Moore_Well Abandonment_20240507

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1, o c f matio f\n WELL ABANDONMENT DETAILS
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-301is needed. Indicate TOTAL NUMBER of
j� � wells abandoned: !
J ��i J
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
Inc. FOR WATER SUPPLY WELLS ONLY:
Morgan well & Pump,
Company Name 7c•Type of disinfectant used: L t/
2.Well Construction Permit#:
List all applicable well construction permits C.e. UIC,County,State,Variance,etc.)if awn 7d.Amount of disinfectant used:. 1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public at 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
❑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 ❑Groundwater Remediation \k �cC
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer /" t ��/` k q e�L cp
LIC—
DGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) UI
4.Date well(s)abandoned:
5a. ell location: �'� � G am\(E'��C �'�ny a I j(17l}
tY ID#(Facility tfa applicable) 8.Certification: ;;emu.^� Ss'a>'.��✓�"
Facility/Owner Name pP ) }'••
Physical Address,�Citty,and Zip S ture edified Well Contractor or Well Owner Date
!� l �Z �� By signing this form, I hereby terrify 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:
(ifwell field,one lat/long 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
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)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
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
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: j
6d.Water level below ground surface: / (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&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): (ft.) abandoned.
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6g.Screen length(if known): X/ (ft.)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.nzF7
atio M: WELL ABANDONENT DETAILS
V47a.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
ff��C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan well & Pump, Inc. FOR WATER SUPPLY WELLS;ONLY:: a
Company Name `''I( /(�' IIt 7c.Type of disinfectant used:
i
2. Construction Permit#: 1,�p
Listt all all applicable well construction-permits
.e.UIC,County,State,Variance,etc:)if known 7d.Amount of disinfectant used: , Y L �( \)/V�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/PublicNeat 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
❑lni 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
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the a andonment procedure:
❑Geothermal(Closed Loop) ❑Tracer C L
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �j lS l/lJ
4.Date well(s)abandoned: LJ
1 cl�lJ: .
Sa.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.Certification: _ r ?'•"7• . ?�'
Physical Address,City,and Zip Si re of Certified Well Contractor or Well Owner Date
(/��t �� 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
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 lat/long is sufficient) 9.Site diagram or additional well;detaffs:
W You may use the back of this page to provide additional well site details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: 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: S (ft.)
1617 Mail Service Center a ,Raleigh,NC 27699-1617
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10b.For Injection Wells: In addition to sending the form to the address in 10a
(in.) above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter:
abandonment to the following:
6d.Water level below ground surface !V (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Clenter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.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
�j,�j� abandoned.
6f.Inner casing/tubing length(if known): —(ft.)
6g.Screen length(if known): (ft.)

i
WELL ABANDONMENT RECORD For Internal Use ONLY.
� I
1.Well Con or I ati _ WELL ABANDONMENT DETAILS
'n I
( G 7a.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same
11 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:
NC Well/Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
il
Morgan well & Pump, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name ( .q 0 7c.Type of disinfectant used: l Z D Z
2.Well Construction Permit#: l�
List all applicable well construction permits(i.e. UIC,County,State, Variance',etc.)ifknown �i
7d.Amount of disinfectant used: /bbb
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑/M+unicipal/Public ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) )f�esidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑hri 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 �
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the aband nment procedure:
❑Geothermal(Closed Loop) ❑Tracer M`f' L(�K( 'n �p
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ,
4.Date well(s)abandoned:
r
5a elllloccation:
FacilimlOwnerN}amfe �Facility ID#(if applicable) 8.Certification:
ea
Physical
Address,City,and Zip gna -e 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
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 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
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.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#: abandonment to the following:
�j Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
r� above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: v (in•) 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): t/ (ft.) 10c.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): (ft.) abandoned.
i
6g.Screen length(if known): (ft.)

i
If
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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
T. Benford Graham 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-�0 lis needed. Indicate TOTAL NUMBER of
wells abandoned:
NCWC 2373-A
7b.Approximate volume of water remaining in well(s): 0'00-(gal-)
NC Well Contractor Certification Number
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Fermit#: Unknown
I
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: '1 OZ
3.Well use(check well use):
FD
ter Supply Well' 7e.Sealing materials used(check all that apply):
gricultural ❑MunicipaVPublic ❑Neat Cement Grout A Bentonite Chips or Pellets
i
Geothermal(Heating/Cooling Supply) eResidential 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: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4 - 50 lb 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 Cut top of casing below ground level. Disinfected well.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Poured Enviroplug medium Bentonite into well per
4.Date well(s)(s)abandoned: manufacturer pour rate recomm'en atpns::t.
5a.Well location: I MAY V 'i W4
Albatross Land Development
Facility/Owner Name Facility ID#(if applicable) 8. ertif atio
lie •. ��;.<. . . . ,
Rowe Street, Aberdeen, NC 28315 ` ' l7`b 202
Physical Address,City,and Zip Si ture of Cert d Wye acto wner Date
I
Moore By signing rm, /hereby centify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0'100 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 latnong is sufficient) 9.Site diagram or additional well details:
35.137844 N -79.465351 W You may use the back of this page f 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
At!acl!ucll conq!r!tctian cecord(.r)ifavailable.k'orntultinle it jection or nott-u•atersuroly wells- - - -- - -
ONLY with the saute construction/abandonn!en!,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Unknown abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 33 (ft.)
10b.For Iniection Wells: in addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 4'5 (in.) abandonment to the following:
I '
Gd.Water level below ground surface: 22 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
t �
Unknown 10c.For Water Sunniv&r IniectioIi 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
Unknown abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): N/A (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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