Wake_Well Abandonment_20240301

WELL ABANDONMENT RECORD For Internal Use ONLY:
•
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Virgil Wilson 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 130 is needed. Indicate TOTAL NUMBER of
4473A wells abandoned:t I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4.48 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: ' , __
2.Well Construction Permit II: ,
List all applicable well construction permits(i.e.U/C,County,State, Variance,etc.)ifknown
7d.Amount of disinfectant used:' 1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaLPublic 0 Neat Cement Gr __ A Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Gr u G�l^ 3 "D,1) Clay
( g pPY) pPY4 - ;d g� Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout MARili l Cuttings
❑Irrigation 0 Specialty Grout J 1;L,24❑Gravel
-,Non-Water Supply-Well:---- = _----- - -
" '�Bentonite SI '`'( 0 Other(explain under-7g) -- - - - -
eMonitoring 0 Recovery ��e
Injection Well: 7f.For each material sele tQbdv provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
; I
4.Date well(s)abandoned: 1/11/24
•
5a.Well location: '�
KANE REALITY CORP 1 —
Facility/Owner Name Facility ID#(if applicable) 8.Certification: /� .
4321 Lassiter, North Hills, Raleigh 27609 y �'V�s✓ - ��'
Physical Address,City,and Zip gnat of Well Contractor'or•We 1 Owner Date s>
WAKE
By signing this form, I hereby cert fy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C1.0100 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 lat/long is sufficient) 9.Site diagram or additional well;details:
353 i�35 512 N —1 8 r i _t,/ 1: W You may use the back of this page to provide additional well site details or well
�/ �+%J C71 '� ! abandonment details. You may also attach additional pages if necessary.
1
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 constructionabando,unent,you can submit one form.
�� 10a. For All Wells: Submit this form within 30 days of completion of well
#.:6a.Well ID
IVIN:01- : abandonment to the following: , !
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 37.5 (ft.) 1617 Mail Service,ICenter,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 8 (in.) above, also submit one copy Otitis form within 30 days of completion of well
abandonment to the following: ; ,
none Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: _(ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 (ft.) 1Oc.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit oe copy of this form within 30 days of completion
of well abandonment to the coiinty health department of the county where
6f.Inner casing/tubing length(if known): 27.5 (ft.) abandoned. I
I
6g.Screen length(if known): 10 (ft.) 1
I ''
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
I.W Contracto Info lion: WELL ABANDONMENT DETAILSII 1
I
fl A t5(t°/' 7a.Number of wells being abandoned:I
injection or non-water I supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiplei
3 3,3 q constniction/abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): (gal)
NC Well�o�tractor Ce`�'fic ion Number
GI t6tP- I¢/.j,/ Vie- 4-S5OL, FOR WATER SUPPLY WELLS ONLY:
V `t tt I•
Company Name 7c.Type of disinfectant used: • ®®®__
2.Well Construction Permit#: k
ii-
List all applicable well permits(i.e.Cmmty,State,Variance,Injection,etc.)ijknown 7d.Amount of disinfectant used:
3.Well use(check well use): ;'
Water Supply Well: 7 •Sealing materials used(check allithat apply):
❑Agricultural OMunicipal/Public Neat Cement Gro �1, '. J Bentonite Chips or Pellets
�f Gro '+
DGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) D Sand Cement �.�,r 1�''t;1 1 �rClay
j
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout crDnll Cuttings
❑Irrigation- • 0 Specialty Grout MAR J 1 20243 Gravel
N n-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
tthtori1"ee:fe^i1 Jr ;.fir^•4 •n
onitoring ❑Recovery V
FIX
njection Well: 7f.For each meter al selectiWe@ov a ovide amount of mateerials used:
. DAquifer Recharge ❑Groundwater Remediation /5 fj.S, 5e q'tl -dip i ; /2 lb, .Apidwed 4t -
DAquifer Storage and Recovery ❑Salinity Barrier /�� TpG ��r��lc�[.�yll
DAquifer Test DStormwater Drainage os I, 1
❑Experimental Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer j, r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) t
oC ICt,� sttrCitlz. .�'slit1•9e pots VieLeZ -�.-
aI131a� � I 1 0 lv
4.Date wel(s)abandoned: rCiVitItier 0/4_ I,t,t' 'wet 1,6thA f irntt i t I' -f
Sa.Wel location: 5ut/(rGL�
Ns ( Ca., 0-oovioi "
Facility/Owner Name Facility MP(if applicable)
8.Cert• anon•
l aI t R I Li, MOrrssi wl�ei /V 4 ‘ ,_,,2 41: gi 13/2-
Physical Aiddrss,City and Zit)? Signature of ertified Well Contractor or Well Owner Date
10e e_ LCH , 0" ' '2 43 n By signing this form, I hereby cert/'that the well(s)was(were)abandoned in
County tt Parcel Identification No.(PIN) accordance with ISA 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 ,
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
B You mayuse the back of this page to provide additional well site details or well
j, Sb�v I8 N �, �tl23 W abandonment details. Yon 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 construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ur t IA)> 2-3 abandonment to the following:
6a.Well ID#: ,
t Division of Water Resources,Information Processing Unit,
�( 1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: (ft.)
