Wilkes_Well Abandonment_20230428

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Edward W. Taylor, Jr. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personalty abandoning well on his/her property) well construction/depth,only I G W-30 is needed. Indicate TOTAL NUMBER of
2440—A wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): ' (gal.)
Geonetics Corporation FOR WATER SUPPLY WELLS ONLY:
(ompany Name 7c.Type of disinfectant used: IH-
2.Well Construction Permit Nc F NA • `��� �;'�
List all applicable well construction permits(i.e.UIC County.State,Variance,etc.)tj"known nn
7d Amount of disinfectant used: Q PR 2 s 202.3
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):I r,#Cf lit''" far^^bC**A] V'n�
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slunv ❑Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approx. 56 Ibs coated pellets
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimerdat Technology L"7Subsideme Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Removed manhole cover, well plug and bailer
❑Geothermal(Heating/Coohng Return) ❑Other(explain under 7g)
Measured total well depth and water level
4.Date well(s)abandoned: 04/19/2023 Filled well pipe and manhole w/ bentonite pellets
5a.Well location: Hydrated pellets w/10 gallons water, replaced manhole cover
Carolina West Wireless, Inc. 00-0-0000005067
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1858 US Highway 421, Wilkesboro, NC 28697 Ectwa4r&w, rAyitx ,Jr 04/19/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wilkes 3848-90-5893 gv,signing this form. 1 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.
Sb.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.150170 N 81.203015 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 WELLS)BEING ABANDONED SUBMITTAL,INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same
�,cons/truction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1Y1 V V-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 00 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 22.9 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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
6L Inner casing/tubing length(if known): 0 — 15 (ft) abandoned.
6g.Screen length(if known): 15 — 35 (fL)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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Figure 9 Carolina West Wireless, Inc. Property
State Project: U-5312 Parcel#021 Seramur&Associates, PC
Site Plan with Monitoring Well Wilkes County, NC 1858 US Hwy 421 Facility I.D.#:00-05067 Boone, NC
Locations Wilkesboro, NC