Richmond_Well Abandonment_20240205 (9)

WELL.ABANDONMENT RECORD For Internal Use ONLY:
I �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 7a.For Geoprobe/DPT or Closed-Lloop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:one
NC Well Contractor Certification Number 7b.Approximate volume of water re iaining in well(s): 3 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name None
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown None
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 a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 1 ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement Grout 5 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonoite 30 Pounds ;
❑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) Grout well in place.
h
4.Date well(s)abandoned: 1-22 8t 1-23-24
'c-'f P;�--•-
Sa.Well location:
CSX Transportation-Hamlet Yard FFrD
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
803 NC Hwy 177, Hamlet, NC 28345
1-24-24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Richmond
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.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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.894380 N -79.689101 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 constructionrecord(s)ifavailable.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
abandonment to the followin
6a.Well ID#: M W-4A g:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 47 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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):
None (ft.) 10c.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
6E Inner casing/tubing length(if known): 37 (ft.) abandoned.
1
6g.Screen length(if known): 10 (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Jeffrey Grant 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
4328-B wells abandoned:
11
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name None
7c.Type of disinfectant used:
2.Well Construction Permit#: NSA I I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown None
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 a Neat Cement Grout r 11 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement Grout 5 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonoite 50 Pounds j
❑Experimental Technology ❑Subsidence Control
[]Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Grout well in place. .
Remove manhole and concrete pad.
4.Date well(s)abandoned: 1-22 & 1-23-24
5a.Well location:
CSX Transportation-Hamlet Yard
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
803 NC Hwy 177, Hamlet, NC 28345 FEo 0 5 '2024 1-24-24
Physical Address,City,and Zip Signature of Certifiedffell�G ptrdetpr or Nall: ner,J uri'? Date
Richmond ;vE ;
By signing this form, I hereby cerfzjy Mat the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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: i,
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.894380 N -79.689101 �, You may use the back of this page to.provide additional well site details or well
abandonment details. You may also at I tach 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 same construction/abandonment,you cat?submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well m#: MW-5A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 48.5 (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: 2 (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: 30 (ft.) Division of Water Resources,Underground Injection"Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I1
6e.Outer casing length(if known): None (ft) 10c.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 countyi health department of the county where
6f.Inner casing/tubing length(if known): 38.5 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1
WELL ABANDONMENT RECORD For Internal Use ONLY: I '
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Jeffrey Grant 7a.For Geoprobe/DPT or Closed-loip 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
4328-B wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name • None
7c.Type of disinfectant used. �
2.Well Construction Permit#: N/A
i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown None
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 a Neat Cement Grout 11 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout j ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery 1
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement Grout 5 Gallons
[]Aquifer Storage and Recovery ❑Salinity Barrier Bentonoite 50 Pounds i
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Grout well in place.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Remove manhole and concrete pad.
4.Date well(s)abandoned: 1-22 & 1-23-24
Sa.Well location: - r
CSX Transportation-Hamlet Yard
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: FED 0 5 [r1�24
803 NC Hwy 177, Hamlet, NC 28345 1-24-24
Physical Address,City,and Zip Signature of Certif�dWJeirt6 ii'cior or*ell'O%v e�"'" Date
Richmond G'rVQ 'G
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: I
(ifwell field,one Iatflong is sufficient) 9.Site diagram or additional well details:
34.894380 N -79.689101 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 same construction/abandomnent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-6A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 48•5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
2 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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): None (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 j health department of the county where
611 Inner casing/tubing length(if known): 38.5 (ft) abandoned.
iI
6g.Screen length(if known): 10 (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

I
r
WELL ABANDONMENT RECORD For Internal Use ONLY:
� I
1.Well Contractor Information: WELL ABANDONMENT DETAIILS
Jeffrey Grant 7a.For Geoprobe/DPT or Closed-Lo pp Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-k is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:-0-
NC Well Contractor Certification Number 7b.Approximate volume of water re aining in well(s): 4 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name None
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known None
7d.Amount of disinfectant used.
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout I ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 1 ❑ Other(explain under 7g)
FlMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement Grout 5 Gallons
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonoite 50 Pounds
❑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) Grout WeII In place.
Remove manhole and concrete pad.
4.Date well 1-22 & 1-23-24s)abandoned:
5a.Well location:
CSX Transportation-Hamlet Yard
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
803 NC Hwy 177, Hamlet, NC 28345 G:`aC:` J=a 1-24-24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Richmond
By signing this form, I hereby certify that the tvell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.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:
34.894380 N -79.689101 �t 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.
i
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple n jection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-7A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 47 (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: 2 (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:
30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
None (ft.) 10c.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 i health department of the county where
611 Inner casing/tubing length(if known): 37 (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
f ;

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JeffreyGrant I
ran 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-90 is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:-On.
NC Well Contractor Certification Number 7b.Approximate volume of water I e I aining in well(s): 1 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name e
7c.Type of disinfectant used: None
2.Well Construction Permit#: N/A : 1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown None
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ail that apply):
❑Agricultural ❑Municipal/Public 19 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation Neat Cement Grout 5 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonoite 20 Pounds
❑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) Grout well in place.
Remove Protective casing and concrete pad.
4.Date well(s)abandoned: 1-22 & 1-23-24
r..•_, .
Sa.Well location:
CSX Transportation-Hamlet Yard C_
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: FEa 0 5 2024
803 NC Hwy 177, Hamlet, NC 28345 s �.�.� 1-24-24
Physical Address,City,and Zip Signature of Certified Well Contractor orW.e!l 19%Vg6r � Date
Richmond
By signing this form, I hereby certify that the tivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.894380 N -79.689101 N 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 same construction/abandonmem,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: H MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 36 (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: 2 (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: 30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): None ( ) 10c.For Water Supply&Infection Wells:s: 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
36
6E Inner casing/tubing length(if known):
abandoned.
I i
6g.Screen length(if known): 10
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
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 7a.For Geoprobe/DPT or Closed-Loop p 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
4328-B wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water le aining in well(s): 1� (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ON
Company Name None
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.)ifknown None
7d.Amount of disinfectant used:
3.Well use(check well use): i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
El Aquifer Recharge ❑Groundwater Remediation Neat Cement Grout 6 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonoite 100 Pounds'
❑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) Grout well in place.
Remove Protective casing and concrete pad.
4.Date well(s)abandoned: 1-22 & 1-23-24
5a.Well location:
YrJ
CSX Transportation-Hamlet Yard LL
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification. rCD J J 2024
803 NC Hwy 177, Hamlet, NC 28345 ]n;:err, is a fr, ;:;w::;, ��,;, 1-24-24
Physical Address,City,and Zip Signature of Certified Well Contractor or e11- 22 Date
Richmond
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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been,provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.894380 N -79.689101 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)ifapailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonmem,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: HMW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 93 (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: 2 (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: 30 (ft.) Division of Water Resources,Und i erground Injection Control Program,
1636 Mail Service Cent i r,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
None (ft.) 10c.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
611 Inner casing/tubing length(if known): 83 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016