" 10b.For Infection Wells: In addition to sending the form to the address in 10a
V.y above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: v (in.) abandonment to the following:
/
j Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: �� ` (ft.) 1636 Mail Service CeP ter,Raleigh,NC 27699.1636 •
i
3 IOc.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit'one copy of this form within 30 days of
• /L completion of well abandonment to�tfie county health department of the county
//1"{ /T where abandoned. ,
6E Inner easing/tubing length(if known): (ft.)
6g.Screen length(if known): i (ft.) 1
•
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELLABANDONMENT A NDONML'{NT RECORD For Internal Use ONLY: L'
1.Well Contractor Info ation: WELL ABANDONMENT DETAILS
; �A Note, 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or ell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I
IVV vr�ii Ciruuautu i:cuiiadUim1 vwLwu - - .
r li, I . �_ t.1all !' I i_AV .�JJl I.F0R WATER SUPPLY WELLS ONLY:
7e.Type of disinfectant used: 411 111 \''
Company Name `�,
2.Well Construction Permit#:4 W t 1 r S 65 o - " ` ! 4
List all applicable well construction pernnis(i.e.UIC,County,State,Variance,etc.)tflaiown 7d Amount of disinfectant used:
3.Well use(checkwell-use):
I 7e.Sealing materials used(check all that an v):
Water Supply Wcti: f❑Neat Cement Grout .Bentonite Chips or Pellets.
❑ tta uucpUPublic
[]Agricultural - --_ .� .� ..•._-,-.. r, c....,+r�o...Pnr!'�nnt : 0 Dry Clay❑Geothermal(Heating/Cooling Suppfyj tyttesin'eutiai r.aiv,:�t•t'•;.��.e--,
El Drill Cuttings
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout
❑ 0 Specialty Grout ! 0 Gravel
Non-Water- aon Supply Well: Slurry 1 0 Other(explain under 7g)0 Bentonite
❑Monitoring ❑Recovery
Injection Well: ,7f.For each material selected above,/ provide amount of materials used:
[]Aquifer Recharge 0GibundWater Remediation ,:bei 1'i n i - r �t?�p!�ii
•
:,_ ❑Aquifer Storage and Recovery OSalinity Barrier ,l �f� ���pli
❑Aquifer Test ubrormwatet ua, diagv `� _ . 'I
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of theta ndonment procedure:
OGeothermal(Closed Loop) ❑Tracer jC4
(i11,1
� �1'j'�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
FXt.... .oL.:i; �VEta..
A.Date well(s)abandoned: 4 4 b ;
MAR 0 1 2074
52-Well location:..- • µ_w ..._ :, •
Na>n l� N f I,S i Ittfo.kr, ,, -g UFO
Facility ID#(if applicable) 8.Certification: / 1 �t T )"2
Facility/Gamer N me �� /� t
i CI v 4 FrelIcL era gd)t jlc 'A,�c I/ t) Pe r l
-Physical Address,City,and Zip
5i„.Ile of Certified Well Contractor or Well Owner Date
\Jc kL '4 1' ,'.3 4 By signing thts form,I hereby cei t that the well(s) was (were) abandoned in
.County Parcel Identification No.(PIN) accordance with.15A NCAC 02C.0 l0(or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latium anti rouguu uv in.,. � W�.. � -••-._-
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page,td 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)ifavallable.For multiple injection or non-watersupplywells
ONLY with the same constn ction/abandonment,you can Mibinit oneform. 10a. For All Wells:- Submit.this form within 30.days of completion of well
abandonment to the_followiiT- ,
r;a_wPn!IMP
Division of Water Resources,Information Processing Unit,
5 1617 Mail Service(enter,lta i
leigb,NC 17659 i i i
6b.Total well depth: (ft•)
lob.For Infection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this:form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
::6d Water level below ground surface: a 0 (ft.} 1636Mail Service Center,Raleigh,NC 27699-1636
a •t tue:.i or water�untnv rsc tmectiou wens: m amnion.to sewing me torte to me
6e.Outer casing length(if known): t t } t"t address(es)above,also submit one copy of this Cum!,.ill.a 33 day:,r..fc="t"'^a
a of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.)
