Wake_Well Abandonment_20231229

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WELL ABANDONMENT RECORD f - ., — - j
1.\\ktt(",+t)(ea�tettulul�attia►:
BattyWL(,1,,�N\vIIii•N IE:`wTUU\ lS
70.For fkopcebeMrr(rClosed-1w ,(fruteermalX%elks taros Ihesame
• .,H<.,,.v Nv 0r4.Y0 0.(+n4wMy wall er►1is11ce pt peetyl well osasinvdiooklepOk,only I GW 7 is Needed bobcat TOTAL NIAIBEit of
••'"a. liKWett______n1 7b.A,pprn Itn3le Vaal.*UfW awake* nt reririoat1 areal* Waif
N \V �-'o • el&Pump Co. I.OR 11 A11.K Sl`PLYWBLISONLY;
\.,Kr 7e. I spc of di gin fc•c•t:)n !�t a! I
Nit:11.n.1t + +/Y"` "t l� 1/2lb.
. ...,-.,.t,..emrawf,or fir;rier n;woe,Oiweawx_ert,t➢wwa _ ___
7d.,.Amvuut of tksinfccfant used'
,,\\etl.h'RCef.tae0 uve4
\\:slew urr( -,44, 1e.**Kitt inatcrialx u%ed itherk all abet ap�JC r
3NpAkAakkirsta 17NlWtcertakrublw C1 Ncal C anent Cuaul }jtatoolie Chips OfPoom
If E'KWOramx4at41ikvtrtitgl:kvItas Suct40. 7itcliitntial Water 5uppt}Noodle' • Cl Sand Cenunt(unto Di7C4 DEC 2 9 2023
ctp,4.,„.,kw"y t4t.0.1, 'IRc,tdcntrnt\\;ucr stir ply(slhued) I:7 C`Cnctctc(intut 0 QIMCYMrFs
141mmx aww pcoaltv Lin,,,)t 0 Gated IT1fOrwatiti1 Pr!?^.aIFQroi Ufa
A\\aler CCtlpp \%1 n 7:1 Uentunde SIwn- p Odor(imam wader at: DrCO3O3
CNAka4.k $ UR,xoyct\'
lojectier Writ 7E For each matrrial caner led aAm6 provide oaroontoffoNleiflrtlstd:
C tptttWt 4k Aettt CJGmmndtwter Remedlanon geWiy f _a j iia522`
C1k auctir$tltECatl1: .:,`sc d)Salnuts furrier
,a.).44]itkrIAN UStormssaier Uiutuage
CINtiotoptool.1-6..lo..•Id,, rlSiihsidence Conlon
" nridc a b•'^(drerrinlinn of the it,.tnd•nttatM,llr.[tdrr►-
L((ioDslww►tl.,C s d I.eel,t Cl l r aecr �+ �/
ZvbCIId2t(1011;,I I:al,o;. Cooleis: Rctwnl L1C)tltcr(explain under 7g) Far got��.///X- e•-p41/f-?
t _ 5J 'n�3� � ' _
.1k llatewelItt)abandoned: f1"/3`
ta.tt elt Neal ion:
Fu itty IDll(If applicable) S.Certifice tinu: / q
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U *we n(C sit :il ,ii .Y.irl,:t\Cell(.
\I`f/' Qt•xrttuttg tier,,l,u,k f iketeet.Coif tr.(i.Mbar Ike re1100 teat f+m,+000000neJ i
Parcel ldanhllcanon NO(PIN) acct.dant c a,rh l?,.t rll'C„IC 02C.0100 or .0200 reit Cemineneejyie,',
silk!lh.11.l ru/n,>J tbs oreartfArs 6eel pyyryrt to the ramm r
^I•.L.ztmnde:tail longitude in dcgrecvtmututes/seconds us-decimal degrees:
. :;1: •••e:1,1ten,;,suit6.cutl r'n
yl ', e1 Y dtP "1 V.1•t 1. 1 \\ 9.Site diagram or addttiululwerdMl�:
. f 1 h ) You 111.1y use the back of this wog Ip provide adilinoid via Sae druids or u 6:
ab:uidonmcttt detail Yon nury abeam&al ooad pages if accessary
Ctit\'s Mil( f IU\DE1•\11 S OFWE L1.(SLtiFI 1G All.*NDX\ED sL I. IIT'GU.INS RI t Furs
-3xsn,::•• - •...,,..•.••,,a,,nu','•aiiiii bk.ref meJn),lc lines te,Inns orWtl-,rarer supply x nh
O)4} ':toy.t•,itnlso-oat 4husiiiesarot.till r,m„lhm,l rule I,,,,,l
10a. Fur All 11 chin: Submit th:; !min .n.l610 30 AIDS at oorlptenoa of ur.'I
fa,'et e!i Ilk:: abandonment to the tollo,ann
1)a.ision of 11'ater Kesourecs.lufo formation Pr.etstiag Unit.
