Chatham_Well Abandonment_20231215 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor information: WELL ABANDONMENT DETAILS,
Brian James Bellis 7a.For Geoprobe/DPT or Closed-LI op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GIN-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name '
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well consiniclion permits 0.e.UIC,County,Slate,Variance,etc.)ifknown
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 ❑Neat Cement G , Pentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout+� +'�,, i �1 q �r Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout DEC1 LO2�❑ Drill Cuttings
q � ry
❑Irri ation ❑ Specialty Grout °' Gravel
Non-Water Supply Well: ❑ Bentonite Sl['� yt er(explain under 7g)
fi'1'WTYtY✓v«4'n t_rn.;�.,�.�,`lti.�.C�t✓ 4
RMonitoring ❑Recovery �v��
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips —45 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑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) Bentonite chips were poured into the well and tamped
until chips rose to top of well casing. Casing was
4.Datewell(s)abandoned: October 10, 2023 then capped with original locking cap.
5a.Well location:
CPF, LLC Not Applicable
Facility/Owner Name Facility ID#(if applicable) S.Certification: _
Moncure Pittsboro Road & NC Highway 87, NC 27559 �,z12-11-2023
Physical Address,City,and Zip Signature ofCerti fed We Contractor or Well Owner Date
Chatham 95729
By signing this fornt, I hereby certify that the ivell(s) was (were) abandoned in
County i 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 longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.692759 N -79.169751 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 records)ifavailable. I,or nmliiple h jection ornon-watersupply nrells
ONLY with file same construction/abandonment,you can submit one firm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW 4A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (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: 8 (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: —39.13 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) loc.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): 20 (ft.) abandoned. i
i
6g.Screen length(if known): 20
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: I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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-3b is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: !
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.)iflaown
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 ❑Neat Cement Grr�(, _ R Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gr,u4,.6— °- + ''t;/
�,•a.a.r �f &I y
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout DEC 1 C, 2021 Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery IRwTi,?2 S�:Tl ia1:�6.r t,-.J
Injection Well: 7f.For each material seleAt"A lOw- Rovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —60 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Bentonite chips were poured into the well and tamped
until chips rose to top of well casing. Casing was
4.Date well(s)abandoned: October 10, 2023 then capped with original locking cap.
5a.Well location:
CPF, LLC Not Applicable
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
Moncure Pittsboro Road & NC Highway 87, NC 27559 S�— 12-11-2023
Physical Address,City,and Zip Signature ofCertifi We Contractor or'Well Owner Date
Chatham 95729 By signing this fora, 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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.692759 N -79.169751 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(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the saute construction/abandonment,you can submit one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-6B abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 52 (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: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
i
6d.Water level below ground surface —39.13 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
NA (ft.) IOc.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
6f.Inner casing/tubing length(if known): 20 (ft.) abandoned.
I
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I