abandoned.
6g.Screen length(if known): t 1l cL' (ft.)
Form CW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-32-201 G

WELL tiDtil\irviliVIE.lr 1 IVE .,ULVJ For internal Use ONLY:
i I
1.Well �Contractor1t Information: WELL ABANDONMENT DETAILS
Y l ®l V if
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) welt'construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of'
. • art i A •
wells abandoned: @• 1
1;,:,vrcn'Conti sctu,���rruruuutrn vmaucr =�+ I -:-. •.."••...•- "'--�
6 raat ®6)>�i U �t �� FOR WATER SUPPLY WELLS,ONLY:
Company Name 7c. of I
2.Well Construction Permit#: QV" . 0 a ft. a 015 Type disinfectant used: ih h
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown ' /
•
7d.Amount of disinfectant used:' .i 6- e I
iD.'i4
3.Well use(check well.use): '
Water Supply Well: 17e.Sealing materials used(checkall that.ap v): •
Q lieuiiulai O' unieipautvouc .•`u Neat cement urout ilentonite Chips or Pellets
•0Geothennal(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
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g).
❑Monitoring ❑Recovery. • ,
Injection Well: t 7f.For each'material s ected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation -1 4 7 bags b e fAiv 1(
`.Uitquifcr Siorage ant i ecovery uSaiinity Barrier efe ®q b a
❑Aquifer Test ❑Stormwater Drainage t ,
•
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the ab ndo went procedure:
OGeothermal(Closed Loop) OTracer
f
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) r� f ( �
,V !
�] i I'— ,, - 1 f(7.
iL
4.Date well(s)abandoned: (3.j 15 v"0 I � s `"'�� i ifs
MAR 0 1 2024
Sa.itiei lo�ywc�ation: r�l�p/D( c 1 1
V V VI 11 WVl V'�,�� Inforif z,..n?rrf: eo;%,raV
Facility/Owner Name Facility TD#(if applicable) 8.Certiileation: I. ��y+ M. 4
Lia.i a crbOtto dr. Rqleli, ricll , P f - !_- : 3.3
Ph sical Address,City,and Zip .' Signal) of Certified Well Contractor or Well Owner Date
}
�'eK�" By signing this form, I hereby cert0 that the well(s) was (were) abandoned in
unty Co - Parcel Identification No.(PIN) accordance with 15A NCAC 02C:01100 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:
N 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)ifavailable.Formultiple injection or non-water supplywells
ONLYwith the same construction/abandonment,,you can submit one form.
10a. For All Wells: Submit this 1 form within 30 days of completion of well
6, WeititriPt abandonment to the following.•
. I, I
fivision or Water Resources,intOrmation Processing Unit,
6b.Total well depth: B 5'$ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
f_ IOb.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (P (in.) above, also submit one copy of{his form within 30 days of completion of well
abandonment to the following:
' !I
Division of Water Resources,Underground Injection Control Program,
6d:Water level below ground surface: (ft.)
1636 Mail Services Cnter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.)
� 1 VC.HUI'W ale!'JUpr11Y 4Y IIIJCL't11/11 W e118: III aUUIUUII lV SCillllllg we IUIIII Wine
addtess(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): a (ft.) abandoned.
6g.Screen length(if known):• tii`a. •qft)
Form CTW.-30 North Carol inaDepartment oTF.nvironmental Quality-Division of Water ResourcIes Revised 2-22201-6

WELL ABANDONMENT RECORD For Internal Use ONLY: 1
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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
ry 4 A wells abandoned:5: 0Y1t"i 1 I
.,•:,TV-kill LUlllUUi.Uit C ltilicalluil IV UIilU1i1 ••• - c , ,e
CA r a a? Pi"IV VI 1( S I41VVt? 04 FOR WATER SUPPLY WELLS',ONLY:
Company Name pp_
W P 1 0 M a� 7c.Type of disinfectant used: u I'1
2.Well Construction Permit#: I
List all applicable well construction permits(i.e,UIC,County,State,Variance,etc)ifla own r PII
7d.Amount of disinfectant used:, I .
