Beaufort_Well Abandonment_20240401

...nELt B&t,'1 U ON MEri Y A r RECO3'A.D. trodntemrtltsc t7'4t 1. , ° ,5
•f S5sil t nttrtaer taint ulaaFsn : � r• WELL ABANDONMENT DETAt14 a y;5 •
i traitSpruill 7a.For Geuprobefl)PT or Closed-Loop Geolherinal Wells.itOyIngAne,tile. •
well constnicfionhis pth;only i G\tl 3tlasineedzti: tndtrtre iY)fi11L 1113!ifi•oY- ,'
;.r taI a anti,ctrtnn well on Miller prepeny) i
s t st ,afar tw zEcit;.r t we. _ ' wells abandoned +St'o , •'
193A ` . ,: t ; • ,
•
-= 7b.Approximate volume of water,rem aining'in aelt(s) ,;(gal..)" .
a 14 ':l'Contnacinrtrnific.tildi Iointier • •
, - -
RES-SG1 FOR WATER R Sure!Y 1!ELLS t)NI.r
7pairl}hamr - ;'N/A
r 7c Type.of disinfectant used: I
HCL
��cti Cnnstrtictton•Permit 3 /2 inOh labs
r.,;.:liapn 6.,abk.si i eat,imtftair.. wit,ats.t'1E'.CauuR State. Gttr.ititre,i.ts,liflatmsrt ,
?d;"Amount of disinfectanY.tised '1
.1.Well use)check well itse) • • • • • •
' '\\ate'Supply well: • ,1 7e.Sealing materials used(check aOlthat apply) -,
>'i;r;culitiral • i lwa...ipa r ub�it. CMe!re.-" t rvmriti(irtatat I • lisntanits C nsp4 or P•lluv
IC:+Cii=othrnnal(l•leatsn),.'Caa}itns-Supply)'•; Residential Water Supply(single) 0 Sand Cement Gniut E]1)iy CiayF i
• ,i:iindustrial;,(:orruneresal.., t • ,0Residcntiat Water Supply(shared) G Concrete Grout ❑Dri1l Cuttings . . __ . .
lltri atioti • CI Specialty Grout • 0 Gravel .
r t)n-Vi:tier Suppl) Well - ' 0 Bentonite Slurry Ill Other(explain under 7g) .
Mnits onog .. C1Rccosery -
'7f For each material selected above,provide amount of materials used •
1 `i Aquifer Recharge.- - Ciroundwatcr,Reinediat ion`' 2 lbs bentanite-3/8 cips.i
,idjuifer Storage titid geeos ary. 1._Stthelty'Barrier 1 'i
t igiitlr^Is t, • i t)Stortnuater Drainage- JJ
,4 ll:,e)terimcntal'faclinala CSubsidciiceControl I` i
gy • i 7g.Provide a brief deseription of the abandonment pt i ecdurc:
t�t;ecrihrrma((Ciosed Loop) C,Tracer poured bentonite t4, 3 f1< BLS-Top,3 ft•concrete..I
Cttlevthrtittat,(licattng"Cuoitn�Return) DOthsr(ezrlain under 7g)
• • Fp r,,. G'^ r
.Dale well(s)abandoned: � t•
f� •
5e.Well location • APR,R. O, '2024;;. . , t• f
Next to 7442 Hwy 17 . .;at.;�ct Ar r
f �tftl '� ts�pc
a;i;h; r)tl-nei,Nanr Facility ID:(il'spSpiteabie) $ Corti , . '
-Right of Way 7442 Why.17 Washington.•NC 2781 . 1 '� 2d1212024
Pt y s;u ai Address-City,and lip Signature of Certified's e IC aetar or WdltOuner Date
[� • • . 567-38-0858 ' ; , ti. , •
Bea i-ItOf By signing this.jortn,I here1 Certlfi,.that tite'itet!(c).niis{uere) abandu ii to
i ` un
,"'" -Parcel ldnitifi:t�tian Np.(PIN) 'iccordance w th I,S.I VCAC 02C.0100 me.2C 0200 Wdii Cvttstturtion Bata trtarit - '!
i - • , V and that q cops u/�thas rerorrl fins fieetf provided io the tl,elt uwtte t•.: ' r
>!a 1,attttide and longitude in degreestuthtntdsiseeonds or rlecinial degrees:
it,welt @old,cne intttenl,s sii cn.nt) •" .. = 9.Site diagram or additional well details
5 653763 . t77{ 7�3 w ' You may use the back of tail page to.provide additional,tell ei e details pr veil ,
(S = • abandonnientdetails< ;' musnav'alsoattachadditionaipagea,ifntce'.rs.
A
CONSTRUCTION STRUCTiON DETAILS'OF W ,LL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS ,
Arm-it wet(eaatstrtctrrnrc w-dtrlif na;ta),te:For aazrtspieyerriunor non-water supply wriis,
t3, LY,suit the:anu ci)ipp'„d'nts r/n4iii inincttt,Ya P,bit 9nb„dr one fo,tta.,I 10a, Fo• r All wells: Submit this form lvtthitt 30 ti.ty, et cantplett.)rt'at well
Hand.Pump a - abandonment to'ti?e following: ;r,
' Divi sion of'Water Resources;Information P,Kteessing Lint ,
1617 lilai!Service Center;Raleigh,NC 27699-1617
•
Oh.Total well depth: 2� . ' (D.): i '
' - i ' • ' .10b,For injection Wells: In addition to_sending the farm to the addti.s in tt)u
Washed , above,,also submit One copy of this�oam withal 30 days at contpteuon of nett
- 4c.Borehole diameter:_, ) abandonment to the following E
Division of Water Resources,iltidergraund 1njecUCo aa ntrol erogrtitt,
tsd.\t afar level below ground s»rf t c: (rt) t633(,'Sail Service Center,Raleigh,;NC 27b94 1636
' i 0e.Far 4i stet Supply&lnieetion Wills In addition to sending the fnnn to the
} (ie.Outer.eating lengly•(if knilayn)i " (ft.) 'address(es)above;;u1so submit one cOpylof this fonts within 30 ditys of coniplettt>n
. • • Of.wet) abandonment,to the aount(r health department of'she c.ount1 wht_rc,•'. .
abandoned. . ,
Gf.Inner easing�tubtng length(if known):•. (ft)
(sg ;Green length(if known). •
t • • (It.?
i
•i'atm row-3o -. Neat;Carolina Depas<.ntcat of t nvironinentai Quality-Division of W ater Rc; rCCS
,

