Mecklenburg_Well Abandonment_20230828

WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.W Contractor Igt'ormation- , WELL ABANDONMENT DETAILS,
7a.For Gcoprabc/DPT or Closed-L'oo'p Geothermal Wells having the same
Well Contractor Name(or well o vner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
9"12 j� wells abandoned: yp
NC We oulyaetor Certification Number 7b.Approximate volume of water remaining in well(s): 23 (gal.)
0/1 Y ���r FOR WATER SUPPLY WELLS ONLY:
Company Name U 7c.Type of disinfectant used:
2.Well Construction Permit#: )v IQ
List all applicable well construction penal s(i.e.UIC,Connl,Slate,Variance,etc.)ifknowit
7d.Amount of disinfectant used: A
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
0(gricultural ❑Municipal/Public ❑Neat Cement Grout entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential-WItter��slr re ) " oncrete Grout ❑Drill Cuttings
❑Irti lion 44 11 + Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery AUG 2 8 2023
Injection Well: 7E]For each material selected above,provide amougt of materials used:
❑Aquifer Recharge ❑Ground 4 F8f01e O'Q1'30 �W i- -y e &
❑Aquifer Storage and Recovery ❑Salinity Barrier t U /�
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer / � 7P
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) [,�
/) t
4.Date well(s)abandoned:
58.Well location:
Sl Fea' 10l tJ LIB l)I) &&iM
Facility/Owner Name Facility IDIl(if applicable) 8.Cer fieation:
Physical Address, acid Zip Signature of Cer fled Well Contractor or Well Owner Dale
By signing this farm,I hereby certo that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in Degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field.one lat/long is sufficient) 9.Site diagram or additional well details:
"' ��a� N ��� �� 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.
CC!DISTRUCTION DETAILS OF WELL(S)BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
Allaclnrellcauinrctionrecord(s)ifmallable.Forinulliple injection ornon-watersapplywells
ONLY will,the same constnuctiatVabandonment,your can subml one form.
10a. For All Wells: Submit this forth 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: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
'��,�+t ,p� 10b.For infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.)�J L°Dr`-i! dell above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): �— (gt) 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
6E inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): (ft.) I
I
f
Font GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

31p, P5, �)D
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.WelivXontractor Information: WELLABANDONMENT DETAILS
bh,
Y ✓//� 7a.For Geoprobe/DPT or Closed-LI op Geothermal Wells having the same
Well Contmcto Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-3b is needed. Indicate TOTAL NUMBER of
v6L-- �
wells abandoned:
NC We 1 Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
c FOR WATER SUPPLY WELLS ONLY:
Company Name /]f 7c.Type of disinfectant used: P
2.Well Construction Permit#: I A
List all applicable well cautrtclion pernills(i.e.VIC,Counly,Stale,Variance,era)iflohonw
7d.Amount of disinfectant used: Pz
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout O,Bego_nite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri Lion. rn Eff p ialty Grout ❑Gravel
Non-W er Supply Well: ` '"� ❑Bentonite Slurry ❑Other(explain under 7g)
onitoring ❑Recovery !j )�
Injection Well: f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity BarAlatA`nr^` b �'! !J
t / .
1W QJ30G
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief d cription f the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
d.Date well(s)abandoned: �/
Sa.Well location:
Facili /Owner Name Facility ID#(if applicable) 8.Certf cation:
1 �l/� Tel%Ile QC/' - -/�
Physical Address,City,and Zip Signature ofC ffied Well Connector or Well Owner Date
6_6x By signing this form,I hereby cert6 that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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:
(if well field,one lat/ong is sufficient) 9.Site diagram or additional well details:
��-���� N t ��� 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
Atlaclnrellconstrteliahrecord(s)lfmallable.portun/dpleinjedilonornan-rvatersupplywel/s
ONLY with the saute cothshructioth/abandonuhent,you can subnhli 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 (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: (in.) above,also submit one copy of this form within 30 days of completion of well
n abandonment to the following:
6d.Water level below ground surface: '✓ (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
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
~'
6E Inner casing/tubing length(if[mown): (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

