Rowan_Well Abandonment_20231101 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: NMENT DETAILS
Frank Beecher 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 his needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:w"
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): 1.42 (gal.)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well constrrctionpermits(i.e.U1C,County,State,Variance,etc.)ifknoivn
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 19 Neat Cement Grout ❑ Bentonite 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
❑hri'ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Portland-27.07 pounds Bentonite-1.13 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier Water-2.00 gallons
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Tremie grouted with a portland mix.
The well was abandoned in accordance with
4.Date well(s)abandoned: October 03, 2023 15A NCAC 02C .0113
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5a.Well location: I -
Products(SE)Pipeline Corporation N/A Nov n9
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Facility/Owner Name Facility lD#(if applicable) 8.Certification: i' : 1 2023
1615 Jake Alexander Boulevard West, Salisbury, 28147 ":-octQber, 0,,,2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner 'I)aV
Rowan 450 011 B signing this onn,I herebyceni that the wells was were abandoned in
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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:
35.6817328 N -80.5083382 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 I
Attachrvellconstructionrecord(s)ifavailal)le.For maltiple injection ornon-uatersupplywells
ONLY with the same constructionlabandonmew,yat can submit one form.
��/ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
M V V-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter• 2.0 (tn.) 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.) i
6.28 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NIA 00 10c.For Water Suooly&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 departrneat of the county where
6L Inner casing/tubing length(if known): 2.0 (ft.) abandoned.
6g.Screen length(if known): 13.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Frank Beecher 7a.For Geoprobe/DPT or Closed-Ipp Geothermal Wells having the same
Well Contractor Name(ar well owner personally abandoning well on his/her property) well construction/depth,only I OW-30 is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:w^
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.40 (gal.)
I
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
Company Name N/A
7c.Type of disinfectant used:
N/A
Well Construction Permit#: N/A
List all applicable aell construction permits f.e.U/C.County.State.Variance,etc.)ifknown
7d.Amount of disinfectant used: N/A
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
❑Industrial/Cornmercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry I ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
OAquifer Recharge ❑Groundwater Remediation Portland-27.07 pounds Bentonite-1.13 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Water-2.00 gallons
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Tremie grouted with a portland mix.
The well was abandoned in accordance with
4.Date well(s)abandoned: October 03, 2023 15A NCAC 02C .01;13".
Sa.Well location: NOV s
��,�
Products(SE)Pipeline Corporation N/A rs-
Facility/OwnerName Facility ID#(ifapplicable) 8.Certification: i If. -.^n
1615 Jake Alexander Boulevard West, Salisbury, 28147
C October 30,2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Rowan 450 011 1
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
Sb.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 Iattlong is sufficient) 9.Site diagram or additional well details:
35.6815625 N -80.5082232 �, 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 WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attaclravellconstructionrecord(s)ifavailable.Formultiple injection ornon-watersupplywells
ONLY with the same consiruction/abandonment,you can submit one form.
n n�Y V/ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• t V' -4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter• 2.0 (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• 6.42 00 Division of Water Resources,Uniderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(d known): NIA 00 10c.For Water Suoaly&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
6f.Inner casing/tubing length(if known): 2.0 (ft,) abandoned
6g.Screen length(if known): 13.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016