Durham_Well Abandonment_20230428

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WELL ABANDONMENT RECORD For Internal Use ONLY:
i
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood
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/O is needed. Indicate TOTAL NUMBER of
4165A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
N.W. Poole Well & PUmp Co. FOR WATER SUPPLY WELLS ONLY: l
Company Name g� HTH
* P- " 7c.Type of disinfectant used:
2.Well Construction Permit#: it/ , r7 �
List all applicable well constnrction permits(i.e.UIC,County,State,Variance,etc.)if known 1/2 lb.
- 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 Grpt r,y ,. R`�^ $entonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) 2esidential Water Supply(single) 0 Sand Ceme rg°'u 4,., : Aa.LEI Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout APR 2 2023 ❑ Drill Cuttings
❑Irrigation L. Specialty Grout ravel
Non-Water Supply Well: ❑ Bentonite SI r •1-=i1C4r g UTLFFOther(explain under 7g)
❑Monitoring ❑Recovery Cint,:SOG
injection Well: 7f For each material selected above,provide amount of materials use
❑Aquifer Recharge ❑Groundwater Remediation i- (�/'' j 16 41 la)
❑Aquifer Storage and Recovery ❑Salinity Barrier �, '�- /�j
.a.)),,...5-
❑Aquifer Test ❑Stormwater Drainage iftid 9 & #6) A 1:/.14 esd
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) . ❑Tracer a -4"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
i i9_I
4.Date well(s)abandoned:g-gi.-N,9-3 " ,J [ p A.,f�
5a.Welllocation: ® P
. F,-ean
/ , f /a
/ e y
e0---.-
Lam.
Facility/OwhName 1� Facility IDll(if applicable) 8.Certification:
0, 041707,,,,,„/
Physical Address,City,and Zip At - Sig'attire of Ce 'led Well Contractor or Well Owner Dale /f I
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I 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 field,one lat/long is sufficient) 9.Site diagram or additional well details: •
35,q 'o(Oc N _1 k, •-j-1- 1 39 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)ifavailable. 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
•
6a.Well ID#: abandonment to the following:
• • Division of Water Resources,Information Processing Unit,
Gb.•Total well depth: /DO (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6lOb.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abanddnment to the following:
Gil.Water level below ground surface: e (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Liil (ft.) .IOc.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
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 For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood
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/O is needed. Indicate TOTAL NUMBER of
4165A wells abandoned: �rP�
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): /e (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS,ONLY:
Company Name HTH
7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e. IC, ouno,,State,Variance,etc.)ilknown 1/2 lb.
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 Neal Cement Grout eXBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement GrAtt�, ,� ry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout a 4j v� 4Dl ill Cuttings
❑irrigation Specialty Grout ��Gravel
Non-Water Supply Well: ❑ Bentonitc Slurry APR 2 b 20L 0 Other(explain under 7g)
❑Monitoring ❑Recovery �^ o one
injection Well: 7f.For each matE3 iiaff�t }}erAlc amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ,,p0 A
❑Aquifer Storage and Recovery ❑Salinity Barrier ^I �
❑Aquifer Test ❑Stormwater Drainage ��/v it Ra "p� & /. `"
❑Experimental Technology ❑Subsidence Control
7 Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer J� e �4� f�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) e"� j ,q�J/ /+/�� �d4^�e'//�v v L. ,® io` �� '�,'z,
roe _
4d-747-41
7.
t,
re01014. Iv r
4.Date well(s)abandoned: ,✓ ` +7(ea3 Af/® ; l te-a
5a.Well location: .„,
M
Owner Name FacilityIDN(ifapplicable) 8.Certificalion:
Physic dress,City,and Zip
f ° 6��7 Signature of alined ,ell Contractor oi•Well Owner Dale
(�'I� I 1/ ' 6�sJ By signing this form, 1 hereby cerlrfj'that the well(s) was (here) abandoned in
Coin. 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 latltong is sufficient) 9.Site diagram or additional well details:
35, 3 32f- N _11k 1-11 Z q 5 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)ifm'ailable. For multiple injection onion-water supply wells
ONLY with the saute construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well IDl1: abandonment to the following:
, a� i ; Division of Water Resources,Information Processing Unit,
Gb.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
610b.For Injection Wells: In addition to sending the form to the address in 10a
Gc.Borehole diameter: (itt,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Gd.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Ge.Outer casing length(if known): --.5 (ft.) lOc.For WaterSupply&Injection Wells: In addition to sending the font to the
address(cs)above,also submit one copy of this form within 30 days of completion
��o • 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 I Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood
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 7_30 is needed. indicate TOTAL NUMBER of
4165A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in wcll(s): (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY:
Company.Name HTH
q 7c.Type of disinfectant used:
jJ
2.Well Construction Permit#: /4i� / '. ' •
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)if known 1/2 lb.