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.We Contractor Information: WELL ABANDONMENT DETAILS
rr
J/ 7a.For Geoprobe/DPT or Closed-LooplGeothermal Wells having the same
Well Contra r Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30�Is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC we aptractor Certification Number 7b.Approximate volume of water remaining in well(s):4_(gal.)
l%i��l/ FOR WATER SUPPLY WELLS ONLY-
Company Name f 7c.Type of disinfectant used: l .
2.Well Construction Permit#: / 310
List all applicable well consnniction pcmitts(i.e.U1C,Cou»ly,Stale,Variance,etc.)iflmouvr / ��
7d.Amount of disinfectant used: CS/
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mu cipal/Public ❑Neat Cement Grout �tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residen to wr PEg1k, I oncrete.Grout ❑Drill Cuttings
❑Irri ation n��-- 1L..•.• �� ❑Specialty Grout ❑Gravel
Non-Water Supply Well: A11r $ 20�3 ❑Bentonite Slurry ❑Other(explain under lg)
❑Monitoring ❑Recovery V l7
Injection Well: 1[Kor each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwa`fef R�e �t t©nJ� Yor- ��J
❑Aquifer Storage and Recovery ❑Salinity Barrier +�� ���/��U
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the'aba'nd/onment procedure:
L/J
❑Geothermal(Closed Loop) ❑Tracer
❑GeoUtermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
Sa Well locatro :
�Fe - -,-��
Facilr Owner Name Fa 'litylD#(ifapplicable) 8.Ce cation:
z Aw.
Plryr1Jr,7C_
C ty,d Zip Signature ofC ified Well Contractor or Well Owner Date
/, 1
By signing this form, I hereby certify drat the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Consiniction Standards
and thal a copy of this retard has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,We lat/long is sufficient) 0 9.Site diagram or additional well details:
��/�f' � N f7l' 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 consrnictionrecord(s)ifavailable,ror multiple Injection or non-watersupply wells
ONLY wide the saute cotiriructio»labandoment,you can stibnrit 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: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.Far 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
abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: � ((ft.) ,
1636 Mail Service Center,Rateigli,NC 27699-1636
6e.Outer casing length(if known): ([[) 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
611 Inner casing/tubing length(if(mown): ([t,) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources C Revised 2-22-2016
i

i
WELL ABANDONMENT RECORD For Internal Use ONLY;
S / WELL ABANDONMENT DETAILS
1.Wa01 Contractor Infgrmation:
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
w
7­7 r �J wells abandoned:
,py
NC Well Contractor Certification Number 7b.{Approximate volume of water remaining in well(s): ! (gal.)
L rr FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: 1 i
2,Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Couno%State,Variance,e(c.)lfknown
7d,Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural =idelntlal
l/Public ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Wtatfr aup).y(smgl)•- IO,•Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residentiki' e t}ppipsltaild) .-Concrete Grout ❑Drill Cuttings
❑Irrigation a ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery ,�,, un
Bijection Well: I 8"i�,BOG 7f.For each material selected above,provide am unt of materials used:
❑Aquifer Recharge ❑Groundwater Remy tatton 1
El Aquifer Storage and Recovery ❑Salinity Barrier -
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the aldonment procedure:
❑Geothermal(Closed Loop) []Tracer '' �• — ✓�j/
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
0� �� /P i
4.Date well(s)•abandoned: 1� 3
Well cation:
. J ,
Facility/Owner Name Facility ID#(if applicable) 8.Certifrcation:
Physical Ad
City,
nd Zip Signature of ertified Well Contrac or or Well Owner Date J
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 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:%atitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lorig 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 G ` W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
,leach well construction record(s)ifavailable.For multiple irjectiorr 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#:
J�� Division of Water Resources,Information Processing Unit,
6b:Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Infection Wells: In addition to sending the form to the address in I Oa
`6c:Borehole diameter: � (in.) above, also submit-one copy of this form within 30 days of completion of well
abandonment to the following:
G.d.Water level below ground surface: 3 >(� (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunnly&Infection Wells: In addition to sending the form to the
6%Outer casing length(if known): t (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
6E Inner casing/tubing length(if known): ' (ft,) abandoned.
69.Screen length.(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality•Division of Water Resources
Revised 2-22-2016

r r Y'JaJAJ IajL .Lj"YY V1 Il1J 4 Y a aYu�V vi..v I1'Ul 11llel llGl V�D V1Y l.l, I ,
A
1.We Contractor/IInnformatio�n^a WELL ABANDONMENT DETAILS
P P g 7a,For Geo robe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or wel owner pwsonally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
1 wells abandoned: t
!F 7b.Approximate volume of water remaining in well(s):"P (gal,)
NC Well Coj#mctor Certification umber q
FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2,Well Construction Permit#: pe `/ 4` I
List all applicable well construction permits(i.e.UIC,Couno�State,Variance,etc.)ifknowu ! �!
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 WN-MIt Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) [A•Residential Water Supply(single) ❑ Sand Cement Grout ¢ lay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Dn uttings
❑Irrigation ❑ Specialty Grout AUG 2 8 NN-1
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery `rftr ;aV.- l tPror..5wigmg UnS
Trajection Well: 7E For each material selected O?V`t4gd&am nt of materials used:
❑Aquifer Recharge ❑GroundwaterRemediationf ��� � PLT1A
.❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Pro 'de a brief descriptio of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer y T
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) JI/���
4.Date wells)abandoned:
5%WelWeation-
Facility% wne Name Fac'lity IDp(if applicable) S.Cer I cation:
Plrysi a Address,City,and Zip Signature of Cp tified Well Contractor or Well Owner Date
/.
By signing this farm, I hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISANC.4C 02C,0100 of 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„gne lat/lorig is sufficient) © 9.Site diagram or additional well details:
W You may use the back of this page to provide additional well site details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION!DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructiodrecord(s)ifavailable.For multiple iljectionornon-water supplyW014
ONLY with the some c nstruction/abandonment,you can submit ale foral.
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources,Information Processing Unit,
6Ir Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6ci 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,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if]mown): ' (fW 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):
• _ I
'Form GW-30
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