3.Well use'(check well use):
Water Supply Well: I le-Sealing materials used(check call,that aoo vl:.
❑Agricultural ❑ unicipal/Public 0 Neat Cement Grout I tif Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) BdResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout I 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: la-Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery I
Injection Well: '7f:For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 'a C I L Q_.,.�., -,m-G. :2, I ,,, s
❑Aquifer Storage and Recovery ❑Salinity Barrier a M 1 v° I —L'a �'
❑Aquifer Test ❑Stormwater Drainage hta I p I GA.� he tvire:h l to
11
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer G
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) CA It.,R '.0 (tu( •
4.Date well(s)abandoned: 1 ' 111 ':`,3 W
MAR 0 1 2024
Sa.Wee'il'ttocanon: �y w . ,
1g`Ccligfd 816W6,S2y iC,WSKv ti,nLir(.rw.c•tr':...t'14..4:1Un:.
Facility/Owner Name Q rr Facility ID#(if DiNQISOG
applicable) 8.Certification:
likl oo� 5fY (h ..2110111 5 9 5 ' .' :%'' %" fi ;,/' t),—/ 1- 3
Physical Address,City,•and ip Sign•j e of Certified Well Contractor or lt-;g-sin
l Owner Date
WI(t i-04g111161 4 5 By signing this form,I hereby cert0 that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) acc»rdctnce with 15.4 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 recordhas peen provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N 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 records)ijavailable.For multiple injection or non-water supply wills
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
6, tvpn.enn, abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:_ _ _ _(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:. (ft.) Division of Water Resources,ILJnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): l ,�uk (ft.) oe.ror vvater mu DM a'mecuun IN cm: ill annu mn to sewing me loan 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 easing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): .... 1°'•(ft)
Form GW=30 North Carolina Denaiinlent ofF.uvironmental Ounlity-Division of Water Resources I Revised1-22-2016
l

WELL ABANDONMENT RECORD For internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS '
• 070 A. P?J3 it, 7a.For Geoprobe/DPT or Closed-L I op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) weirconstruction/dIpth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
' c 44 r A wells,abandoned: ' 1
1
wc,wuu-wuua%U .:.i:unicar a wumuer •• .�
r a kl fObie, VI(1,I 1 if i)ctiwf Co, FOR WATER SUPPLY WELLS ONLY:
Company Name
.1 t 7e.Type of disinfectant used: V t ill
2.Well Construction Permit#:6 t 4 I(L111.3 "' )•D 41 '
List all.applicable well construction perndts,(t.e.UIC,County,State,Variance,etc.)if known : eI j,b
7d.Amount of disinfectant used: I( ,it,
3.Well use(check we'll use): i 1
•
1 Water Supply Well: 1.7e.Sealing materials used(check all that apnl ):'
' ❑Agricultural ❑ unicipal/Public 0 Neat Cement Grout ' Vbentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) I{ esidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 1 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ;❑•Bentonite Slurry 0 Other(explain under 7g)
- [Monitoring ❑Recovery. I
•
Injection Well: . "7f.Tor.each material selected above,provide amount ofmaterials used:
., ❑Aquifer Recharge ❑groundwater Remediation ��y--aJ L..1e�1i#�. -
_
DAquifer Storage and Recovery OSalinity Barrier t y r, t ...I t r r
❑Aquifer Test ❑Stormwater Drainage all
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief des ription of theabandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) f❑Other(explain under 7g) - l q l i, .fitted_
, !
4.Date well(s)abandoned: Z.- U'b '_-.%11 ' :' r-- ' . f=., --
, .... "-- �-t
5a.W` Iell location: yr ) MAR 01 20Z4
illlity��,/Owner Name FacilityTD#(if applicable) 8.Certification: trgot�{ tip, • 4 U
Fac
4'1OG
JO Freh� I Rq I N G )1('a, ? ,. �34 9.-�� �`f
Physical Address,City,and Zip 1 /' Si' of Certified Well Contractor or Well Owner Date
:DTek e.) I 1 By signing this form, I hereby eertify that the well(s) was(were) abandoned in
County Parcel'Identification No.(PIN) accordance with 15A 1 TC.AC 02C.?100 or 2C.0200 Weil.Construction Standards
and that u copy of this record Has beerproviued iu irre welt un%iler.