lb,I%talltwe 3jepee (tl.) 1617 Mail Service(-enter.Rakich.NC27t7 1017
;re) IUb.For lnlecnuu Writs: In addtu.ut Gm Seriu6 re form 20 the addrtss I 24a
Or.IttrrtMR111araerer. � f (in.) above,also submit one dory,,f[Inv forts unbolt 30 days of oomplamon of.mill
ahantluuntent to the follunnur2
ha,\\aim Md Omits ground sat tace:__-�. _^eft.) Ili.ivun of 11 ater Resources.Underground Iaajtct o.Caand Program.
-' 1636 Mail Sets ice(-enter.ltalei::11,,NC27611111-lifdli
Kt,.Comte losvogg tt 04str,tl kuo,.(,): 3 '2 (IL) IIle.For NValcr Supply Se Irt}ccIto it 1\ills: la addtaiioat0 senda4 the folio l4 Lhe
addrese(ci)abose..ds„<ulatut one:ary of this tots ritd.r 30 dais of cent¢et,.x;
of ttrll ,ah.mdnnnacut I., the :.,outs hraph dcputment of the auaun whoa
ea Irrettose ttgatlbNr,•;Iclu lPt(,1 411o011): in4 aheud.•o,,l
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,,ie Well Pump Co, FM WATER tiluret.r WELLS WILY':
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7d.Amount of 1651r1feetaat north:_ Y
7r.Srahag matct Oils used(rirrrh Al(JIit a()illy):
CIMinsaapal:l uldic O Neat Cement(hail ❑ 13rart,uu'c r.iulr,or?eirc4f
''I' . ''i'i'it ici;delut,d\\atrr Sniryilv illogic) ' S.111,1 Comm'rirntrl ❑Dry'.lay DEC 2 9 2023
ORlsnlcntial Watch Supply(shared) U Cnncrdc t;n;ul C1 Dial canals
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❑Stumm:ttcrDisinngc Il � '444/�
..,... I c,:a.lo)U;v °Subsidence Control l✓ � _"'
,�Ic:ved Loop 71'.•,I;t'nvidc abrief description nl'the a uS lotion mat procedure,
iacer
, .:I1 ., ..iting/Cly+iing Retu n) OOdtcr(explain under 7g) di 4 kl ! S NO .—C.7-4MEA -47/X
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:.1i'e!1 l:uativa: f 'r�
• ,`. �1'c =%& racdity mil(iranpficabtc) 3.Certification:
.ircn!nd,c.•«.Op'.and Zip C •� ,r.
� �/�_ Stunaul cn,,cti Wen Can r c whey � fina
��, By signal this forma. l herehr cerrib,that the ,m8(s) was('.Cr' e)nba,u;o•c_:i '•
Parcel Identification No(PIN) accordonca u,d,15.1,VCv1C 02C.nl on ar:C.0
200 Well Catsrrrcaar 5'::r;r{.- :.
,it.Latitude:ntd Innoittlde in degrees/minIIIc)/seconds ur decimal degrees: haul rdar it co({r n(eius reemd hrrrbcerr(aruridcd to the,rr.!(aa•rrer,
I Sdti..7.IrUlnu is suffie.cni)
"' C I.Site diagram or additional well details:
�J.�L� ! 7Q 4
/>- I)�a \Y 'I You may use the back of this gaze to provide additional well site d c:.ts.r..i . .L\s
abandonment details. You may also attach additional pages ifinettons. -
co.silo.CrION ILC'rAILs OF wt?LLISI BEING ABANDONED
aacllcn:r.,uncnur.l cccur/(s)tiavailable.lot um(nt,k tnycnnu or non-oaten mtpply wellsSf/[3i\[1"E-CAf,I\$('ItllCllf)Nti
u'L I" ,;'lie clone cr,nntrncfuu aaalulna,aenl,tm,cat ashen,:nut/r,rn,.
