WQ0013181_Well Abandonment Record(s) (GW-30)_20240205

WL L A-HANDONMEN 1 -ELU" For Internal Use ONLY:
1.Well Contracto Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed Loop Geothermal Welts having the same
Well Contractor Name(or well owner personally aband well on his/her property) well construction/deptb,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
LA
I q —A wells abandoned:
NC Well onaacror Certification Number 7b.Approximate volume of water remaining in we11 s): _(gal.)
�Qk' D�M -
CompanyFOR WATER SI7PPLX WELLS ONLY:
Name 7c-Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i e.(AC County,State, Variance,etc)ifknown I r�
7d.Amount of disinfectant used- /a- L?�' ( U�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that appl
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout MBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
No ater Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation (,C) u; Rom`\vk
❑Aquifer Storage and Recovery ❑Salinity Barrier �
❑Aquifer Test ❑Stormwater Drainage
❑ExpetimentaI Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothennal(Heating(Cooling Return) ❑Other(explain under 7g) GUr %)
4.Date well(s)abandoned:
Sa.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Physics}`Address ity,and Zip Signatuff8RCertified Well Contractor or Well Owner Date
By signing this form,I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(P]N) accordance with I5A NCAC 01C.0I00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner_
5b_Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
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_
�304, 9r1 � - qpl 13&
ONSTRUCTIO AILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form
ly� 10a. For All Wens: 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: UP 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 (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
6e.Outer casing length(if known): (fL) 10e.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
6f.Inner casing/tubing length(if known): t.) 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 Contriactor Information: \ WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(orkwell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
i f go
_ wells abandoned:
NC Well C ntractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Ct G J t; 1 9 t FOR WATER SUPPLY WELLS ONLY:
Company Name �
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable wll construction permits(Le.U1C,County,State,Variance,etc.)iflrnorvn t
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 El Neat Cement Grout en'.
Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commcrcial ❑Residential Water Supply(shared) Cl Concrete Grout ❑Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
No,%Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
�Nlonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 0 C) LB qe,\l fA�
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) L?
LB
4.Date well(s)abandoned: C !d v
,L
5a.Well location:
at��1n� C'_1
Facility/Owner Name Facility 1D#(ifapplicable) 8.Certification:
')V< L'—/
Physical Address,^City
n d Zip Signature of Certified Well Contractor or Well Owner Date
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
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 laUlong is sufficieryt) 9•Site diagram or additional well details-
IMMMMW 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_
� s
CONS RU I NfR T O OF WELLS)BEING ANDDONED SUBMITTAL INSTRUCTIONS
.4naeh well construction reeord(s)ifavailable. For multiple injection or non-xatersupply 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#: #Z abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
101b.For Iniection Wells: In addition to sending the form to the address in l0a
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: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (D) 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): (ft) abandoned.
1 i
6g.Screen length(if known): !:a 1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016

. � I i.Well Contractor Information:1 WELL ABANDONMENT DETAILS
11
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning welt on histher property) well constnlction/deptil,only 1 GW=30 is needed_ Indicate TOTAL NUMBER of
0� wells abandoned:
NC Well Contractor Certification Number � ) D
7b.Approximate volume of water retraininginwell(s):�_(gaL)
a 0 ��/ � V" �11 FOR WATER SUPPLY WELLS ONLY:
Company Name 1
7e Type of disinfectant used:L► ��" C h�0�1 yl-t,.
2.Well Construction Permit#
Liv as opplicvble x 11 ronspaction perndu G 117C.3.Well use(check well use): Catorty,State-laiia �n etc if;� m
)
7d.Aonat of disinfectant used: L 6
Water Supply WeIl: 7e.Sealing materials used(check all that app
❑Agricultural ❑Municipal/Pu blie ❑Neat Cement Grout Bentomte Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commcrciai ❑Residential Water Supply(shared) ❑Conetde Grout ❑Drill Cuttings
Ellnigation ❑Specialty Grunt ElGravel
No ater Supply Well: ❑Bentonite Slurry
Monitoring ❑Reco 0Other(explain under 7g)
very
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation (` ) r
❑Aquifer Storage and Recovery ❑Salinity Barrier — ( h UC fY( �j OW
❑Aquifer Test OStormwater Drainage 1
❑Experimental Technology ❑Subsidence Control
❑Geothermal �P) ❑Tracer
Closed 7g.Provide a brief description of the abandonment procedure:
(
Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) 6u C I
4.Date well(s)abandoned:
52.Well location:
'-�ou'r a Un- �c.1�.00IS
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
Physical Adds,City,and Zip "
Signature of 'fled Well C ctor or Well Owner pare
County By signing this form,I hereby certify that the well(.-) was(were)abandoned in
ParcelldentificationNo_(PIN) accordance with 15A NCAC 02C_0100 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 latAong is su cicm) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
W
��j �j 7 JJ t1 abandonment details. You may also attach additional pages if necessary.
CONS RU(.T10N� 1�LS OF WELL(Sl BEING"AB NED SUBMITTAL INSTRUCTIONS
Attach well construction records)#iFmilable-Formtdaple injection or non-µ ateravppl�x e11r
0AZY,A*h the same consuuctionlabandonmae{you can submit one form.
10a. For Ali Wells; Submit this form within 30 days of completion of well
62.Well ID#- / abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Tote!well depth: (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. (uy) 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
6e.Outer casing length(if known): 00 10e.For Water Srnriv&Injection Welts: 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 comity where
6f.inner casing/tubing length(if
known)*. (R,) abandoned.
6g.Screen length(if known):