• 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling mattirirtls`u`Ac b i yf�t:it((p fay):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout dd %Bentonite Chips or Pellets
//tt e
❑Geothermal(Heating/Cooling Supply) Atesidential Water Supply(single) 0 Sand Cement Grdd2' a 2023 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Otout.........• hi;:^. �( 0 Drill Cuttings
AR
❑Irrigation Specialty Grout .^,•ksjo/3�Q Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: If.For each material selected above,provide amount of materialsra used:
❑Aquifer Recharge ❑Groundwater Remediation �3/�/� 02— r ,f// ,
❑Aquifer Storage and Recovery OSalinity Barrier
,,p�/�(�f�t /�
❑Aquifer Test ❑Stormwater Drainage W fry'°i lAf1/dr / ' ;,? L 6 �
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description ofthe abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer .s � q /
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Par 3-P141f' L/AIM /4J-EI L
/.....- 1_,. € ,,,... ' 'fP'etlirl 4,10/n 770 7.5‘W*•A _M'''
4.Date wells)abandoned: y ib. r.
5a.Well location: c am +
g— Pit-
ac+lity/OwncrName FacilityIDfl fifappli ble) 8.Certification:
, ,
.,-„,-,,„
Physics ddress,City,and Zip sir. tire of Cer`red V1 elontraclor or'Well Owner Date
ii . ,,,, ,„,
�� a By sighing this form, I hereby certify that the well(s) seas (mere) abandoned in
County • Parcel identification No.(PIN) accordance with 1 SA NC/IC 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: •
3 , Ii 50(4 5 N _ ") D ."l119 3� /� `v You may use the back of this page to provide additional well site details or well
` l 1 ` abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifarailable. For multiple injection or non-water supply wells
ONLY with the saute construction/abandonment,you can submit one form.
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: 6a2... (ft.), 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6
6c.Borehole diameter: (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: . (ft.) Division of Water Resources,Underground Injection Control Program,
17.4..
��� 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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
of well abandonment to the county health department of the county where
''-"'"f abandoned.
6f.Inner casing/tubing length(if known): (ft.)
•n
• 6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-20I6

WELL ABANDONMENT RECORD For Internal Use ONLY:
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood 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
41 65A •
wells abandoned: tk
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): / 2 (gal.)
•
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
�) 7c.Type of disinfectant used:
2.Well Construction Permit#: —e --r�� — 7T
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if known 1/2 lb.
• 7d.Amount of disinfectant used:
3.Well use(check well use): , •
Water Supply'Well: 7e.Sealing materials used(check all that ap ly):
❑A ricultural ❑Munici al/Public 0 Neat Cemen 'ot1r 4-% _* •.:2,i entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) reou'�'
sidential Water Supply(single), 0 Sand Cement GP '1/4-" ' I:..1 Dry Clay
❑Industrial/Commercial a�❑RReesidential Water Supply(shared) 0 Concrete Grout APR 2 8 7023 0 Drill Cuttings
❑Irrigation 1 cjSpecialty Grout r r Gravel
Non-Water Supply Well: 0 Bentonitelglt`Irf .6.tt�Pr:FC,G ir,Ufa Other(explain under 7g)
❑Monitoring ❑Recovery C'ir'et 3OG
Injection Well: , 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3 / `99OL. s,
❑Aquifer Storage and Recovery ❑Salinity Barrier g'Go f .Y eF ''P 6 11,570 g,,--01-6's
'
❑Aquifer Test ❑Stormwater Drainage �YC�►r V/�
❑Experimental Technology ❑Subsidence Control
7 ..Provide a brief description of the abandonment-procedure:
❑Geothermal(Closed Loop) ❑Tracer �9�� 3 Vf°'L.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
.� FROM M 'i 2 35 i
4.Date well(s)abandoned: / P IUD 12 -770
5a.Well locationPa8,hJP,+rf
i A �Y 0 91vrT�
FacilityIVF/ wiser Name Facility IDi/(if applicable) 8.Certification:
� , Al
Ph s al Address,Cit .Id Zip signature of'ertified Well Contmctor or Well Owner Date
t By signing this form, I hereby certi&that the well(s) was (were) abandoned its
r y Parcel Identification No.(PIN) accordance with 15,4 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:
9 GA r„3 2— N 1 a 3 �5 Z W You may use the back of this page to provide additional well site details or well
` `� Q q l abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifarailable. For multiple injection or•non-water supply wells
ONLY with the same construction/abandommuent,you can submit one form.
