Rowan_Well Abandonment_20231101 (10)

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher
7a.For Geoprobe/DPT or Closed Lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GWV 3Q is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'79 (=al.)
AECOM Technical`Services of North Carolina FOR WATER SUPPLY WELLSjONLY:
Company Name 7c.Type of disinfectant used: N/A
/A
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,Counts State,Variance,etc.)iflmown
7d.Amount of disinfectant used: !1�'V/A
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout I N 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 ❑Gravel
Non-Water Supply Well:
❑Bentonite Slurry � ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-50 lb's
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
Water-1.00 gallons
❑Experimental Technology ❑Subsidence Control j
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer i
Well to within 1 foot of surface
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Slowly filled Monitoring We� -
while checking for bridging!,Topped off with Concrete.
4.Date well(s)abandoned:October 03,2023
The well was abandoned in accordance with
sa.well location: 15A NCAC 02C .0113'i
Products(SE)Pipeline Corporation N/A iNO (�
Facility/Owner Name Facility ID#(if applicable) 8.Certification: I' 2023
1615 Jake Alexander Boulevard West, Salisbury,28147 - "` =` �� ' „ - i
�Or QCtdlieP `1023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owncr Date
Rowan 450 011 I
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 beeit provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) 9.Site diagram or additional well details:
35.6814051 N -80.5079359 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 construclion record(v)ifavailable.Formu/tiple ityeetion ornon-watersupply well.
ONLYwith the same constructionlabandonment,you can submit one form.
MW-141 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# abandonment to the following: i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25.0 (fL) 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: 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: 7•88 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,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): 10.0 (ft.) abandoned.
6g.Screen length(if known): 15.0 00
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Intemal Use ONLY:
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-30 is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:-
NC Well Contractor Certification Number 7b.Approximate volume of orate i remaining in well(s): 1.39 (gal.)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLSIONLY:
Company Name
7c Type of disinfectant used: NIA
2.Well Construction Permit#: N/A P
List all applicable urp construction permits(Ke UIC,Count.State,Variance,etc.)if1monm
7d.Amount of disinfectant used:i
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public S 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 I ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slung ❑Other(explain under 7g)
amonitoring ❑Recovery j
Injection Well: 7E For each material selected above,provide amount of materials used:
❑A uifer Recharge ❑Groundwater Remediation
q g Portland-27.07 pounds• Bentonite-1.13 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier I
Water-2.00 gallons
❑Aquifer Test ❑StormwaterDrainage
❑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 02 C .011311' _
t. r�
I", 7_ '
5a.Well location: 1, J
Products(SE)Pipeline Corporation N/A
Facility/Owner Name Facility M#(if applicable) 8.Certification:
1615 Jake Alexander Boulevard West, Salisbury, 28147 :LOgtober�6,2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Ir
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 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.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:
35.6813147 N -80.5083010 `,Ir 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
Atiacb well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
1t A'tt, 10a. For All Wells: Submit this form within 30 days of completion of well
V'62.Well ID#• ' V V-16 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 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• 6.49 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ce i ter,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
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 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-30 is needed. Indicate TOTAL NUMBER of
3225-A wellsabandoned:wA
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.16 (gal.)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS�ONLY:
I '
Company Name N�A
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A I'
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.)ifknorvn
7d.Amount of disinfectant used:!N/A
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check ull 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
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry j ❑Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f.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 ❑StorrnwaterDrainage Water-2.00 gallons i
❑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 NCAC 02 C .0,' 13 .
j t,
5a.Well location:
Products(SE)Pipeline Corporation N/A NOVj
Facility/Owner Name Facility ID#(ifapplicable) S.Certification: I 2023
1615 Jake Alexander Boulevard West, Salisbury, 28147r,,Lud. r
r,;OctQbei 302U�3.�
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date ~
Rowan 450 011 1
By signing this form, 1 hereby certify'that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.010d 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:
35.6814051 N -80.5079359 `l, 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
Alracbrvellconviructimirecord(s)lfavailable.Formultiplcinjectionornon-rvatersupplytvells
ONLY with the same canstruction/abandonment,you can submit one form.
A 10a. For All Wells: Submit this form within 30 days of completion of well
MW6a.Well ID#' -17 abandonment to the following: j
I
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: j
6d.Water level below ground surface:
7.91 Division of Water Resources,Underground Injection Control Program,
(ft.)
1636 Mail Service Center,Raleigh,NC 276994636
I-
6e.Outer casing length(if known): NIA 00 10c.For Water Sunaly&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 Vt.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016