Union_Well Abandonment_20230419

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frankie L.Oliver 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
3002A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Carolina Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 70% HTH Chlorine
2.Well Construction Permit#: 23-66
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List all applicable well permits(i.e.County,State, Variance,Injection,etc.)if known 7d.Amount of disinfectant used: 10 oZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipallPublic ❑Neat Cement Grout fjd'Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑hrdusnial/Comtncrcial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
• ❑inigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
0 Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation (43)501b.Bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Chlorinated well.Terminated casing below surface.
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) -
Completely filled with bentonite. ` ; {' w�.._
4.Date wells abandoned: 4-6-23
O APR 1 9 2023
5a.Well location: .
Isabel Alvarez
Facility/Owner Name Facility iD#(if applicable) S.Certification:
509 North Lake Dr. Monroe 28112 — 3 4-7-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Union 09-207-004 By signing this form,I hereby cerli,/ir 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:
(it well field,one latllong is sufficient) 9.Site diagram or additional well details:
34.56.233 80.31.332 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 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 form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the tbllowing:
6a.Well iD#: -
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 165 (ft.)
lob.For injection Wells: In addition to sending the form to the address in I 0a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources;Underground injection Control Program,
6d.Water level below ground surface: 19 (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
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10c.For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft) 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 abandoned.
6f.inner casing/tubing length(if known): N/A (ft.)
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
John W. Huneycutt • 7a.Number of wells being abandoned:
1
Well Contractor Name(or well owner personally abandoning well on his(her property)... For multiple injection or non-wafer supply wells ONLY with the same
, y :, construction/abandonment,you can submit'one form.
2465-A • 4 t ; t - , 442.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gaL)
Derry's Well Drilling, Inc. APR 1 9 ZQ23 FOR WATER SUPPLY WELLS ONLY:
Company Name ,,; . �-._ r 113 Granular .
' 7e an�Type of disinfectant used:
2.Well Construction Permit II:
22-238 o 2,�l .
List all applicable well permits(.e.County,Stale,Variance,Injection,etc.)ifknown 7d.Amount of disinfectant used: 1/2 lb.
3.Well use(check well use): '-
Water Supply Well: 7e.Sealing materials used(check ali that apply):
❑Agricultural ❑MunicipalPublic 0 Neat Cement Grout Fi Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) .11Residential Water Supply(single) P.Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑Concrete Grout _ , . . 0 Drill Cuttings
❑i rigation 0 Specialty Grout , :.,, ❑Gravel- . .
Non-Water Supply Well: l Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge • ❑Groundwater Remediation ' .'600 lbs- Bentonite 50 lbs-Bentonite Chips
❑Aquifer Storage and Recovery 0 Salinity Barrier .
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ' .7g.,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well was--pump grouted with bentonite slurry through
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
a 1"tremie pipe extending fully down in to well
4.Date well(s)abandoned: 12/28/22 (full:extent grout)filling it from bottom to 3'below surface.
5a.Well location: Remaining 3'was gravity filled with bentonite chips.
Michael Ryan
Facility/Owner Name Facility ID#(if applicable) &Certification:
5209 E. Lawyers Rd, Wingate 28174 . a). gi 1/15/23
Physical Address,City,and Zip • .Si a of Certified Well Contractor or ell Owner Date
Union 02-199-006M '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:
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 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 form. 10a.For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#: •
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. Division of Water Resources,Information Processing Unit,
1617 Marl Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 325 (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 6 (HE) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 30 (ft.) .. 1636 Mail Service Center,Raleigh,NC 27699-1636
••10c.For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): 43 ( ) 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 abandoned.
6E Inner casing/tubing length(if known): (ft-)
6g.Screen length(if known): (ft.) •' '
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013