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,
Gb.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
,=.0=- lob.For Infection Wells: In addition to sending the form to the address in 10a
Gc.Borehole diameter: P (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
a
Gd.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
98
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
'..R..
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 For It-annul the ONLY:
-':..This foiiiica,t be used for single or multiple wells '
I.Well Contractor Information: WELL ARANHONMENT DETAILS
Brian Ewing . 7a.Number of n'L.`lli being aban&uncd:.1
. Writh Ceurad'or Nome fah well ow ed persarially.aberelatdno uedam liOlier prolicrty) fcr ftndrtp& bijeuttar w• rwn-liFtrcr si 'pA wells O.W.) u ab the swne
conshweamabhadaneteni•,tnu cart,ri va tvaefiIrnt.
4240-B •
NC Well CornraaorCenlficatiatrNmncer 7b.Appmsinrate volume of wind-remaining in wcli(a): (gaL)
SAEDACCO Inc FOR WATER SUIT LY WELLS ONLY:
•
Company Name 7e.Type of disinfectant ti'cd: •
2.Well Constnlctinn Permit ti:, ,
•
Laiall.0,sphroble nettlarrrtits fie.CteariRS SIVA!.lurlairee.Lrlectain%,elc:J iifkac,ieri 711,At[SOnot Of:tILllnfl'Ctaltt used:
3.Well use(check well use): .
•Water Supply Well: 7e.Scaling coat&gins'lsKt' f(Ixteicalyt rt • h'):
❑Agricultural pl4ittnicipal/Public. itd,Neat Cement:C.rinmi�t `asr Bentonite Chips or Pellets..
• ❑C;cothermal(HergittglCooling Supply) DRasidenti al\Vaster Supply(single) El S uid Centeni(�t h R 2 b 2023 ❑ Dry Clay
❑htdustrlal/Commercial ❑Rcsidenfl:d Water Supply(slurred) ❑Cont rctr( roue ❑Drill Cuttings
�r;::,s:s0,�Pra�,4,,
❑inteatiou D Specialt•Grunt �Vr '1 Vitt Gnavef
5
Nou Watcr.Suppiy Well: ❑Bentonite Shiny ❑Other(explain under 7g)
®hionlloring- ❑Rec crew .
• injection Well: . 7f.For each material selected above,provide amount of-materials used:
DAquifer Recharge ❑Grmtnduatcr l elltedLiti0P Neat Dem.:471b ,Wtr•3gal. Sand Cem.:lb ,Wtr•gal.
❑Aquifer Storage aisl Recovery ❑Salinity Barrier•
❑Aquifer Test ❑Stormwtiter Dniitutge - _ - _
oExperitftental Technology ❑Subsidence.Control • 7g.Provide a brief description of.the abandonment procedure
ClGeotherntal(Closed Loop) °Tracer.
.❑Geothermal tiieauinacCooling Return) DOtiter(explain under 74).
TREMI GROUT FROM BOTTOM TO SURFACE
•
4.Date welf(s).ah;indoned: 3-21-23
5a.Weil location:
Former White Star Laundry
Facility/Owner Name RattyIDS d1appb eblcl 8..Ccr11(Ieadotl: •
610 Lakeland St. Durham, .NC 27701 _ R
- _Brian Ewing: . 4/4/2023
Physical Addresr.Ciiy.-and Zip ' Sii�itlare of CeriGed Well Courtin uir . :91 Oisrir Date
• Durham • By sic'a/n`g this firm,-I ketthy certify-that the cell{a) was(mere)ahaiidand in
County. Panel ldenlifidiilnttNo.(FIN) nexvrdnlrre a;ilk IJ...YC-IC 02C,,0100 or 2C.0200 IFell.Cinisinattiori Standards
and drat a copy'villas record has been provided to the well owner:
Sb,.1.ltihide and lougitudein durgrses)atinutcs(secnnds ardecun ii degrees:
Orwell talc,one Iatnun;ts..aliitc?cla) 9.Site diagram or-additional well details:
You.may.use the back Of this pogo to provide Ad(1itieual well.site details or well
• • • • N• W abandonment details. You tuay alio:mach adduional pages if necessary_
CONSTRiICTION B}'CAlLS ON WELuti)BEING ABANDONED SIIB1$11fTAi.INSTRUCTIONS
..Plod,u•rlt roryrrnclieW recvrd,,st if,nial,tfc. 1 heir nrnlrrplr t,leericut ur rv)n.nx ter.,ippii' .
