Rowan_Well Abandonment_20231101 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
II
1.Well Contractor Information: WELL ABANDONMENT DETi1I LS
Frank Beecher 7a.For Geoprobe/DPT or Closed-LIoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GV�-30 is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:- I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.59 (gal)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
I
Company Name NIA
7c.Type of disinfectant used:
N/A
Well Construction Permit#: N A
List all applicable well construction permits(i.e.UIG Couaga State,Variance,etc.)if known
7d.Amount of disinfectant used:l,NIA
3.Well use(check well use): ,
I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic N Neat Cement Grout I ❑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
❑Irri ation ❑ Specialty Grout I ❑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 ❑Groundwater Remediation Portland-27.07 pounds Bentonite-1.13 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwatcrDminage 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 0213 .0113".
5a.Well location:
r.4 .,a•_
Products(SE)Pipeline Corporation N/A -- /.: •,.:t
I
Facility/Owner Name Facility ID# 8.Certification: NOV2023(if applicable) � N Y � �
1615 Jake Alexander Boulevard West, Salisbury, 28147 October 30,2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Wcll Owner �Dale
Rowan 450 011
By signing this forth,I hereby certify that the wells)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:
35.6817989 N -80.5078494 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(v)ifavailable.Formultiple injection or non-water supply wells
ONLY with the same construction/abandonmeni,you can submit one form.
/ 10a. For All Wells: Submit this form within 30 days of completion of well
62.Well ID#:
M V V-10 abandonment to the following: !
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.0 (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Injection Wells: In additii n,to sending the form to the address in 10a
2.0 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) , ,
abandonment to the following:
6d.Water level below ground surface• 5.25 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ceriter,Raleigh,NC 27699-1636
6e.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
6L Inner casing/tubing length(if known): 2'0 (ft.) abandoned. 4
I
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

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 7a.For Geoprobe/DPT or Closed-Li op Geothermal Wells having fhe 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:,-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.52 (gal.)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
Company Name N/A
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable it-ell construction permits r.e.UIC,County,State,Variance,etc.)iflmonm
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 S Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) p Concrete Grout yy ❑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 ❑GroundwaterRemediation Portland-27.07 pounds Bentonite-1.13 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage Water-2.00 gallons
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothennal(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.Datewell(s)abandoned: October 03, 2023 15A NCAC 02C .01;13". T
; a
Sa.Well location:
Products(SE)Pipeline Corporation N/A Facility/Owner Name Facility ID# if applicable) 8.Certification: N O V V ! 20 23
.�"
1615 Jake Alexander Boulevard West, Salisbury,28147 Ddt0berr,P!_2923
J: '�.
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner bate`
Rowan 450 011
By signing this form,1 hereby certify that the well(,) 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 oJ'this record has beeit provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.6816927 N -80.5081967 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
Attack well cotcclruction record(,)ifava!luble.Farmultiple injection or non-water supply r+•elGs SUBMITTAL INSTRUCTIONS
ONLY with the same�ctotnsstructionlabandonment,you can submit one form.
ivi V V-1 1 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,
15.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Infection 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: I
6d.Water level below ground surface• 5.70 (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) 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 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
I

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
I ,
1.Well Contractor Information: WELL ABANDONMENT 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 1301 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): 1.39 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 1
List all applicable well construction permits(i.e.UIC,Colony.State,Variance,etc.)ifknoivn
7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ail that apply):
❑Agricultural ❑Municipal/Public S Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustriaVCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation q 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 ❑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
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating(CoolingReturn) ❑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 CA - W C 02C .011.3
5a.Well location: NOV J 1 2023
Products(SE)Pipeline Corporation N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: ,; ._ ,,.. ,• I
1615 Jake Alexander Boulevard West, Salisbury, 28147 e rX4"�� 'y J
October 30,2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Rowan 450 011
By signing this form,I hereby certify that the well(v)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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 6ee'n� provided to the well owner.'
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.6815263 N -80.5083613 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(y)ifavailable.For multiple injection or non-water supply»elly
ONLY with the same constructionlabandonmem,you can submit one form.
A 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-12 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 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: I(
6d.Water level below ground surface• 6.48 (fb) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 00 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy bf 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): 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 I Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher '
7a.For GeoprobetDPT 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 Glly-30 is needed. Indicate TOTAL NUMBER of
3225-A wel Is abandoned:w^
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'43 (gal.)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
Company Name -
7c.Type of disinfectant used: '1�'V/A
2.Well Construction Permit#: NIA
List all applicable well construction permits(i.e.UIC,County.State,Variance,ere.)ifd7rorwr
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 S Neat Cement Grout '. ❑Bentonitc Chips or Pcllets
❑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 Slur
ry El Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland-27.07 pounds Bentonite-1.13 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
Water-2.00 gallons
❑Aquifer Test ❑Stotmwater 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 .011311 - . __"`I `, - -.,
Le
5a.Well location: NOV J 12023
Products(SE)Pipeline Corporation N/A
Facility/Owner Name Facility ID#(if applicable) S.Certification:
1615 Jake Alexander Boulevard West, Salisbury, 28147 j , 1 October 30,2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well 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 degreestminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.6814803 N -80.5082044 `,1, 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(v)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandomnent,you can submit one jam.
MW-13 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: 15.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6a Borehole diameter: 2'0 (in.) above,also submit one copy of this'form within 30 days of completion of well
abandonment to the following: j
6.23 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface. (fG) 1636 Mail Service Center,Raleigh,NC 27699-1636
N/A loc.For Water Supply&Iniection'Wells: In addition to sending the form to die
6e.Outer casing length(if known): N/A 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): 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 i Revised 2-22-2016
4� ;