Cabarrus_Well Abandonment_20230419

, WELL A15A1V1)V1 LIV.LE V.J '<EULJKU For Internal Use ONLY:
.I.Well contract
or In ormation: 0 3 WELL ABANDONMENT DETAILS -
• l-,-, Sheri,/1)
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor a�or well 9wner pe Wally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
•
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): I (gal.)
%(l/ Sift 5 1/Ye FOR WATER SUPPLY WELLS ONLY:
'Company Name I i T�
f/� 11 7c.Type of disinfectant used:
2.Well Construction Permit#:C )1/9-P,1�-px-PPP/'`
. List all applicable well construction permits(i.e.UIC,Coun%, tate,Variance,etc.)((known /� /
!/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 Vtentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑In strial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
D'Qgation • 0 Specialty Grout 0 Gravel •
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
❑Ivlonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation V 3 9 C Bee:p n r bpi& P1 yt
❑Aquifer Storage and Recovery ❑Salinity Barrier J t-iR�/ /t�/C
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence.Control 7g.Provide a.brief description of the abandonment procedure:
❑Geothermal(Closed Ldop) ❑Tracer PR[�1i v1' tli'�1 fr Tv 'p f 9 c e
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) J
1 4.Date well(s)•abandoned: (!'? t.'J '�• •a•`w-'x• le'' 't ,:!}I
5a.Well location:
•
` APR 1 2023
3 Der Ali Ail .
FacilitWOWnerName Facility MN(if applicable) Infc r' "-.-1 71 ``,^`F ''' Ur5
8 Certification: .'
;a CR1ycv Piaui /�f . 11-,25-,P? .
Physical Address,City.and
)Zip Signature of ertified Well Contractor or Well Owner Date
��Ar�v" By signing this form,I hereby certl that the well(s)was(were) abandoned in
: County • Parcel Identification No.(PIN) accordance with ISA 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/lodg is sufficient) 9.Site diagram or additional well details:
• 3 s 3ya? a N ep ‘7 75£9 W You may use the back of this page to provide additional well site details or well
LL abandonment details. You may also attach additional pages if necessary.
• CONSTRUCTIONIDETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
. Attach well constuctiorilrecord(s)(((available.Formultiple infection ornon-watersupply wells,
•, ONLY with the same copstru3ctton/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
• 6a:Well lb#: ( •
abandonment to the following:
Division of Water Resources,Information Processing Unit,
• 6b:Total well depth:. 3 t�� (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
' 10b.For Infection Wells: In addition to sending the form to the address in 10a
'41 Bbrehele diameter: 6 (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: f (ft.) Division of Water Resources,Underground Infection Control Program,
7 1636 Mail Service Center,Raleigh,NC 27699-1636
• 6e.Outer casing length(if known): A (ft,) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
J�/ of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): /tv I/ (ft.) abandoned.
' .6g.Screen length.(if known): Ni9 (ft.)
I
Form GW,30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016

, WELL ABANDONMENT RELORD For Internal Use ONLY:
4 •• . J5PPL P7I
1.Well Contractor Information: WELL ABANDONMENT DETAILS ••
• 4j 0� t el,///1 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Conttactdr Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GI J30 is needed. Indicate TOTAL NUMBER of
dt�
AP v r/�J wells abandoned:
( i
NC Well Contractor Certification Number 7 / [Yb.Approximate volume of water'remaining in well(s): (gal.)
. M✓C9l/ N j'g,j.1/4`_ FOR WATER SUPPLY WELLS ONLY:
Company Name T�
G#11.0/#4472
rO107c Type of disinfectant used:" 2.Well Constructton Permit#: nList all applicable well construction permits(i.e.Uty,State,Variance,etc.)(fknoun �( O Z
7d.Amount of disinfectant used: V
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ty�sentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑ strial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
-igation • . • 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 ❑GroundwaterRemediation /A f J�j� !� hide�de plvc Q.7mo iTe
.❑Aquifer Storage and Recovery 0 Salinity Barrier ! y ✓
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Pro e a brief description of the abandonment procedure:
❑Geothermal(Closed Ldop) ❑Tracer ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) (,JDv,, Pel �P l I y 5 r ID
4.Date well(s).abandoned: APR � � �n��
•
x U tILJ
5a.Well location: •
Bl yrhe p ey kill itt}�.,,�.:1:.; ,i :_ : _. r..: �, :,
Facility/Owner Name Facility ID#(if app icable) 8.Certification:.fia/k v N _
.ggP.0 Pii/ P)61 Ph'? 5 .
" . 11- 3--2a1 .
Physical Address,City,and Zip Signature of Cerfified Well Contractor or Well Owner Date
� A l'iM 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/lodg is sufficient) j 9.Site diagram or additional well details: • •
3 SD,3937144 N D -� /_q y7 W You may use the back of this page to provide additional well site details or well
V (Y / abandonment details. You may also attach additional pages if necessary.
-CONSTRUCTION bETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructio record(s)ifavailable.For multiple infection or non-water supply wells.
ONLY with the same cdryslnrctton/abandonment,you can submit one form. 10a, For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: i abandonment to the following:
•
Division of Water Resources,Information Processing Unit,
• 6b.Total well depth:. '/"LC?5 (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: (in.)12 above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: • •
• i
6d.Water level below ground surface: I (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known); (ft.) IOc.For Water Supply&Infection 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): // (ft.) •
•
Form GW-30 • North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