welts.ONLY.wall lie same co,ntn¢4ronia4mpgiumnicni.iuu cart milyina cure font% 10a:•Fat All Wells: Submit this fora within 30 days of completion of Well
lice Well ID§:M14.-6 abandonment to the'folIewbi : •
• Division of Water•Reoureer,-Information-Prueessing Unit,
6h.Total well depth: 20 (ft.)• I617 Mail Centcr,,Raleigh.NC 2-7699-1617
10b.For Injection Wells: In addition to sending the foam to the address lud0a
f►c.Borehole diameter;2 (in:) above,aim submit one copy.of this-form•w•ithiu 30 days of cmuptetioit of►t•ell
abuttdnurttenl to the following:
Gd.Water lcccl below ground surface:. (ft.) Division of Water Resources;iiudeagruund injection Control Pritgram,
1636 Mail Scnice Center,Raleigh,NC 27699 1636 •
1
Gr.Outer casing length(if loran n)t (ft) 10c.For Water Smutty,Cr.i ileettnn 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 comity
6f.Inner Lining/tutting length(if 1paowu)h (ft.)
where abandoned,
6g.Screen length(if Ituon n):10 (ft.)
Foam GW-tit North Carotins Dcpvnnem of Environment arsl Natural Retainers-Division of Warcr lt. ourres Revised August'2013

WELL ABANDONMENT RECORD FM Internal UMONLY: '
o This form can be usiil.for single or multiple wells
i.
L.Well Cootrarctor Information: WILL ABANDONMENT DETAILS •
Brian Ewing . 7a.Number of IS CIS being;abandoned:.1 •
Welt etataeror Name(or bell0lcttef rsionalfy'.alrantl rdir;u_ll.riri liislln'r•property)' For rrnrfttpli'. ,o vecl,•oir or Iran-ri'iitct sxpl!h' aegis .ONLY teeth Ai .snob
-COnionrcfm nirdirNn.'kirt,IYlrr cur rojI,i r r le f irat.
- 4240-B I.
NC Well CoairactorCcitl>lwliarNnniter 7b.Approximate volume of trato-remaining in yiclf(s): (gaL)
i I
SAEDACCO Inc FOR WATER SEIPpi,Y WELLSQNI.Y:
Coupany Name: 7c Type Of disinfectant used: .
. 2.Well Construction Permit li:r , .
Idiot ul1 iriplIcullc awl/pernrirr ti.e.CuNNNfv,Strad,l uriariice.lirjecuisirOtis tf&tmlrrr 7d.Amounl.ofdisinfectant used:
3.Well use(cheek well use):
Water Supply Well: 7c.Scaling matenails u heek,all:it awe):
°Ataricuburit DMitnicipal/Ptiblic 6d NGIl Ccnictat:gtadt C L,E a V fr tonitc Chips or Pciicts.
OCrl:ntherm:tl(HcgtingiCapliug Strppl}•) °Residentttil Water Supply(single)- El smug Cement Grunt. . , El DIY Clay•
❑htdustrial/Conm ercial ❑kesidential Water Supply-(shawl) ❑:.Concrete-Grout APR 2 ' 2023❑ Drill Cuttings
❑ir[r'ailion �..._... _ __._....—.--- ❑ Specially Groin ��?=?tl icaff .` Ske4'•r❑ rryy�:rlt'el
Non-Watcr5uppls'Wel@_._.----_ __._.. ClBentonuteSlut ;.JC Other(eplain under 7g) .
