Wake_Well Abandonment_20240116

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 7a.For Geoprobe/DPT or Closed oop 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
2700b wells abandoned: t
NC Well Contractor Certification Number 7b.Approximate volume of water;remaining in well(s): (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorox pool shock
7c.Type of disinfectant used: p
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 20 oZ
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing mate 'ass jw-- i e%e-W a7Pth�t a rplp)tt
❑Agricultural ❑Municipal/Public ❑Neat Cement CrPoti iD" ' i I—B€ntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ❑ Sand Cement GroutJ A N 1 6l 2024 C Dry Clay
�
❑Industrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ❑Drill Cuttings
❑Irri ation ❑SpecialtyGrbvforrn,:--V 71 i'�':':'•1^,�; �gt�jjavel
Non-Water Supply _❑-Bentonite Slurry � = ` _ ❑Other-(explain under 7g) _
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Clay placed from 37'to 3"bis Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete Cap from V to t•below land surface Poured in top of well
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 20 oz of chlorox pool shock poured in well followed by filling
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
with clay to 3' bls. From 3'to 2'
4.Date well(s)abandoned: 12-19-23 filled with concrete',. ", Dirt on final foot
sa Well location: to cover concrete cap
IM LIVIN LLC na
Facility/Owner Name Facility ID#(if applicable) 8.Certifieatio
500 Grisby Avenue Holly Springs NC 27540 1-5-24
Physical Address,City,and Zip Signature ofCcrtified Well Contractor or Well Owner Date
Wake 0649907168
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 degrees/minutes/seconds or decimal degrees: f
(if well field,one]at/long its sufficient) 9.Site diagram or additional wellide'tails:
35 38' 46.88" N -78 49' 56.86" 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-watersupply 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#: W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 37 (ft.) 1617 Mail Service C Ien I ter,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 60 (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: 32 (fk) 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 Suuuly&Iniectiol 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 co 1 ty health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned. 7
6g.Screen length(if known): N/A (ft)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Usc ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E. Meyer 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute
Well Contractor Name(or well owner personally abandoning well on Iris/her property) well construction/depth,only I GW-30;is needed. Indicate TOTAL NUMBER of
2527—p wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name H T H
GW-115277-2023 7c.Type of disinfectant used:
2.Well Construction Permit#:
6' OZ.
List all applicable it-ell construction permits(i.e.UIC,County State,Variance,etc.)ijknonr+ 1
7d.Amount of disinfectant used: w i > )'
3.Well use(check well use): r �024
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural- -- ❑Municipal/Public - e Neat Cement Grout — _ ❑-Be��iila+Cltl(lslgrelLe(s�
❑Geothermal(Heating/Cooling Supply) RResidential Water SuPP1Y(single) ❑Sand Cement Grout ❑D nClaY
v�_3
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected abo i e,'provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remcdiation 150 gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
El Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(HeatinClosed/Cool ❑Tracer Pump pulled from' ' well,well, well sounded
❑Geothemtal(Heating/Cooling Return) ❑Other(explain under 7g)
12/18/2023 chlorinated, filled with neat cement
4.Date well(s)abandoned: grout t0 —8' bls; top 8' casing remove
5a.Well location:
Joey from Dover LLC na
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
3717 Baugh Street Raleigh, NC 2760f 12/19/23
Physical Address,City,and Zip Signature of Certified Well/Contractor or Well Owner Date
Wake 1725480047
By signing this jorm, I hereby cer that the tvell(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.
Sb.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:
35.83205833 N 78.58115556 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
Allach well constriction records)ijavailable.Fornmlfiple injection or non-ivatersapply nrlls
ONLY with the same construction/abandonment,you can submit one jorm.
10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#: 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (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• 4 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: c
`�
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6d.Water level below ground surface: 30 -(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,' Raleigh,NC 27699-1636
6e.Outer casing length(if known): 40 (ft.) I Oc.For Water Supply&Iniection Wells: In addition to sending the form to the
address(cs)above,also submit one copy of this form within 30 days of completion
of well abandonment to the count
y'ty health department of the county where
611 Inner casing/tubing length(if known): n a (ft.) abandoned.
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6g.Screen length(if known): n a (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E.Meyer 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 23d is needed. Indicate TOTAL NUMBER of
2527-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water iremaining in well(s):0 (gal.)-
Protocol Sampling Service,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
GW-1100352-2023 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Couno-,State,Variance,etc.)ifdmorm 16;oz.
7d.Amount of disinfectant used: i
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agriculmra] — —— -- —---❑MunicipaVPublic - - eat Cement-Grout- - ❑_Bentonite.C}iipS oralle ,,,� �{
-;
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
( ) g JA N 1 U" 2024
❑IndustriaUCommercial ❑Residential Water Supplyshared ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel iT1i0 -rR i^B .��'` r
Non-Water Supply Well: ❑ Bentonite Slurry ( P❑Other ex lain under 7 i iw;
U%
a
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected abov I e,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 200 gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
i
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well pump and pipe pulled from well(380')well sounded
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
found flee from obstructions,1 filled with neat cement grout
September 21,2023
4.Date well(s)abandoned: top 3'casing removed,backfilled and compacted
5a.Well location:
Creedmoor Road Holdings LLC na
Facility/Owner Name Facility ID#(if applicable) 8./Certification:
5904 Creedmoor Road 9/21/2023
Physical Address,City,and Zip Signature of CertifieffWell Contractor or Well Owner Date
Wake 0796497665
By signing this form, I hereby certify that the ivell(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.01,00 or 2C.0200 Well Construction Standards
een provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a cop),of this record has b
(if well field,-one lat/long is sufficient) _ _-- --- 9:Site diagram or additional well details: —
35.86443 -78.68014 You may use the back of this page to provide additional well site details or well
N W 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.Formultiple injection ornon-watersupply wells
ONLY with the same constntction/abandonment,you can submit one form.
1 10a...For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# abandonment to the following:
i
405 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Ce4 ter,Raleigh,NC 27699-1617
6 10b.For Infection Wells: In additions to sending the form to the address in 10a
6c.Borehole diameter (in.) above, also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6d.Wate'r level below ground surface: 31 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
21 l
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectiori;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 coun{y health department of the county where
6E Inner casing/tubing length(if known):na (ft.) abandoned.
na
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016