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:
N 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.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supplywells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit thi§;form within 30 days of completion of well
• xrt WWeWIng• abandonment to the following:
(ilvisro0 or'water Kesources,information rrocessing unit
6b.Total well depth: • 0 (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: ri1 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: .
it
o Division of Water Resources;Underground Injection Control Program,
'' 6d:Water level below ground-surface: (ft.)
1636'Mail Service itenter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): F ) (ft,) we.cur rrarer auupsv CIL usrecuun r,eua: Ill auuuwu w scuuwg ule ruiin-tea
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 1 as (ft.) abandoned.
6g.Screen length(if known): r.,i. �"(ft)
Form.CrW-30 North Carolina Department of Environmental Duality-Division of Water Resources Revised 2-22-201G
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rt, 1
WELL ABAND.ONNIEN.T RECORD For Internal UscONLY: ( 1
• This forth can be used hat single or multiple wells D •
I.Welt Contractor Information:. \ •WELL ABANDONMENT DETAILS'
Brian.Ewing . . - 7a.Number of wells being abandnuerI:it -
%WitCocrraclorN3me(oruallowsupc.sanallyalranJnniu;xononldall1erpropeny) For rrigople. Infix/far ar mor-wateii !strpply wells ONLY with ?!e some
cariarection4rbamlmiment,1JN cNP snlutut one.juror,
4240-B
'7b.Appro imate solemn:of water rent:lining in well(a): . (gat.)
itiC•We11 ContracmorEeilifcntion Narita i-i I
SAEDACCO FOR WATER.SUPPLY WELLS OritY:
- -
tympany Name 7e.Type of disinfectant used: . I i
2.WettCousavction Permit#:r , I
List all fwtheople wlllurmire(i.e.Cvsor',Sure.#'adaia.httOt•tiar;atbt Pf,Gmkrr 7dL AntaW.nt of dlsinfecttinfltstil:. •
•
3.Well use(checkwell use): -
• Water.Suppl.Well: 70-Scaling materi;dsused(check all ilia t apply):
❑Agricultitiat tJhhinicipallPublic 50 Neat Cement Grout . , I ❑13crdonitc Chips orPcllcts,
: . ❑Geothermal(HcatingiCooting Supply) . ❑Residential Water Simply(single) '❑S411ki Cement Gmut , 1 0 Dry.Clay .
❑htthistrialiComntcrcial ❑Residential Water Supply.(sbarcd). El ConcteteGrout j I El DullCuttinls
0inigati8n. El Specialty Grout • , 1 ❑Gravel
N -Vatcr Supply Welt: - - [1BentoniteSlum I. ' ❑Other(explain tinder 7g)
lMouitorbte . IJRecovety 1,
Injection Well; • 7f.For each material selected aho!r,''pro ide amount of-nnitcrialsused: •
❑AquiferRecharge. ❑Gmuisdanler.Rentediation Neat Cem.:471b-,Wtr:3ga1. j, , Sand Cerq.:lb ,Wtr:gal.
❑Aquifer Storage mid Recovery DSaliriity Barrier -
1DAguifer Test ❑Slomnu ter.Dntitiage • I I
DE cperinrerital Technology OSubsidetxe Control 7g.Provide a brief description of the'abandonment procedure:
❑Geothemlal(Closed Loop) . ' CITracer ' f •
TREMZ GROUT.FROM BOTTOM TO, SURFACE
DGeothenmt(Heating/CM:lingReturn} . DOther(ev'plainunder7tt) I• - -1 ! ,._._,,,,.
, l L,:L L)
4.patewrU(s).abandoncd:2-7-24 I
. 1 ; MAR a 1 Zn7Q
Sa.Well location: i
,• ..
tcl,z:ram:::, : r-:•�,:•.•:�t1R�
Holly-springs Exxon-- Quality Food Mart - " I' r�',r, ' '
Faeilii}yewmr Name Facility IDS(ifapplicabic)
.S.Cetlilicatigit: �
•
300,N:'Main St. Holly Springs', NC 27540 Brian... Ewing I 2/14/2024
Physical Addmss.City.and Zip Si me of enifuvl Well Contnnlnror-r.°ell astir Date
Wake - .•_ fly signing this firm 1 hereby certifj+ Gat the well(s)was(were)abandoned in
Comity Parcel Id nllltcfUnu No.(PlNj accordance with 15A:\CAC 02C,0100kor 2C.0200 II Lii Constiauc(ron Stiaarlamis
'and that a copyoflfris record Irasbeeil provided to the well oivner.