ISIManitotine_ Dl oterj'
-injection Weil: - 7f.For each inatcri,rl•selected above provide amount of materials used:
❑Aquifer Recharge ❑Grtiundnuter Rentediatidn Neat Cem.•471b ,Wtr•3ga1. Sand.Cem:•lb ,Wtr•gal.
• ❑Aquifer Storage and 1teeovery ' ❑Salinity Barrier
❑AipiiferTest. ❑StuiiniiaterDniitiagc
❑Eaperiuienlul Ttithuaioi. DSubsideuca Cortittil 7g.Prcnvide a brief description of the abandonment procedure:. •
UQeodmcrmnal(Closed Loop) • - ClTracer
TREMI GROUT FROM BOTTOM TO SURFACE •
• ®G fi eothermal( eatting,'Cooling Return) ©OtilesiesDlain under 7g).
•
a.Date wells)abandoned:3721-23 . . .
-- -5a.Well tucatioq:' � - -- — -
Former White Star-Laundry
FaciltlyiO•rttcrNtunc Facility IDSileapgiliwblcl 13..Cer11(irnlivtt: •
610. Lakeland St.'Durham, NC 27701 .Brian E `i n 4/4/2023
Physical•Address:Citp••artdZip SintignreorCciliPIAViill00aun,taieir',it(ticrir • Dine
Durham I v srmrl'rig Ihis Jinn, !hereby certify•I/r t.'he styli{s) was(ware)-aiantanc'd in
faintly Ivied 41cr1liE6011it No.WIN) 'occ rilnlli•s with 15:I"C IC 02C;0100 Or 2C-.0200.1€'E11 Cormtruitithi.Slaru/t+rds
and that.a c•opp od dais record kris been providedla lfre u eld citsirer.
Sb:L ttihi de•amd tongitu.de in.degtcesirimitcsfstcnnds or decimal.degrees:
Woo fittd,am I;lttluitg IS Ottfiev11) 9.Site diagram or additional well details:
You may use die back of this page to Pies ide uddiH4nal nell.site.details or well
K' %" adiaudounietrt details: You may also attach additional pages if necessary. .
Ct/NSTRtICTIfIN.DETAILS-OE WELLS)BEING ABANDONED SUBMftrAL INSTRUCTiONS
:mach r.eif can imthii,JN rcixrrd{S1 l3`uv.il ilt.-l.rir multiple OIjAtialr or'rbn•uwfrr xt p.,0{r- • •
nel&4ONLY tiidi 10 svinv efAtr rtItt:wt ii4Ciltrrhitrs!:iru.i'Ort LON gr1irril OW fumy_ IOj: For All %Vclts:; Submit this farm within 30 days of completion of well
6a:Well 1114:MW-2
abandonment tb the rollow'ing;
DIANNn of Water ftesuurem,-1information Practising Unit;
' I611 tlsail-Senlce Ceuter,,Raleith,NC 21699-1617 '
6b.Total well depth: 17 (ft.)
.10h.Igor Inicctiou WOW In addition,to sing the form to the address in.10
6c..Iitlichole dianictcr:2 (In.) above.also sitbotil one Copt' of this forum ivithiii 30-days of cotnpteiion of.welf
;ibundouinem to the fallowing:
Division of Water Rtsonree;.iduderground iu jectlon Control Program,
Gd.Water level below ground surface:. (ft.) 1636 Mail Service Center,Raleigh,NC 276'99-1636
Gr..Outer. casing length(if!mown): (ft.) 10r.For Wager Simply.tr.Injection Wong: In addition to sending the forum to
the•address(es) above. also Submit one copy of this foul; Within 30 days of •
conipletion of well abandonment'to the County heattli•deparintenf of the comity
where abandoned,
61.-Inner easin�„ltubing length(if known): (ft.) 1
•6g.Screen length(If knoii n):10 (ft.)
Form GW41 Noah Carolina Dagxanimty of Emwiromncnt aril Natural Resources-Division of Water Itooarces • Revised August 2013

1 I
WELL ABANDONMENT RECORD rot lnlen iI UK ONLY:
This form can be used for single or multiple wells •
‘XSIDETAILS
I.Well Cautraemr Information: WELL.ABANDONMENT 1)E
Brian Ewing 7a.Number of wells being all:u li ned: 1
Well Cotstactor Name or well Direr(1Ctsdtt ith abamlaaine i,c11 Caal tics er ptupcny) For unrlpplc 81lurtiorr or rna-i,ii-atar supper »ch's ONLY with lire Nome
r,ettrrrarchaatbnxrlrvretunt,tram trur.n'btnir even,fftr,'n.
