Wake_Well Abandonment_20230419 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Virgil Wilson 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 I GW-30 is needed. Indicate TOTAL NUMBER of
4473 - .^��wells abandoned:
NC well Contractor Certification Number 7b.Approximate.volume of water remaining in well(s): 2.90 (gal.)
Parratt-Wolff, Inc. APR 1 Q 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name ! li.
7c.Type ofdisinfectant used:
-,
2.Well Construction Permit€l:
Ir`e ;`
List all applicable well construction permits(i.e.U1C,County,State, I'ariance,etc.)tf'laioun
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 a Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
—'Non-Water Supply Well— ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring El Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.2 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned: 4-4-23
5a.Well location:
TForce Holdings USA, Inc
Facility/Owner Name Facility ID#(if applicable) 8.Ce ificatip
/
150 International Drive, Morrisville =:�A�
Physical Address,City,and Zip Signature o rtified Well Contractor or Well Owner Date
Wake By signing this form, 1 hereby certify that the ivell(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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one lat/long is sufficient) 9.Site diagram or additional well details:
35.834917 N -78.821557 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(+)iif a,•ailable.'l-or multiple iiyectioii ornoti-waiersupply wells
ONLY with the saine c'onsiruciionabandamteai,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDN: MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole 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: 1.9 (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&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
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 10 (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016