Sit Latitude and longitude in degrccslininittcslseeends•or decimal'degre s. l
(ifaeIl field,one tin/loilg is WI-tete:a) 9.Site dlagrant or additional well details:
• . You nuag use the back of this page to provide additional'tell site details or well
•
N - • - SY .abaudoiunent details.,You may also attach additiotrat pages if necessary'.
•
CONSTRUCTION DETAILS Olt WELL'S)BEING ABANDONED ' SLIBhiTTTAT.INSTRUCTIONS
l I l
:itln6 trz11 crtahn ifika manila)if available. For mulnple injection's'raun•nrtta7•supptp - - - i; l
wells ONLY us the sow ruy.corettmdubareloyitent l UN con submit are fools. 110;r:liar All•\Vclis: Submit•this form wit in 30 day,.of completion of well
6s.Welt IB§iTMW71 . • abandonment to the fallowing; '
• Ditisian of WaterReminiers,Information-Praclssing Unit,
41h Total.av'ell depth: 25 •• (ft.) 16I7 Alai!Service Center,Raleigh,NC 27699-1617 .
Inh.For In'cello':Wells in addition to sending the form to the address in Ilia
6c.Borehole diantetcr:2.25 (in) above.also subunit one Copy of this fonii within 30 days of completion of well
abandonment to die following:
1
Division of Water Restiurces,Underground injection Conetvl Frogram,
60,Water tercl.bciow ground surface: (!L) 1636 Mail Service Ccatcr,Raleigh,NC 27659-1636
IOe For WatarSurinh•:C Tinleetlol SVells: In addition•to sending the Pm!to
. 6e.Outer.casinglength(if kilowatt (RJ tine address(es) abase, also submitl'one copy of this fonts within 30 days of
completion-of well abandonment toiltle county health department of the county
6L Inner casinaltnbmg length(if lmnwn);15 (ft.)
where abandoned„
.6g.Screen length(if lnoon n):10 (ft.)
Form GtV-30 North Carolina Dcpannxm mm Natural
of ant N al Reisastes-Division of WarerRcsOu In.s Revised Aqua 2013
1
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t .•: .
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WELL ABANDONMENT RECORD For Irstrnal•Ose ONLY;
'MIS folio can be used for single or onthipte wells.
.. . '•
it,.Wen enamour Information:. WELL ARANDONAIENT DETAILS!
. .
Brian'Ewing . . 7a.Number el wells being.abandonedIi•1 -
WnliConiraciorNanie(or ntlf num'lx:nonallialimia Wag unit on Itisikr propcm.) For undople otieetton or IkiN,11'arerf IsOply wells ONLY wsb lire. s01110
consreireneniebanaViiiinair,pin can.substif oneinin,
42 40-B
7b.Appntiimate volume of natty.reWniining in well(s): (4011)
NC Well ContractorCeil ilk:Ilion Wroitcr •., i ' .
SAEDACCO . _ . FOR WATER SUPPLY WELLS ONliVt.
1. !
CoMpani Name •7e.Type of disinfectant used; I, I , . •_ „,
. i.
•
I WeR•Constraction Penult el:, , 1 .
.. 1
. -Gut qiInpyInvIie u•ell permits fie.away,Snee,Variative.Injoction..olci)tanner, .
Id.Athotint of disinfectant Used: I' I
• 3.Well use(check well.use):
.
• WaterSupply Well: ' 7e.Sealing materiais-used(cheek all that apply):•
•
°Agricultural 0MtinpaltPahhe. Cl Neat Cement Grout l' 1 0 Bentonite Chips or Pellet's
• Ulticothennal(Beritingtooling Supply) PResideraiat Water-Supply(single) , 0 Sand.Centent Grout • II I El Dty Clay
I I
phidlisidalICOmmucial OReSidentitd Water Supply.(shared) a cOlqGmut 1, i 13 DrillCnitings
• tlinigation V.• . . . . • . . El SPechthy Grout ' 0 Gravel Non-Natcr Supply-Well: • . El Benlonite Slurry ' Cl Other(explaistooder 7g)
ISIMonilotine• , EIRecovety . . • . l' I .