4240-B
NC\Yc11 Confrtgort cnifie(newt Nan her 7h.Approximate volume of water remaining in events): (gal.)
SAEDACCO Inc FOR WATER SUPPLY WELLS ONLY:
Company Nam; 7c Type of disinfectant used:
2.Well Coustructinn Permit l:, ,
Lin all applicable well la'oratr U,C. l4104r,State.I iaraaree•.La./edam,err.i of&nra;ert let Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling te 'aIIq;e eeke'l:all(bat apply):
❑Agricuitur l ❑MtnicipahPublic 6d Neat Cement fJ a C$4.0 e tivnite Chips or Pellets
❑(Ieothcrtnnl(Hcatint!Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout/I f `El y Clay
01ndusttia1/Contmerciai ❑Rcsidenti:d Water Supply(shared) 0 Concrete Grout A r R 2;S 2023❑ Drill Cullinp
t 0 Specialty 0 Gravel
nstiOn a eNon-Waer Supply Welt: •0 Bentonite SlutyBe er(explain under 71)
Dtltvlauitoriug ❑Re'coe-ex"
Injection Wcit: 71.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater ltcntedlatian Neat Cem.•471b ,Wtr•3ga1. Sand Cem.•lb ,Wtr•gal.
❑Ay:liferStoogeand Recovery ❑Salinity harder
❑Aquifer Test ❑Slorlmealer Drainage
❑Experimental Technology ❑Subsiden`e Central 7g.Provide a brief description if the abandonment procedure:
DGeothernzwl(Closed Loop) °Tracer
TREMI GROUT FROM BOTTOM TO SURFACE
°Geotltennal(Heatingt/Cooling Return) l lOther{explain under 7g)
4.Date well(s)ab;mdaued: 3-21-23
5a.Welt location:
Former White Star Laundry •
I adility-rta:crnr Name wilily 11!t cif appt eablct S.Certification:
610 Lakeland St. Durham, NC 27701 Brian Ewing 4/4/2023
Physical Addres.City.and Zip Sicrcalnx of0:slited even Coein,tar r•r.'.110wrcr Date
Durham Dr snowier linos farm, I he,nhy c o'tily that the well o was mere)ahandimed ut
COMA) I:ncel ldentificit+rw No.4PINm helm-lance with ISA:VCIC 02C.0100 or 2C.0200 Frei/C_i,nslnrcrion Standar:5
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude it dcgrecslotinuteestseermils or decimal degrees:
tir welt(alit,one latilnng is snlfs:cra t 9.Site diagram or:additional well details:
You may me 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_
C()NSTRIiC ION DETAILS OF WELL(S)BEING ABANDONED StIRMMITTAt.INSTRUCTIONS
:iamb vedt -emxwndiot/recvrelrs!N'oaaildrie. trio•nrar/reply ityee.tiolt or con-mow x.upptr
welts mil.).myth t e mvne entrstrrx•nror'abatuhnoihaa_tort ran su;nrci)nretbnre. 10a. For All Welts: Submit this famt within 30 day of completion of well
Oa.Weil ti MW-5 abandonment to tits following:
Division of Water Resources,Information Processing Unit,
17 1617 Mail Scriiee Center,Raleigh,NC 27699-1617
Ob.Total well depth: (ft.)
lOb.Fur inle'ction Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter:2 above_aka submit onto copy'of this form within 3t)days of Completion of well
(in.) abaudotintent to the fallowing:
6d.Watcrtc►cl below m'uunttsurfacc: (ft.) Division of Water Resources,1Uoderground Injection Control Pritgr.itu•
1636 Mail Servicel Center,Raleigh,NC 27699-1636
6e.Outcr easing length(if laton n): (ft) Inc,For Water Sunnly& Infection Wells: In addition to sending the form to
the addresses) above. also sub'ntit one copy of this form within ?ii days of
completion al'well ab:ntduntnent to the county health department of the county
where abandoned,
6f.Innercasing/tubing length(if known):_ (ft.)
� I
6g.Screen length(if known):10 (ft.)
Faun Guy-;t.a Noah Carolina Delxtnm:ra of Eltri:otnocnt argil Natural Resou.ecs-Dii isioa of Vraicr Resources Rev sed An use 2I)13