Columbus_Well Abandonment_20231228 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
NMENT DETAILS
1,Welontractor Informatn:io WELL ABANDO
l -
f 79.Number of wells being abandoned:
�r N A, �s`^"pay For• mulaple injection or non- ater supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) consrnrclian/abandonntent,you can submit one form. --{�
7b.Approximate volume of water remaining in well(s): �/ (gal•)
NC Well Contractor Cc fits on Number 1
/�1 /[�r ���t�i JS•(1L, FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name /�r
2.Well Construction Permit t!: ' `t
List all applicable well permits(i.e.County,State,variance,injection,etc.)ifhno>+n 7d.Amount of disinfectant used
3.Well use(check well use): y):
7e.Sealing materials used(check ell that a pp 1
Water Supply Well: ❑Neat Cement GY' �"':* ` Bentonite Chips or Pellets
❑Agricultural ❑Municipal/Public 6 L�( r .�,/ D Clay
❑ Sand Cement Grout
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Drill Cuttings
23
OResidential Water Supply(shared) [I Concrete Grout pE 2 8 20
❑Industrial/Commercial ❑Specialty Grout ❑Gravel
❑Irri lion ❑Bentonite SI . n PrCcS, - ❑ Other(explain under 7g)
U PA
Non-Water Supply Well: DWQi'�
rovide amount of materials used:
❑Monitoring ❑Recovery 7L For each material set ctedLabove/p
Injection Well: I r 3 gu bL';L IUtb Pi CUt1
Groundwater Remediation
❑Aquifer Recharge
❑Aquifer Storage grid Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control L
v'de s brief description of the abandonnimentt procedure:
� �/
❑Geothermal(Closed Loop) ❑Tracer G� but t?� `3�4 �(4111 " 64 r dot"",� —❑Geothermal(Heating/Cooling Reum ❑Other(explain under 7g) pj eA ,It IL
Z 6 7i3 -•�,Lt?, e; g c%S � G✓� 0 ,te �Br+'dv!►•tG"� dOt.�YI-
4.Date well(s)abandoned: r
Ss.Wel I ton:( ' ` � w�" "
, N S.Certify on:
Facility/Own r Na �1i NV
ty 1DH(ifapplicable �� ��
ignat6re of Certified Well ntractor or Well Owner Date
PI, al y'�ddres,City,and Zrp
�l�s1, By signing this fortis, I hereby cer[ifj,that the well(s) was(were)abandoned in
( Parcel Identification No.(PIN) accordance.with I SA NCAC 02C.0100 or 2C.0100 Well Construction Standards
County 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: 9.Site diagram or additional well details:
(ifwe115e1d,one lat/long is sufficient) �(� You may use the back of this page to provide additional well site details or well
3 1 0 I�t`� N (�s Z s Zc�r ( ti W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLfSI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non voter supply
wells ONLY with the same constructionlabandonrnent.you can srrbrnit one fort. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well I 1 Division of Water Resources,Information Processing Unit,
t 1617 Mail Service Center,Raleigh,NC.27699-1617
6b.Total well depth: (ft.)
lOb.For Iniection Wells: In addition to sending the form to the address in IOa
Uy► AV tivN above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: �J` (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: s (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
U�+��b�� loc. For Water Suaaly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (it) the addresses) above,-also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
.tom where abandoned.
6E Inner casing/tubing length(if known): —(it•)
U��r►�D W?ti 6g.Screen length(if known): (it.,
North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
Form OW-30

WELL,A BANI)ONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1,Well Con actor information:
WELL ABANDONMENT DETAILS
79.a �
Number of wells being abandoned:
For rnulttple injection or non-water supply wells ONLY with the same
Well Contractor-Name(or well owner personally ebandomng well on hrs/her property) constnrction'abaudonnreni,you can subndr j ne form.
