Wake_Well Abandonment_20240205

WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E. Meyer 11
7a.For Geoprobe/DPT or ClosediLoop 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
2527-A 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 7c.Type of disinfectant used: H •
2.Well Construction Permit#: GW-11282-2023
List all applicable well construction permits(i.e.(IIC,County,State,Variance,etc.)if known 8 oz.
Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(checklall that apply):
0 Agricultural 0 Municipal/Public S Neat Cement Grout 0 Bentonite Chips or Pellets
•
0 Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial _ ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation 270 gallons
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
IGeothermal(Closed Loop) 0 Tracer
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pump pulled from well, well sounded, 4" liner present
chlorinated, filled with neat cement
4.Date well(s)abandoned: 1/19/2024 grout to -3' bls; top 3' casing removed
5a.Well location: .
Peak 360 LLC na ; ,
Facility/Owner Name Facility ID#(if applicable) 8.Ce ifreation: `"� �'(Lu � •�...
7809 Jenks Road Apex, NC 27523 �„ J4 ;�--F La 0 5 2024 1/19/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Wcll Owner Date
Wake 0722888770 In""'i`,. n .471 i✓ ;:.
By signing this form, I hereby certify+that iiii:•
veff(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C,0I00 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: 1 '
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.75191 N -78.90241 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)ifavailahle.For multiple injection orison-water supply wells
ONLY with the same carstr:rcllon/abmtdonutwu,you can submit one forth. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1 abandonment to the following: i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 251 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Inflection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6.5 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1
6d.Water level below ground surface: 90 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 30 (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
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): na (ft.) abandoned.
6g.Screen length(if known): na (ft.)
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT Il RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E. Meyer 7a.For Geoprobe/DPT or ClosedLoop 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
2527—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 30 (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
H
2.Well Construction Permit#: GW-1 1 28 1-2023
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known 2 oz.
7d.Amount of disinfectant used:
3.Well use(check well use): l
Water Supply Well: 7e.Sealing materials used(checkiall that apply):
❑Agricultural 0 Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) I'Residential Water Supply(single) 0 Sand Cement Grout U Dry Clay
❑Industrial/Commercial - ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ 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 . 3.5 yds
❑Aquifer Storage and Recovery ❑Sal inity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
IRGeothermal(Closed Loop) ❑Tracer
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pump pulled from well,'well sounded
chlorinated, filled with'sandy clay, compacted
4.Date well(s)abandoned: 1/24/2024 top 3' casing removed
5a.Well location:
Peak 360 LLC na rT
Facility/Owner Name Facility ID#(if applicable) 8. 'fication:
7825 Jenks Road Apex, NC 27523 ,- �, Fro �� Z024
1/,24/24
j
Physical Address,City,and Zip Signature ofCer`tified Well ContractoTpif.gt11Ownail : ';}: " 'Date
Wake 0722886419 ',e��; ,-,v
By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C 101'00 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:
35.75166 N -78.90380 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 necessaty.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailahle. I"or 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#: 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 24 (in.)
abandonment to the following:
Division of Water Resources,FUnderground Injection Control Program,
6d.Water level below ground surface: 22.5 (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniectioni Wells: In addition to sending the form to the
6e.Outer casing length(if known): 24 (ft.)
address(es)above,also submit one 1 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): na (ft.) abandoned.
6g.Screen length(if known): na (ft.)
Fonn 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
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-30 is needed. Indicate TOTAL NUMBER of
2527—A wells abandoned: l ,
0
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
GW-11281-2023 7c.Type of disinfectant used: HTf'I
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.)if known
7d.Amount of disinfectant used:'8 oz.
3.Well use(check well use): I
Water Supply Well: 7e.Sealing materials used(checktll!that apply):
❑Agricultural ❑Municipal/Public IN Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) III Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slur
❑Monitoring ❑Recovery ry ❑Other(explain under 7g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 300 gallons -
❑Aquifer Storage and Recovery ❑Salinity Barrier
•
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
GGeothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pump pulled from well, well sounded
chlorinated, filled with neat cement grout
4.Date well(s)abandoned: 1/24/2024
top 3' casing removed
5a.Well location:
Peak 360 LLC na •
't L,L.i, @y Fn-.,,.. .
Facility/Owner Name Facility ID#(if applicable) 8.Certification: --
7825 Jenks Road Apex, NC 27523 —�w cij F�a [G241/24/24
Physical Address,City,and Zip Signature of Certified Well o ntract¢ 11;Ottner;a,•-,..,r..7,:,_ eats,..
Wake �,R w�,...:10,. ::....., ,,
0722886419 I �,t:; _:f.,,
By signing this form, I hereby certify that t)se well()Ives (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.01100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.7514593 N -78.9035652 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(.$)tfarailable.For multiple injection or non-water supplywells
ONLY with the same consiruction.abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 2 abandonment to the following: i,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 179 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6.5 (in.) above,also submit one copy of this 1form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 55 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 25 (ft.) 10c.For Water Sunnly&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): n a (ft.) abandoned. 1
6g.Screen length(if known): na (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
,