Injection Welk • ' ' .7f.For each Material sciecte l*above;'provide amount of litakilOSIIISqd: .
0Amdfer Recharge 0Grinnidualer.Ftentediation ' I
Neat Cem.:471b ,Wtr:4gal. I i Sand Cem.:lb ,Wtr:gal. .
. 0Aonifer Storage and Recovery 0Saiini1y Battier . ' •
. ,
0Agnifer Test . OStonnwater.Drainage •
, • ! , .
0Experinterial Technology 0Subsideme Coning. 7 .Prosidea brief description of thObantlonment proettiute: -
0Geothennal(Closed Loop) - 0Tracer
TREMI.GROUT FROM BOTTOM TO SURFACE . .
• 14Geothennat(treating/Cooling Return) . 0011ter(explain under 7u) .
1, ,I
4.Date well(s).abandoncd:2-7-24 MAR .a 1 21174
5a.Welt location:
. • , I •
• • '-:---.'!;..71 .:‘-_-.7...-..Z.: ,-
- I tin.. ...L.. . .,... .
Holly.springs Exxon•- Quality Food• Mart - • . - • .
' 1 Dwoinok-;
a ,
tion: , 1
Fecilityithvner Name Facility UM S.Certific
(iFupplkablc) i ;. •
-.
300 N. Main St. Holly.Springs, NC 27540 Brian. Ewi iig 1 - 2/14/2029
Plgskal Adtbc.s.City,and Zip Silltrilint.orp:itilkd Well Coltrogiort:g•-...,4110-mur Dalo •
Wake ,
13y signing ibis firm; I heneby certij y-tliat the welltsi Was(ireiw)abandoned in
• Catnliy • PalrelldeffigiiiiintNo.(PINj pecintlance with Mil NOW 02C.0/l101.or 2C.:02Oft Irell:Condniction air:dards
• and thin a copy of this record bat been provided lathe well owner:.
Rt
.ILatitude and longitude in degrcestutinuresfsce ,onthsbr detintali'degrce: • • I;
, I
(iretil fled,one latiinitg is strfiekis) 9.Site diagram or additional welt details:
' . .. . You ma).-use the•back of this page to pros additional well site details,or well
. •
" N . - W abathioiuttent details..You may also'attach lidditiowattiages if necessary.
• i ! ' .
CONSTRUCTION DETAILS OF'WE LUS)BEING ABANDONED ,SURMfITAI.INSTRUCTIONS
mock hill eonsinietian nktorillS)if[Wadable. For lradrip/e infection'or adn.wolir siMe ' - . • • 1. r .
wefts ONLY Ilith the count coptstrarnwigninoronaientoon can nrintaions Ann.' Oa.For All Wells:• Submit-this thrill within 30 days of completion,of well
6g.Well IDthTMW-2 - •
gbatuloomeot to thOfol1oWing; i '
• ' Division al Water Resources.lalormatiom,Procting Unit,
6h.Toral well depth: 25 . (ft
.1617 Mail Seilice Center,Raleigh,NC 27099161.7
.) , .
• •
10h.For Iniection Wells: In addition to sending the loon to the gclthesi itt lOa •
abow,also submit one copy of this,fon)]within 30 days of completion of well
6e.Borehole diameter:2-25 (itt.) abandonment to the following; 1:
.
Division of Water ResouretN,Utmergrtuntd Injection cocain'PrOgratn;
6d.Water level.below ground surface: - (R.) t636 Mail Service Center,Raleigh,NC 276994636
I 'I
• • 10c.For Water.Suriniv&Infection l,Wens: In addition to sending the form to
Ge.Outer easing leap%(if leanwn):. . (fil:) the address(es) ?hove also submit Otte-copy of this than within 30 days of
completion-of well abandonment ed the county health department of the calmly
• where abandoned.
6f.tuner easing/tubing length(if[mown);15 . .0t.) I •
• 1
- 6g.Semen.length(if known):1° _M.) ,i
Rim GW-30 Nolo,Carolina pep-tiara a Tana:anoxia and Natural Resotetes-Division of Water R owns " Revised Aqua 2013
'I
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