10a. For All Wells: Submit [his lotto within 30 tans of opstbidyess of sad:
La.Weil Ma: abandonment to the following'
/' Division alWater Resources,Infnrinalion Processing l hit,
i,ta.l',:tn:,sell depth: 1///(... / (ft.) 1617 Mail Service Center,Raleigh.NC I:MN)_1617
Olt.for In(ccrion Wells: lit addition to sending lit ion 01eead.:tss iu :',z
.c'.:tile deic t:tcr: I (in.) abase, ;dso submit inn copy of this font within 30
days abandonment to the following; of eslaplct' t" 'ci:
.'\:,::r I'vet tie)u'•s ground surface: (it.) Dis'islnn of Water Resources.Underground lu ecci.p
1636 Mail Service CentcrR.tleigh„NC 3 6•Y1LI6J Praeraar.
tit.-•'_. •.. g Ica:;:ut(if Latnsu): lac.For Water Savill
e y St tine pills: In ad!it.^u tag s+:WO/inEat{acne 6a:, .
address(es)above,also adnnttntt ate copy of Hies C.,nl ss,Cs:a alp dap 0(001111012,:.,
at well iIandunnte,a to the county Iteal.h d rat:neat air 9Yt COMO were:
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:19NOzilIE111111111J • 611103V U► I0M

WELL ABANDONMENT RECORD For Internal Use ONLY: i
iI
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood
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 I GW-3 is needed. indicate TOTAL NUMBER of
4165A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY:
Company Name
�_ ,+�O 1�,,�f� �� 7e.Type of disinfectant used: HTH � w
2.Well Construction Permit#:614 `� ti�I t ; .
List all applicable well construction permits(i.e.U/C,County,Stare, Variance,etc.)ifh7ron•n 1/2 lb. ' 4 �i\F
7d.Amount of disinfectant used: VVV i
3.Well use(check well use): DEC 2 9 2023
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout B frZ4bi# RrPduu"l um
❑Geothermal(Heating/Cooling Supply) iesidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation al,pecialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: If.For each material selected above.provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Q i�,70��r�i�C Aiw / 'S2?4"
❑Aquifer Storage and Recovery ❑Salinity Barrier (7 %W�l.' �I�i ,�J LO
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control , r>,,midc a bra nfrlrsrrintinn of the ahanrinnmrnt nrncrdrnrr
❑Geothermal(Closed Loop) ❑Tracer .�y�
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under 7g) i, <7 g r� s/ z- i3O ,ki Ao i
4.Date well(s)abandoned: 11'4
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
6 103 Pi€4044. bg golie/&,4/6
.7-ii-oletu
P iysrcal Address,City,and Zip p.,-,ai e3 S' attire of Cert. 'ell 'on racior or Well Owner Date
poi 4�' By signing this form, 1 hereby cert5'that the well(s) was (mere) abandoned in
Count Parcel Identification No.(PiN) accordance with 15A NCAC 02C.0/00 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:
r�5, N 'l�,t��, IV 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)lfavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
3 f Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: in addition to sending the form to the address in 10a
6e.Borehole diameter: 5'73 (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: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
2�Y —
6e.Outer casing length(if known): . ,? (ft.) .IOc.for Water Supply&Inicction Wells: in addition to sending the font to the
address(es)above,also submit one copy of this font within 30 days of completion
of well abandonment to the county health department of the county where
6f.inner casing/tubing length(if known): (ft.) abandoned.
•
6g.Screen length(if known): (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For internal Use ONLY:
J
1.Well Contractor Information: WELL ABANDONMENT DETAILS J ,' � �/'�_ Y4
10 -& C: r'G 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
`-1 J 6r—c wells abandoned: 1
NC Well` Contractor Certification Number 7b.Approximate volume of water remaining in well(s): I CCIII. (gal.)
t /Ir6,kr- t/V i 7_4). J 1L(, FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: 14 T /J .;.-.(-t E i`t:,E Li
2.Well Construction Permit#:List all applicable well construction permits(i.e.U/C,County,State.Variance,etc.)if known DECC2 202 3
7d.Amount of disinfectant used: 6
3.Well use(check well use): u•Of C 1 7l .,yQ'„ n,9 f
Water Supply Well: 7e.Sealing materials used(check all that apply): DW CJ'teOG
❑Agricultural ❑Municipal/Public gloieat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ' ,rt} '�5
❑Aquifer Storage and Recovery ❑Salinity Bather 1/y�L/
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer /, 4- ��I I I Iovy r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) C(A r
• J p��e.et ,Je, - p-)4
4.Date well(s)abandoned: ),i i J � r n IT�,CJ /r /tt Q (�1
Sa.Well location:
Min Pret-#1,C) C0
Facility/Owner Name Facility ID#(if applicable) 8. rtification:
c iti1 wctA-t4ev ei e-t eve c - 7/1 / -3
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Ler-I - - 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.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:
(if well field,one lat/long is sufficient) '�/ s� /j�y 9.Site diagram or additional well details:
`;,41 5r3y N —✓J •7 O 7Clgt�d 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)if available.For multiple injection or non-water supply wells
ONLY with the same consrrucrion/abandonmem,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Well : abandonment to the following:
6a. Division of Water Resources,Information Processing Unit,
6b.Total well depth: I (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
/ jii 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: IlL/, (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: a (ft.) Division of Water Resources,Underground Injection Control Program,
I� ( 1636 Mail Service Center,Raleigh,NC 27699-1636
N
6e.Outer casing length(if known): A (ft.) 10c.For Water Supply&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
jof well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 1� (ft.) abandoned.