333 0 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
� �5�O G FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name J�r
2.Well Construction Permit il: /t/ ' 1
Lirta/!applicable well permits(i.e.County,Stare,Variance,injection,etc.)ijAnor+•n
7d.Amount of disinfectant used:
3.Well use(check well use): 7e.Sealing materials used(check all that apply):
Water Supply Well: ❑Neat Cement Gout,`^- Bentonite Chips or Pellets
❑Agricultural ❑Municipal/Public Clay
pp y( • gle) Sand Cement Group"' �-•i V �ry y
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Su 1 srn ❑ Drill Cuttings
OResidential Water Supply(shared) ❑Concrete Grout DEC 2 8 2023 ❑Grovel
❑Industrial/Commercial ❑ Specialty Grout
❑Irri lion ❑Bentonite$1D�}Ma en r?ft:Cv+W.,p-_Other(explain under 7g)
Non-Water Supply Well: LW
❑Monitoring ❑Recovery 7E For each material selected a�o�ve,provide amount of materials used:
Injection Well: n
❑Aquifer Recharge groundwater Remediation �111ble_
❑Aquifer Storage and Recovery ❑Salinity Barrier ' a l q�� �❑Aquifer Test ❑Stormwater Drainage 1
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
`
❑Geothermal(Closed Loop) ❑Tracer ��_ ��� p tq 3I /j�Y11'Of`+�e i)lt✓ GkGI
❑Geothermal(HeatinEJCooling Retvrn) ❑Other(explain under 7g) ,
4.Date well(s)abandoned: Z t✓ 23 Were, o w D d !N
So.Well I ation:
;1 s Ile- �Qn 8.Certff ion:
FaciLli=ry low ne Name cility 1 N(if a livable) I L
Jl � tl �� t�t � z3
Si nat reofCerti ell ontractororWellOwner Date
Physic .Ad ass,City,and Zip
Q�u� an 5 U r C� r By signing this form, 1 hereb3p certify that the wells)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County 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: 9.Site diagram or additional well details:
(ifwellbeld,one let/long is sufficient) l You may use the back of this page to provide additional well site details or well
g �a o`t R,� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)f available. For multiple rnjectlon or non-waler supply
Submit this form within 30 days of completion of well
wellf ONLY with the sane constrrretion/abandoninent,you can submit one form• 10a. For All Wells:
a
(_6a.Well abandonment to the following:
_ Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: ©` (ft.)
- lOb.For Infection Wells: In addition.to sending the form to the address in IOa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: �n 1 o wA (in.) abandonment to the following:
b s 1 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface (it.) 1636 Mail Service Center,Raleigh,NC 27699.1636
:
loc. For Water Suaaly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): h b L4^ (ft.) 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 abandoned.
6E Inner casing/tubing length(if known):
(ft•)
6g.Screen length(if known): V h k+l (ft.)
I
Form GW-30 North Carolina Department of Environment and No Resources—Division of Water Resources Revised August 2013

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Infor afion: WELL ABANDONMENT DETAILS
_ 7a.Number of wells being abandoned:
lTL 5t �IP-y For inult/ple injection or non-water supply wells ONLY with the sonic
Well Contractor Name(or well owner personally abandoning well on his/her property) constructionlabandonnient,you can submit onejornr.
-373q 7b.Approximate volume ofwater remaining in well(s): (gal.)
NC_Well Contractor Certification Number
s C�,4 FOR WATER SUPPLY WELLS ONLY: ��
Company Name tom' GYM'! 7lr J 7c.Type of disinfectant used:
2.Well Construction Permit /#: v 4—
Listoll applicable well pent»is f.e.County,State,Variance,injection,etc.)i(known 7d.Amount of disinfectant used:
3.Well use(check well use): PP y):
7e.Sealing materials used(check all that a 1
Water Supply Well: ❑Neat Cement Gr ut.. ^* ;cnlonile Chips or Pellets❑Municipal/Public❑Agricultural ❑ Sand Cement G ��,I I � Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Concrete Grout 8n11 Cuttings
❑Industrial/Commercial OResidentialWaterSupply(shared) DEC 2 8 2023❑ Gravel
❑ Specialty Grout
❑Irri lion ❑Bentonite Sl ❑ Other(explain under 7g)
Non-Water Supply Well: + Et :12t)r�ft:C- UM
❑Monitoring ❑Recovery 7E For each material sele 's912maprovide amount of materials used:
Injection Well:
Groundwater Remediation
❑Aquifer Recharge 6
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage l
❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Experimental Technology / n
❑Geothermal(Closed Loop) ❑Tracer WN 3
� t L/nYDI�iU G
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) `� y-- /b 4,
4.Date well(s)abandoned: �Vlltv'
Z3Ss.Well cationJl
1LZ (� " �`j 8.CertiScati
Facility/ ner N e acility IDN(if applicable)
�1 �u�e 00 �11 -ev; . Gi ,
L
t i Sigdat of
Certi ed Well Contractor or Well Owner Date
Physical Address,City,and Zip
r1AS f4fR-1 ' By signing this form, I hereby certi,that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Wet/Construction Standards
County 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: 9.Site diagram or additional well details:
(ifwell field,one lat/long is suf5cient) You may use the back of this page to provide additional well site details or well
3�'i G t 4 j fj� N _q g b 4 2't Z q) W abandonment details. You may also attach additional pages if necessary.
