the hell oiwrer•.
repair under 021 remnrks section or on the back ojrhts fora
23. Site diagram or additional well details:
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells !raving the same You may use the back of this page to provide additional well constnuction info
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
drilled:
9. Total well depth below land surface: 15
For nntltiple wells list all depNas ifd0er•ent (example- 3Q200' arrd 2 tt 100l (ft.)
10. Static water level below top of casing:
if water level is ahave raving, use ,+„ (ft,)
11. Borehole diameter: _ _ 9 (in.)
12. Well construction method: _ ✓ of to r-
(i.e. auger, rotary, cable, direct push, etc.)
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
248. For All Wells: Ori&ival form to Division of Water Resources (DWR),
information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Infection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Su rl and O en-Loo Geothermal Return N'ells: Copy to the
county environmental heaun department ol" the county w ere mst-a—e
FOR WATER SUPPLY WELLS ONLY:
24d. For Water Wells r oducin over 100 000 GPD: Copy to DWR, CCPCt)A
13a. Yield (gpm) Method of test: Permit Program, 161 l MSC, Raleigh , NC 27699-16i 1
13b. Disinfection type: Amount:
pnnn t:w_ r

WELL CONSTRUCTION RECORD.
I. Well Contractor Information:
' h-PrI APR 10 2023
Well Contractor Name
S' %G ,4 NC DEQ/DWR
NC Well Contractor Certification Number Central office
Company Name -r� ,i 2. Well Construction Permit #: 10 ..,(, r f cti,, -'�"T � U)
List all applicable well coushwction perm;ts (i.C. UIC' County. Stale, YariartcG arc.)
3. Well Use (check well use):
❑Ag icultttral
OGeothermal (Heating/Cooling Supply)
❑ Industrial/Colnrrrercial
❑1 alien
Non -Water Supply Wep;
❑Mtmicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wei is > 10%000 GPD
❑Aquifer Recharge
4610undwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
OAquiter Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal(Closed Loop)
❑Tracer
❑Geothermal (Heating Cooling Return) ❑Other (explain under #21 R
4. Date Well(s) Completed: 3 ` / ` /�'z-- well ro#
5a. Well Location: j
Facility/pwnerName Facility IDq (ifapplicable)
112.0 6 Sf r e e t ►ram �^ ,� fG1.tr` 2-6; S-/ 7
Physical Address. City, and Zip
10 ft. ft.
D� — (i U 21. REMARKS
c�umy _ —�
,�. e 4 -r-; 0 a o rs
C� ir°' a �CC� r.Q tom: •!�%�
1S,',ec t `,A TPcF�...� 1�
22. CerttiifieaH�onn:
Signature ofCcnificd Well Contrac o
f Date
Bpsigiring Ntisform, /hereby cerg& that the nel!(s) nuts (rtrrel curssn ttcied in accurrlmrce with
ISA NCAC 02C .0100 or ISA NCAC 02C' .0200 ;fell Cortstrrtctiort Simrdm'in and rhos coin•
of"his record ltas been provided "o the weli orwter•.
23. Site diagram or additional well details:
You may use the back of this page to provide additional Well construction info
(add'See Over' in Remarks Box). You may also attach additional pages if necessary.
24, SUBMITTAL INSTRUCTIONS
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lot/long is sufficient)
,//w
man
6. is(are) the well(s): ❑Perent or 0Temporary
7. is this a repair to an existing well: ❑ Yes mr—
ifllris is a repain.111l ow known mall coushvction intbr•rna"iou and erp/ajrr Nee nature afrlre
repair under #21 remarks section or on the back of ibis /or•m.