WELL A)iAINIUINMEIV'1' RECORD For Internal Use ONLY: I
I'
1.Well Contractor Information: WELL ABANDONMENT DETAILS
4 i
' C k Oe7 S 7a.For Geoprobe/DPT or Closed;Loop Geothermal Wells having the same
Well Contractor Name(or witl owner personally abandoning well on his/her property) well construction/depth,only 1 GIN`-30 is needed. Indicate TOTAL NUMBER of
�' 4 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wafer,remaining in well(s): (gal.)
04. l'IuU11 S"1, WC I l N't( I t
Li FOR WATER SUPPLY WELLS ONLY:
Company Name r_1 •
7c.Type of disinfectant used: r
2.Well Construction Permit#:
List all applicable well construction permits(i.e.WC.County,State,Variance,etc.)if known 5 %J�`
7d.Amount of disinfectant used:. `
P
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 'eat Cement Grout El<tonite Chips or Pellets
❑G p/hennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I . ❑ Dry Clay
6Yindustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ 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 OGroundwater Retnediation I-
�
D
:Aquifer Storage and Recovery ❑Salinity Barrier Do `� LB�T
❑Aquifer Test ❑Stormwaterrainage . -3 so IG5, 0e44zGdr---
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer I .
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under 7g) i
ram. --�4 -, .,.,
4.Date well(s)abandoned: ?—IL('--* g•H J '` ` Ca 4� 'I` ' y
I'. ,
5a.Well location: APR 0 1 2024
)Aj I e_�
Facility/Owner Name Facility ID#(if applicable) 8.Certification: Dwaf c-
13o `-al 5 ,?c306 G1 .k , ' D-15-(ayPhysical Address,City,and Zip Signat4(A
f Certified ell Contractor1,or.Well Owner Date
13 Pxt Si5 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.01100 or 2C.0200 Well Construction Standards
and that a copy of this record ha been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one tat/long is sufficient) 9.Site diagram or additional well details:
35, 3 l D Q N s VVr 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)ifarailable.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 ID#:_ 6-1/✓OS 6 abandonment to the following: I
• Division of Water Res+ou'rces,Information Processing Unit,
6b.Total well depth: (6S (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
�tt 10b.For Infection 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
rI
abandonment to the following:
' 6d.Water level below ground surface: 7P- (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service�Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): ` (ft.) 10c.For Water Supply ScIniec1ion 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): 13S • (ft.) abandoned. 1
1
6g.Screen length(if known): -3 0 (ft.) ,
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

WELL AliAIN ION MEN'! RECORD For Internal Use ONLY:
1.Well Contractor I formation: WELL ABANDONMENT DETAILS
�0s/\. 1
�S S S 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
t , �`l ,`� wells abandoned: ! I
—1I 1 I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
1
`5W1, ktu)S A t-/Git 10il,G I,k,) FOR WATER SUPPLY WELLS ONLY:
Company Name• 7c.Type of disinfectant used: lIl 1 J
2.Well Construction Permit#: 1
List all applicable well construction permits(i.e.UIC,Count State,Variance,etc.)if known 1 . e i j
7d.Amount of disinfectant used: J i IJ
1
3.Well use(check well use): j
Water Supply Well: 7e5ealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public eat Cement Grout , entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I j ❑ Dry Clay
PJlndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I El Drill Cuttings
❑Irrigation 0 Specialty Grout j 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry I ❑ Other(explain under 7g)
❑Monitoring :Recovery '
Injection Well: 7f.For each material selected above,provide amount of materials used:
. ❑Aquifer Recharge El Groundwater Remediation i/
❑Aquifer Storage and Recovery ❑Salinity Barrier HODq5; C�Pa n1u
il
❑Aquifer Test ❑Stonnwater Drainage '35 D (9S, UuA t oe
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer f
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) I , I/
rP�iMCw`f' A-tc..,,D Try•+, fo O t/-�-.41 0f' Lvc it,
4.Date well(s)abandoned: 0-- I 0q ,
Re„Act,A''J 5t-C. 7t;11" IA/;A. HGIt �+ t
5a.Well location! I(J4
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
IS30 f3o6S a-ncG , (� APR a 1 2024
— 15—ay
Physical Address,City,and Zip Signatu of Certifiedyet,
l Cdbh`alliTIIiTiiii Vyelt9pfu r 2, u Date
�C��cJ�o' By signing this form, I hereby cert��th"a`tttTae well(s) was Overe) 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:
3S°.3(C1!6$ N `260 r 8 S 6 S 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)ifai•ailable. 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 fonn within 30 days of completion of well
6a.Well ID#: g11i/0S A abandonment to the following:
F C Division of Water Reources,Information Processing Unit,
6b.Total well depth: 1 6 a (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: t.1 (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: t-7Q (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft.) 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
I.
6f.Inner casing/tubing length(if known): I - abandoned.(ft.)
6g.Screen length(if known): '3 O (ft.)
i '
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I ;