CONSTRUCT TION DETAILS OF WELL BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well catutruction record(s)Javoilable. For mulnple injection or non water supply
wells ONLY with the same constrtction/abondoninent,you can subinit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID 1 Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: (ft.)
lOb.For Iniection Wells: In addition to sending the form to the address in 102
�{ above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: oA E`Al)LOV (in.) abandonment to the following:
r
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: v ' (ff.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c. For Water Su y& Iniection Wells: In addition to sending the form to
fie.Outer casing length(if known):
`rid�l^ (ft.) the address(es) above, also submit,one copy of this form within 30 days of
completion of well abandonment toi:he county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known):_�(ft.)
fig.Screen length(if known):
Uwb1no LVn (ft.)
North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
Form OW-30

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Infor ration• WELL ABANDONMENT DETAILS
Q a P 5� 7a.Number of wells being abandon I d:
For rnull/ple injection or non-water supply wells ONLY with the same
Well Contractor ame(or well owner personally abandoning well on his/her property) eonatntction/abandonntent,you can submit'one form.
3 3 7b.Approximate volume of water remaining in well(s):
NC Well COntr2cto3.r6Ta"og'
umer/�/] LSO G FOR WATER SUPPLY WELLS ONLY: 4-
�J J 7c.Type of disinfectant used.
Co pany Name ,
2.Well Construction Permit#: N//
List all applicable well permits(i.e.Cortnry,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that`ap ly):
Water Supply Well: ❑Neat Cement Gr ut- _ 1� Bentonite Chips or Pellets
❑Agricultural l7Municipal/Public _ t13 Clay
❑ Sand Cement Gr uti �"pper 4 9
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Concrete Grout �`f D Il Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) DEC ❑ Gravel
❑Specialty Grout 2 8 -Z023
❑Irri lion ❑Bentonite SI j ❑ Other(explain under 7g)
Non-Water Supply Well: r�Il3ltEr't r,rt.+C
❑Monitoring ❑Recovery r"o""iwh%om' ount of materials used:
7E For each material sel M15
Injection Well: GI` ���/�j
[]Aquifer Recharge Groundwater Remediation ,
❑Aquifer Storage and Recovery ❑Salinity Barrier �'�
❑Aquifer Test ❑Stormwater Drainage _ 1�
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of Inc abaandonment roced1ure:
[]Geothermal(Closed Loop) ❑Tracer V A It- ()U're ( `3 8-ft a '44 "P.)
��—
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ��A Ali/ 5
4.Date well(s)abandoned:
Sa.Well 1 lion:
t,
UiLe 8.Cert' ation:
F°a ili�ty�ID,(ifappp,ca/b�le) j c
Facility/ N U V�. �'It "1/t e L
i y
Si cure of .fied Well ntracto-or Well Owner Date
Pl;ysal A1dress,Cr and Zip� r'� f�' G / By signing this form, /hereb3 certh�That the wells)wos(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County 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: y Site diagram or additional well details:
(ifwell 5eld,one fit/long is sufficient) o / You may use the back of this page to
3provide additional well site details or well
( 0 [� N �. Z�/� w abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non water supply
wells ONLY with the some construction/abandomnent,you can subrnit one form• 10a. For All Weds: Submit this form within 30 days of completion of well
i y► 5 J abandonment to the following:
6a.Well ID k!' 1 <�
Division of Water Resources,Information Processing Unit,
I 1617 Mail Service Center,Raleigh,NC.27699-1617
6b.Total well depth. (ft.)
• 106.For Infection Wells: In addition to sending the form to the address in]Oa
above,also submit one copy of this'form within 30 days of completion of well
6c.Borehole diameter: 'd 10 (in.) abandonment to the following:
t Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 6t Y (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c.For Water So y&inieetion Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit!one copy of this form within 30 days of
completion of well abandonment to:the county health deparNtent of the county
where abandoned.
6f.Inner casing/tubing length(if known):
6g.Screen length(if known): v�" - 0 w� (ft.)
North Carolina Department of Environment and Natural Resources—Division of Water Resl urces Revised August 2013
Form GW-30