W L'LL A DAlN U V1N Y +1N 1 r l:V" For Internal Use ONLY:
1.7,Vontractor Information: WELL ABANDONMENT DETAILS
7a,For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well Twner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number / 7b.Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS 0 Y:
'Company Name ��Dl
( p 7c.Type of disinfectant used:
2,Well Construction Permit#: I///y/�,
List all applicable well constryction permits(i 0-,State,Variance,etc.)tjknown jZ
7d.Amount of disinfectant used: l
3.Well use(check well use): ,
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mun ipaUPublic Teat Ceme h4isout r� I- e e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidendal Water Supply(single) ❑ Sand Cem ntit tk. 1.- �f 1 Dry Clay
[3Indtistrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout AUG 2 8 2023 ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout 11 Gravel
Non-Water Supply Well: ❑ Bentonit0,LgfWaj;fl ilmuwr ,](:GROther(explain under 7g)
❑Monitoring ❑Recovery DW,0130G
)�ijection Well: 7f.For each ma errs!selected above,provid;_V�
unt of aterials used:
❑Aquifer Recharge ❑GroundwaterRemediation '-7 (/i, /�- • � '/ �`
.❑Aquifer Storage and Recovery ❑Salinity Barrier rrtt ,ate
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence.Control
7g.Pr de a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �f
� e l
4.Date well(s).abandoned:
SR.Well ocatiPn-
Facility/Own Name Facility.ID#(if applicable) S.Certi rcadon:
Physical Address,City,and Zip `Signature of qrtified Well Contractor or Well Owner Date
By signing this form, I hereby ce'rto that the well(q) was (were) abandoned fit
• 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/lori)rin�g'is sufficient) �j 9.Site diagram or additional well details:
Pi C �� 1�7� 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 WETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constntctior record(s)tjavailable.Formul iple Injection ornon-watersttpply welly
ONLYtvith the same colltstnrcllon/abandonttien►,you can submit ottejornt. 10a. For All.Wells: Submit this form within 30 days of completion of well
6a:Well ID#: i abandonment to the following:
Division of Water Resources,Information Processing Unit,
6:Total well depth:._ ot.) 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: (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,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft) address(es)above,also submit one copy of this farm within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 1 (ft,) abandoned.
.6g.Screen length,(if]mown): A)
Revised 2-22-2016
.Fornt GW,30 North Carolina Department of Environmental Quality-Division of Water Resources
I '

WJ!L.t AJ15Ai JJ V1r1VM1N I K EU VK V For Internal Use ONLY:
1.Well Contractor Informationn:: - WELL ABANDONMENT DETAILS
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
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): / i (gal.)
FOR WATER SUPPLY WELLS ONLY:
'Company Name
f r , 7e,Type of disinfectant used:
2.Well Construction Permit#:M1_) 3`� )#
List all applicable well constnrction permits O.e.UIC,Coun05 State,Variance,etc.)Ifknowu
• 7d.Amount of disinfectant used: r3 1,✓
3.Well use(check well use):
Water Supply Well: 7e,Sling mate iaj,µser](chec! ai,t at ply):
❑Agricultural ❑MunicipaUPublic [IYNeat CemetC�r itt � rBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CWgidendal Water Supply(single) ❑ Sand Cement Grout c� ❑Dry Clay
❑Indtistrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout AUG 2 8 2023 ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout
❑Ljj�.-Oravel Non-Water Supply Well: ❑ Bentonite siu Fyn
try Q''�'�tAv'3OC� Other(explain under 7g)
❑Monitoring ❑Recovery
injection Well: If,For each material selected abov provide Finount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier � ������
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence.Control
7g.Pro e a brief description of the abandonment procedure:
❑Geothermal(Closed Ldop) [)Tracer
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 7g) — -- - � ���` r��� v / /l✓
4.Date well(s)•abandoned: 1
5a.Well location:
e
LAC ; + `
Facility/Owner Name FacilitylD#(ifapplicable) 8.Cer tication:
Physic a ddress,City,and Zip ignature of ertified Well Contractor or Well Owner Date
By signing this form, I hereby certo that the well(s)was (were) abandoned in
• Cvunty 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 lAgitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lodg is sufficient) 9.Site diagram or additional well details:
N y��• �y 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.
CdNSTRUCTIONIDETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellcatstnrcdanr record(s)tfavailable.For multiple bjection at-nor-watersupplyw ells
ONLY rvith the same cops/nrctlon/abandonttient,you can submit onejornt' 10a. For All Wells: Submit this form within 30 days of completion of well
6a'.Well tD#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6ti:•Total well depth:. G/`� (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: (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: / I (ft.) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
t 6e.Outer casing length(if known): 10c,For Water Sunniv&Injection Wells: In addition to sending the form to the
(ft.)
w address(es)above,also submit one copy of this form within 30 days of completion
'r of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): ° (ft.) abandoned.
.6g.Screen length•(if known): ,r (ft.)
Form
GW�30 North Carolina Department of Environmental Quality-Division of Water Resourc�s Revised 2-22-2016
I