6g.Screen length(if known): iki JS (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
l
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood
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 I G}V 30 is needed. indicate TOTAL NUMBER of
4165A wells abandoned: / /�
NC Well Contractor Certification Number 7h.Approximate volume of water remaining in well(s): /,i-! (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY:
Company Name
e 7c.Type of disinfectant used: HTH
2.Well Construction Permit# r�e � -� C'7 ( ;L ) E D
List all applicable well construction permits(i.e.U/C.County,,tate, i arrance,etc.)iiAirorrn 1/2 lb.
7d.Amount of disinfectant used: etE C 2 Q 2023
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that a ppixiik,ivrauen pr y:3442v um
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout P Bentonite COW6031Des
❑Geothermal(Heating/Cooling Supply) Atesidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation v Specialty Grout XGravcl
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amou t of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Af3 /,4Av j (�D1) .'
❑Aquifer Storage and Recovery ❑Salinity Barrier [� 'T,,�+ f��/�,,r ///
❑Aquifer Test ❑Stormwater Drainage f z=/V 7VIV/ �- ,4�L.e, ,t y. ( l'--
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Poi 3 V.6L iitirp 4,0,.4...
fob atiro,/r - w p 7--Frea,en
4.Date well(s)abandoned: _ � 'VP , N D ' �� n c ilv�
5a.Well location: �L I'0-I l^ f� iQ wir /�1.$11,4U
6
•a ity/Owner Name Facility IDN(if applicable) 8.Certification:
/z9„1.0 iyidfilicfraiz.p r,��/14 X "+� ff'�"21
Physical A dr ss, ty,and Zip /� �1., 173, & Celure Contractor or Well Owner Date
By signing this form, 1 hereby certt&that the well(s) was (mere) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 A'CAC 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 Iat/long is sufficient) 9.Site diagram or additional well details:
k,3sadt,"3 n 1 y N 1c16 55 44 S M 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
Attadi well construction record(s)Ifavailable. For multiple injection or non-water supply wells
ONLY with the same conslruction!abandonnrent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well iD/I: abandonment to the following:
"' Division of Water Resources,Information Processing Unit,
6b.Total well depth: , (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
o:
"I 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: ' (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: P,..:7210 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) .10c.For Water Sunoly&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): (ft.) abandoned.
•
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood
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 I GW-3}is needed. Indicate TOTAL NUMBER of
4165A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH _ _
7c.Type of disinfectant used:
/+',/ , D
2.1Vd1 Construction Permit#:(9i>YY ��� �' ` � ‘L—
c
List all applicable well canstrucilat permits(i.e. UIC,�rn�tate, Variance,etc.)if known 1/2 lb.
7d.Amount of disinfectant used: DE r 23 ,
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply): trtfcr ;otren Pr^'C.,9eois t,J
4141
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips oar 1
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation III Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Environmental Fill gyaos
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Put environmental fill concrete in well from bottom to top
❑Geothermal(Heating/Cooling Return) ADOOther(explain under 7g)
4.Date well(s)abandoned: .m—,A-- m
5a.Well location: �,���+ Alt( 2
` 'acili '/Owner Name Facility lDff(if applicable) 8.Certification:
+ a delcqqq
Ph sisal AW
ddresss,,}City a d Zip A 0,) nature Certific Wcll Contras or or Well Owner Date
' 1 +� By signing this foray, 1 hereby cert05'that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 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 welt field,one Inn/long is sufficient) 9.Site diagram or additional well details:
13 a44I1 a.31" N 'W S 4 4 S". 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the sane construction/abandonment,you can submit one form.
I0a. 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: iinm (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
2y 10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (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: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): /t (ft,) .10c.For Water Sunnly&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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016