Wake_Well Abandonment_20240306 (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple well,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper Its.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY H ith the smug
3322-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): 0
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 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 ❑Neat Cement Grout O Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Ce re,t�:Gro/it'L �.. ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
ObTigation ❑ SpecialtyGr*AK 0 6 2024 ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery 4niCCi1�: �'-" '•;UAIA
Injection Well: 7L For each material UlikOdIlliove,provide a mount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips: 64lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g. Pros ide a brief description of the:abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled/ hydrated from bottorn-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) —
4.Date well(s)abandoned: 1/255/2024
5a.Well location:
401 Amoco Food Shop-Erwin Oil Company
Facility/Owner dame Facility lD#(ifapplicable) H•(crtification:�
2726 South Wilmington Street, Raleigh Lawrence O er --
9 9 pp 1/26/2024
Physical Address,City,and'Zip Signature of Certified Well Contractor or Well Owner Date
Wake B signing this form, I hereby certify that the wells was
Y Srr S .f Y .f' () (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:
(ifwell field,one la0cing is sufficient) 9.Site diagram or additional well details:
35.745578 N 78.645986 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)if available. !•br 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#• MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 40 (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: well I.D.=2.0(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
D Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: Dry 00 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c. For Water Suooly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
completion of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if known): 25 (ft.) where abandoned.
6g.Screen length(if known): 15 (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

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:
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 HTH --,
,A, 7c.Type of disinfectant used:
2.Well Construction Permit#: G V V-110351-2023
List all applicable n•ell construction permits(i.e.UIC,Counn',State,Variance,etc.)ifkaona MAR
7d.Amount of disinfectant used: 6 OZ. t/ V ?021
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ■Neat Cement Grout ■ Bentonite 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
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 71%For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GroundwaterRcmediation 250# bentonite chips
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 120 gallons cement grout
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothemmal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn ❑Other(explain under 7 ) pump pulled from well, top 10' casing removed
down to finished floor elevation, chlorinated
4.Date well(s)abandoned: February 7, 2024
filled with 22'of bentonite chips then cement grout
5a.Well location: to surface, covered with concrete building pad
919 Storage Creedmoor Road LLC na
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
6120 Creedmoor Road Raleigh NC 27612 2/8/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 0797419113 By signing this form, I hereby certfi,that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 at-2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has heen provided to the well owner. .
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.86854 N —78.67953 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 hellconstructionrecord(s)ifavailable. Fortnithipleinjectionornon-watersupplvr,xelis
ONLY with the same construction%ahandonmem,you can snhmit one form.
109. 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: 110 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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:
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): 68 (it) 10c.For Water Suooly&Injection 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 county health department of the county where
6f.Inner casing/tubing length(if known): na (IL) abandoned.
6g.Screen length(if known): na (ft.)
Fn,m r,W-10 Nnnh ramlina nennrtment of F.nvirnnmental Oualitv-Division of Water Resources Revised 2-22-2016