Durham_Well Abandonment_20230706

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
11
David E. Meyer 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
2527-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 25 (gal.) '
Protocol Sampling Sery e J n.0 ,-,- FOR WATER SUPPLY WELLS ONLY:
Company Name = ).
P y ,-.�-'�I ° �"'` 7c.Type of disinfectant used: HTH
2.Well Construction Permit#: t! pAry
List all applicable well construction permits(i.e.UIC,Cdh!!ntt;�tatP,kris Mena.)if known 4 oz.
7d.Amount of disinfectant used:
3.Well use(check well use): lfF2wP'_Z Pr?-z ..g Ufl
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public II Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) (Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑hmigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry III Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 300 gallons neat cement grout
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Storrnwatcr Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothemmal(Heating/Cooling Return) ❑Odmer(explain under 7g) Submersible pump pulled from well,well sounded found free
of obstructions, chlorinated,filled with neat cement grout
4.Date well(s)abandoned: May 5, 2023 top 3-feet casing removed
5a.Well location:
McKee Homes na
Facility/Owner Name Facility IDtt(if applicable) 13'
cation:4320 Page Road Morrisville NC 27560 (;,y 5/10/2023
Physical Address,City,and Zip Signature of Certified Well Co ctor or Well Owner Date
Durham 07574)8-79-6159
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 Comm:talon 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/Iong is sufficient)
0o 9.Site diagram or additional well details:
35 53' 24.95" N 78 49' 40.47" 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)tfavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonmtent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1 abandonment to the following:
,1 Division of Water Resources,Information Processing Unit,
6b.Total well depth: 134 (ft.) 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: 6.5 (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: 51 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if frown): 60 (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
6f.Inner easing/tubing length(if known): na (ft.) abandoned.
I
6g.Screen length(if known): na (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
I
WELL ABANDONMENT RECORD For Internal Usc ONLY:
l
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E. Meyer 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 constriction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2527-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):25 (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.WC,County,Stare,Variance,etc.)if known 8 OZ
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 U Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concre Gmut y-'a`�,."�'d 1 f y 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ti e `} m—' 0 Gravel
Non-Water Supply Well: Cl Bentonite SPA' 0 G 2023 C Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.Fohmchmaterill select d,gNei wide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 400 gallons nealiar arit;grout
❑Aquifer Storage and Recovery 0 Salinity Barrier
-
❑AquiferTest ❑Stor mwaterDrainage _
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothemmal(Heating/Cooling Return) ❑Other(explain under 7g) Submersible pump pulled from well,well sounded found free
of obstructions, chlorinated,filled with neat cement grout
a.Date well(s)abandoned: May 5, 2023 top 3-feet casing removed
5a.Well location:
McKee Homes na
Facility/Owner Name Facility iD#(if applicable) S.Certification:
4320 Page Road Morrisville NC 27560 7...�4 5/10/2023
Physical Address,City,and Zip Signature of Certified Well Contr for or Well Owner Date
Durham 0757-08-79-6159
By signing this form,I hereby certh'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)
0 0 9.Site diagram or additional well details:
35 53' 21.55" N 78 49' 45.74" 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
Allan,,iell construction record(s)ifavailable.For mtrltple injection ornon-watersupplvwells
ONLY with the sane construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 256 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6.5 (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: 30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): 11 (ft.)
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): na (ft.) abandoned. i
6g.Screen length(if known): na (ft.)
Form OW-30

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E.Meyer 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
2527-A wells abandoned: -
0
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Protocol Sampling Service,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
na JUL 0 6 2Q23 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permit.. ,g( ;LCnuh/tt)tats,fariance,etc.)if known 8 OZ.
l»b:', (}D•(. 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 X Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustriallCommercial ❑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)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑Groundwater Remediation 100 gallons
❑Aquifer Storage and Recovery 0 Salinity Barrier
DAquifer Test ❑Stoimwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well sounded,found to be free of obstructions,
❑Geothermal(Heating/Cooling Retum) ['Other(explain under 7g)
chlorinated,filled with 210 gallons neat cement grout,
June 30,2023
4.Date well(s)abandoned: Top 10-feet of casing removed.Covered with concrete and structure.
5a.Well location:
919 Storage Ellis LLC na
Facility/Owner Name Facility ID#(if applicable) S.Certification:
2104 Ellis Road V 6/30/2023
Physical Address,City,and Zip Signature of Certifie Well Contractor or Well Owner Date
Durham 0749-26-04-0757
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:
35.93869 -78.85785 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 records)ifavailable.For multiple injection otv non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
WSW-1 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
134 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6.5 above,also submit one copy of this fonn within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
6d.Water level below ground surface:30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):22 (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
na abandoned.
6f.Inner casing/tubing length(if known): (ft.)
na
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:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E.Meyer 1
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
2527-A wells abandoned:
0
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
rt
Protocol Sampling Service,Inc.\'.
FOR WATER SUPPLY WELLS ONLY:
Company Name J1IJ /?_ 0 2O23 HTH
na
S' 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permititrk, slattihtf,'Siar ia'n e,Vrt;)4fknown 8 oZ.
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 X Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 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 100 gallons
0 Aquifer Storage and Recovery ❑Salinity Barrier
[Aquifer Test ❑Stonnwatcr Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer Well sounded,found to be filled with brick,6-feet of brick removed
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
from well,chlorinated,filled with 100 gallons neat cement grout
June 20,2023
4.Date well(s)abandoned: effectively sealing bricks and well casing.Top 10-feet of casing removed.
5a.Well location:
919 Storage Ellis LLC na
Facility/Owner Name Facility ID#(if applicable) C 8.Certification:
2104 Ellis Road erv' 6/30/2023
•
Physical Address,City,and Zip Signature of Certifie Well Contractor or Well Owner Date
Durham 0749-26-04-0757
By signing this firm, I hereby certtb'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:
35.93913 -78.85805 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 tie/I construction record(s)([available.For multiple injection ornon-watersupplv sells
ONLY with the same consfnrction/abandonntent.you can submit one form.
WSW-2 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
130 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the fonn to the address in 10a
6.5 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:30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):22 (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
na abandoned.
6f.Inner casing/tubing length(if known): (ft.)
na
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-20I6