, WELL ABANDONMENT RECORD Forinternal Use ONLY:
1.We Contractor Informs on: �D WELL ABANDONMENT DETAILS -
• t/l� drl 1" 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Con or mlr,(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW•30 is needed. Indicate TOTAL NUMBER of
�/ a/1J n wells abandoned: I 1
Q ! '
NC Well C ctor C rtifica' Nu er 7b.Approximate volume of water;remaining in well(s): d j_.J (gal.)
• �'/! C Ili/ 'ile • ie / Z• FOR WATER SUPPLY WELLS ONLY:
'Company Name t'(tr
e i9��•
)// _ qP 7c.Type of disinfectant used:
2. ii
Well Construction Permit#: �f/ �/
. List all applicable well construction permits(i.e.UIC,Counts Variance,etc.)If known 1/ ��
(VOO/ 7d.Amount of disinfectant used:
3.Well use(check well use):
Wa apply Well: 7e.Sealing materials used(check all that apply):
Agricultural ❑MunicipaVPublic ❑Neat Cement Grout &fentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Indtistrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation • ❑ Specialty Grout 0 Gravel •
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
❑lvionitoring ❑Recovery '
injection Well: 7f.For each material selected above,provide amount of materials used:I
❑Aquifer Recharge ❑GroundwaterRemediation f /����,� � is•.❑Aquifer Storage and Recovery ❑Salinity BarrieriVJ
❑Aquifer Test ❑Stormwater Drainage U
❑Experimental Technology ❑Subsidence.Coutrol 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) -
4.Date well(s).abandoned: )P --�� 0t� A _023
APR � ., �
5.a.,vu to +lion• ;I'/"' (i:/),
' I/ 0 eij(10-
Facili,'1AwaerName Facility ii(ifap IPo
8.Cer cation: -+
. - ... 111VP azizsaidRty -5 61/4449 IP-A, 116., . t/P—aV--426,7 .
Physical ddress,City,and Zip ignature o C 'fled Well Contractor or Well Owner Date
•
By signing this form I hereby certr that the well(s)was(were)abandoned in .
ounty • 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.
•5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
' (if well''f fie one let/lodg 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
3g3LL�� N ®0 6�9��sa W abandonment details. You may also attach additional pages if necessary.
• • CONSTRUCTION bDETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructio record(s)IIfavallable.For multiple Injection or non-water supply wells.
ONLY with the same cpstnrctton/cbandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
• 6a'.We •ll ib#: abandonment to the following: ,
• ' • Division of Water Resources,Information Processing Unit,
• 6b:Total well depth:. a 2 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• 10b.For Iniection Wells: In addition to sending the form to the address in 10a
'6c.Bbrehnle diameter: 1,1 (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: 1 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
•
•6e.Outer casing length(if known): 7 (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
•
7 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): &f/ (ft.) •
• .
North Carolina Department of Environmental Quality•Division of Water Resources Revised 2-22-2016
•Form aW�30 •
•