Alamance_Well Abandonment_20240311 (4)

I'
WELL ABANDONMENT RECORD For Internal Use ONLY:
` I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
i
Rawlins E Clarke IV 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-S0�is needed. Indicate TOTAL NUMBER of
wells abandoned:
NCWC 4234-A
NC Well Contractor Certification Number 7b.Approximate volume of water i e i aining in well(s):
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS Oi Y:
Company Name
7c.Type of disinfectant used: I: I
2.Well Construction Permit#: W10400614 i
List all applicable well construction permits(i.e.b7C,County,State,Variance,etc.)if/rnown
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 N Neat Cement Grout ❑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
Ohre ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ®Groundwater Remediation 3-94 Ibs bags
❑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) 0Other(explain under 7g) Three bags of 94 Ibs neat cement grout mix with water and tremie
grouted from bottom of bore hole to the top. . ;teems
4.Date well(s)abandoned: 2✓2812024
Mak 1 i 7024
5a.Well location:
trli`OIPmoUE91;ems^..,..aJmrrtiaa a M
Tarheel Army Missle Plant
Facility/Owner Name Facility ID#(if applicable) 8.Cer'rca'on:
' I
204 N.Graham-Hopedale Rd.,Burlington,NC 27217 ce F 02/29/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Alamance
By signing this form,I her certify that the well(s) 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I.
(if well field,one ladlong is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
36.0988139 N -79.4089299 W 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)ifavallable.For multiple injection ornon-watersupply 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#: IP-S.02 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (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: 4.5 (�) 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: 20 (ft-) Division of Water Resources,Ur(derground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
45 10c.For Water Supply&Iniection!Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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.
I
6g.Screen length(if known): NA (ft.)
Form GNV-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

d I.
WELL ABANDONMENT RECORD For Internal Use ONLY:
it
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 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 1 GW 30I is needed. Indicate TOTAL NUMBER of
wells abandoned:
NCWC 4234-A
NC Well Contractor Certification Number 7b.Approximate volume of water 1 remaining in well(s): (gal.)
11
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: +
2.Well Construction Permit#: W10400614
List all applicable well construction permits C.e.WC,County,State,Variance,etc.)if known
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 ❑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)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge BGroundwater Remediation 3-94 lbs bags
❑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) Three bags of 94lbs neatcrment grout mix�vith�'ate=an emie
r .
grouted from bottom of bore hole to the top.
4.Date well(s)abandoned: 2/23/2024 I K j 2O 44. I Y
5a.Well location:
Tarheel Army Missle Plant
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
204 N.Graham-Hopedale Rd.,Burlington,NC 27217 02/28/2024
Physical Address,City,and Zip Signature of Certified KVell Contractor or Well Owner Date
Alamance
By signing this form,I hereby cert ify
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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.0987107 N -79.4088471 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 record(s)ifavailable.For multiple injection or non-watersupply 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#: IP-S.04 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
4S n.)(i above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: I I
20 Division of Water Resources U Iderground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service�Center,Raleigh,NC 27699-1636
I1
45 ft 10c.For Water Supply&Iniection'Wells: In addition to sending the form to the
6e.Outer casing length(if known):
( ) address(es)above,also submit onelcopy 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 Resource' Revised 2-22-2016

II
WELL ABANDONMENT RECORD For Internal Use ONLY:
li
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed-Lo1op 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
wells abandoned:
NCWC 4234-A
NC Well Contractor Certification Number 7b.Approximate volume of water i einaining in well(s): (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: W10400614
List all applicable well construction permits(i.e.WC,County,State, Variance,etc.)if/mown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaL?ublic a Neat Cement Grout ❑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)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge 19Groundwater Remediation 3-941bs bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storrowater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Three bags of 9416s neat
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ce ment grout mix with water and tremie
grouted from bottom of bore hole to the top. V' "'' '►^
4.Date well(s)abandoned:
2/24/2024 A'
5a.Well location:
Tarheel Army N issle Plant
Facility/Owner Name Facility ID#(if applicable) 8.Certification: DW re i3i 10G
204 N.Graham-Hopedale Rd.,Burlington,NC 27217 -
02/28/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or 7ell Owner Date
Alamance
By signing this form,I hereby certify that the well(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 beA provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.0988656 N 79.4089292 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS i
Attach well construction record(s)ifavallable.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
6a.Well lD#: '' 0p-0.00 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (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:
4.5 above, also submit one copy of this form within 30 days of completion of well
(in.) ,
abandonment to the following:
6d.Water level below ground surface: 20 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 45 (ft..) 10c.For Water SuPPIV&Iniectionl 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 coring health department of the county where
6f.Inner casing/tubing length(if known): NA (ft.) abandoned I
6g.Screen length(if known): NA (ft.)
I'
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources + Revised 2-22-2016
I i