8. For Geoprobe/DDT or Closed -Loop Geothermal Wells having the same
construction, only,. GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:__
9. Total well depth below land surface: /S
For multiple irells iII all deptics ijdi(lereni (esanrple- 3Q200' and 1@1001
10. Static water level below top of casing: _ (ft) 24a: For All Wells: Ori&inal form to Division of Water Resources (DWR),
!f water level a tamhove, casing, u.re "+ information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
ll. Borehole diameter: Z 5 (in.) 24b. For I� o eflon Wells: Copy to DWR, Underground injection Control (IUC)
12. Well construction method: 1b r r ee 1 S Program, 1636 MSC, Raleigh, NC 27699-1636
u
(i.e. auger, rotary, cable, direct pruh, etc.) 24c. For Water Su Iv and O ten -Leo Geothermal Rehn n Wells; Copy to the
county environmental health department o the county where mstalled
FOR WATER SUPPLY WELLS ONLY:
24d. For Water Wells roducin over 100 000 GPD:
L13a. Yield (gpm) Method of test Permit Program, M 1 MSC, Ralcigb, N 27699-161 l
13b. Disinfection type: _ Amount: _
For Internal Use Only:
=::=
14. WATER ZONES
1�6
TOrt. �., ft -- -- - --- —
ft. ft.
ft. 11 ft. in.
INER CASING OR TUBING eother
DIAMETER
To
ft. ft. In.
ft
. ft. ln.
'REEN
SL(qftrtf�
ft. In.
ft. ft.
Ift
ft
nresHUD
ft. ft.
ILLING LOG attach additional sheets if neeessa
TO DFSCKIPTIILY color hardnr snlUrock s, ra(n size, err.)
ft. ft.
ft. 1
ft• ft. t3
It. rt.
ft. ft. -- —
ft. ft. - ----jl
Submit this GW 1 within 30 days of well completion per the following:
Copy to DWR, CCII
Form GW-1

WELL AHANDUN1VILN'1.HL+ UORD
1. Well Contractor Information: RECEIVED
,/ I Gt.1 ytn t) •/✓!/�Il r l �/ �7 _
Well Contractor Name (or well o%%ner personally abandoning well c a erl-940
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth. ll J GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number NC DEQ/DWR 7b. Approximate volume of water remaining in well(s): (gal.)
/ Central Office
E� JI/" r Nst//✓tl�.4 r FOR WATER SUPPLY WELLS ONLY:
Company Name
n � i 7c. Type of disinfectant used:
2. Well Construction Permit #: /V r%X 7[�,�
List all applicable i rll construction permits (i.e. Ulc Courtn' laic•, lariance, ete.) it known
7d. Amount of disinfectant used: _
3, Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
❑Monitoring ❑Recovery
❑Aquifer Recharge 'Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stop mwatcr Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under 7g)
4. Date well(s) abandoned: 3 - ql , I L � < 2'
5a. Well location:
C✓V-�CG'C= C'hejn, f .S� ler NC 0 6,a31c,r 8.3
FaciliwOwner Name Facility ID#1 (ifapplicable)
l l iv p 2 8 5"r 9
Physical Address, City, and Zip
C t- 64., V Ce 0L., 2- U Gi d- G o y
Comity Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
01'well field, one latilong is sufficient)
35".I2-qN-77 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
.-iflach troll ronsn'aclion rc cordLcJ i/arnilnhle. Fur nnrhiple injec'rinn nr uun-u'u7er.ctrpply u'e(!s
ONL I' with the .curare c n+rsb arlinrr.'uhundonment, tofu can .urban! oe" torn.
6a. Well ID#: 36 -Li , tF t K
6b. Total well depth:
5 (ft.)
6c. Borehole diameter: 2 , Z 6' _(in.)
6d. Water level below ground surface: 3 - (ft.)
6e. Outer casing length (if known): Al--4 _(ft.)
6f. timer casing/tubing length (if known): .t 11A (ft.)
7e. Sealing materials used (check all that apply :
❑ Neat Cement Grout d4entonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout
❑ Bentonite Slurry
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Its
r re
7g. Provide a brief description of the abandonment procedure:
_
ca
8. Certification:
Signature of Certified Well Contractor or Well O er. Date
Br signing this orm, I hereby certn& that the irell(s) was (rrere) abandoned in
accordance with 1 SA NCAC OZC .0100 or ?C .0200 I•i ell Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or will
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion `
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10
above, also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition io sending the tone to the
address(es) above, also submit one copy of this forrtm within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
6g. Screen length (if known):_