Rowan_Well Abandonment_20231101 (8)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 7a.For Geoprobe/DPT or Closed- oop 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
3225-A wells abandoned:w^ II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'23 (921.)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NIA
2.Well Construction Permit#: N/A
List all applicable well construction permits(7.e.UIG County.State,Yariance,etc.)iflxoIVn
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 9 Neat Cement Grout ❑ Bentonitc 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 ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonitc Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
Portland-27.07 pounds Bentonitc-1.13 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Water-2.00 gallons
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer 7g.provide a brief description of the abandonment procedure:❑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 N CAC 02C .0113
5a.Well location: 1,
Products(SE)Pipeline Corporation N/A NOV v _ 20203
Facility/Owner Name Facility ID#(if applicable) 8.Certification: j
1615 Jake Alexander Boulevard West, Salisbury,28147 ,.,/ e�w'In" "! 5:" V" 't
� lr';,Otao6e?f 30,2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Wcll Owner Date
Rowan 450 011
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/rninutes/seconds or decimal degrees:
(ifwcll field;one lat/long is sufficient) 9.Site diagram or additional well details:
35.6812790 N -80.5081210 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 cons[ntction record(v)ifavailable.For multiple injection or non-aatersupply wells
ONLY with[he same constructiordabandonment,you can submit one form.
� 10a. For All Wells: Submit this form within 30 days of completion of well
ID 6a.Well #• M d fl y-6 abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.0 00 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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
,t abandonment to the following:
6d.Water level below ground surface• 7.48 (M) Division of Water Resources,Unl erground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): N/A (ft.) 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
6E 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

1
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABA VDONMENT DETAILS
Frank Beecher- 7a.For Geoprobe/DPT or Closed-L loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GIN-36 is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:.-
NC well Contractor Certification Number 7b.Approximate volume of water r j maining in well(s): 1.11 (gal.)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
Company Name . N/A
7c.Type of disinfectant used. i
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmoim
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 i ❑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
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry j ❑Other(explain under 7g)
eMonitoring ❑Recovery I
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
❑Aquifer Test ❑Stormwater Drainage Water-2.00 gallons j
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
Tremie grouted with a portland mix.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
The well was abandoned in accordance with
4.Date well(s)abandoned: October 03,2oz3 15A NCAC 02C .0113".�
5a.Well location: I -s,.�
Products(SE)Pipeline Corporation N/A NOVFacility/Owner Name Facility ID#(ifapplicable) 8.Certification: j. , N J 12023
1615 Jake Alexander Boulevard West, Salisbury, 28147 �023
Physical Address,City,and Zip Signature ofCertified Well Contractor or Well Owner arc
Rowan 450 011
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:
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.6819487 N -80.5077022 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.
I
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 construclionlabandonment,you can submit one form.
n/�,A/ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• 'V'V V-9 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
i '
10b.For iniection 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: 8.22 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I :
6e.Outer casing length(if known): N/A (ft,) 10e.For Water Sm mlv&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
6E 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