NC0024911_Monitoring Well Abaondonmnet Records_20240513

WELL ABANDONIM ENT RECORD
1.'Wen Contractor inforwatioa:
Weil Coinraeror Name (or well ownapem malty sba ndnaing well an hbftr property)
19,1 G :;- - A
NC WellContractor Certification Number
Company Name
2. Well Construction Permit t#:
Luse all applieaUe well conskuctian pemdts (r.e- byC. County.Slate' Slate' YarianCA et -.)
if ltnoivn
3. Well use (check well use):
Water Supply wen:
❑Agricultural ❑Municipal/Public
CiGeotltermal {iieaf'mgfCooEiug 5`slppiy) €7Itesidwbai Water Supply (single)
OTndastriWCommercial . ElResidential Water Supply (sue)
Supply well:
❑Aqui f-- Rjeflarge ❑Groundwater Remediatiom
❑Aquifer Storage and Recovery 0salinity barrier
❑Aquifer Test ❑SwrmnwaterD raiaage
❑Eacneri enW Technology ❑Subsidence Control
r2Geotheeinai (Closed Loop) []Tracer
0Geothermal(Heeteng%G—Mgxotuxa uuuac tom,.
4. Date well(s) abandoned: ) @ a
Por Imeroat Lise ONLY:
A$AN1fONhf�N1 XT£aTAM�
7a. For GeoprobeMPT or Closed -Long Geothermal Wells having the same
well congmctionldepth, only 1 OW-30 is needed. Indio TOTAL NUMBER of
wells abandoned:
7b..Approriasate volume of water rem"rig in
FOR WATER SUPPLY WELLS ONLY:
7G Type of disinfectant used:
7d. Amount of disinfectant need:
58. Well location:
Facility ID# (ifamilcable)
FacilitylOwucr Nam
Physical Address, City, and Zip 1�
county parcel Identification No (PIN)
5b. Latitude and longitude in degreeahminuteafsecoads or decitraa! degrees:
(ifweR field, one lailiong is suffick)
CONSTRLICITONDET SOFWELL_ BE D
dttaeft well contraction MO&rd(a) (favcllable .For multiple injection ornon-vmtersuppty wells
ONLY with the same Construction/trbwadanmettl yore can submit one forth
60. Well ID#:
6b. Total well depth:, M)
6c- Borehole diameter: (i.)
6d. Water level below ground surface: { )
7e. Sealing materials used (check all that apply
❑ Neat Cement Grout
entenite Chips or Pellets
Cl Sand Cemetrt Grout
❑ Dry clay
0 Camcrete GT-W
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
E3 Bentonite slurry
❑ Other (eapj sin under 7g)
7f. For each material selected above, provide amount of materials used:
7g_ Provide a brief Ilmeriptioie of the abandUaament procedure:
S. cation:
dj�
3ig�W a Well C CmEraCtor or well Ownerpy signing this farm, I hereby certify lh& the well(s) was (were) abandoned in
accardanae with I3.f NCAC 02C .0100 or 2C -0200 Well Cons ttedon Stmtdards
and that a copy of this record has bee» provided to the well owner.
9. Stu diagram or sddjtioual well details:
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 lwMaty-
SUSM�'1f.4L i�uG`�IOPTS
10a. For All-Wch.. Submit this foam within 30 days �of completion of well
abandonment to the following:
Division of water ResaWTM Information Processing unit,
1617 Nfail Service Cett>oer, Raaeigli, NC 27699-I617
lob, For Insertion Wells: In addition to sending the form to the address in Ma
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Dlvislon of Wager Resources, UndergrOwd injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-106
10c. For Water I & jniection Wells: In addition to sending the form to the
Ge. Outer casing length (if kaown): ( � ad&vW(es) above, also submit one copy of this form within 34 days of completion
of woil aibondon>ncat to we oo,mty taeatth drpsrturent of due county whore
abaadoaed-
6C Inner easing/tubing length (if knOwm): (ft )
6g. Screen length Of known): ( )
Form GW-30
North Carolina Department of Envirvnmratal Quality - DSisiou of Water ICesamceS Revised 2-22-241 6

WELL ABANDONMENT RECORD
ForloWMI UM ONLY=
L Weil Cemtractor I�armation:
wry cones x e� {te n uwwp=aaMIy&ban&MiV9 Won on fir)
rlcwenC�at�r � ,
CompeayNsme
2. wen Caasdrnctim Permit A
list uIl uppLtccbk wdl aanstrvufo+i Apt* tj-G TJIC, Caw,ry. Stan; Ymim,ce ate} �1otu,un
$.'Well ase (ehwkv"A use):
Water SIWIY WC N:
OAgriadhnal
❑Genthennd (HeffrMwCooling SnpPIY)
❑ IadusuisuCaMRICncial
d - 'on
N a r SMp* WdL:
Iajecdon Well:
o
7a. For G,eoprobaMPT or Closed-Luop twthermal Wells having the same
w,n caaswctioWdqk only l GW 30 is noet e& Tadicatr TOTAL 1 LW13R of
weds abandoned:
71s. Appro>Iate voleane of water remsalning is
FOR WATER SUPPLY WELLS ONLY:
7L TYPO of dhkbftd Treed:
7d. Amonat of met used:
1, Sedtag materials used (ebecic aU that grply-�
�� Pellets
❑Ir�micipaUPnbhc
©l�Toat Cement Cisant
Gips or
tl andenbal Water SnPPIY (Ue)
Q Sand Cement Gtwrt
❑ Dry Clay
t7Re9dutial waxy supply (abate
❑ Cancneto f3ru
D lkill CuUinp
© Spodshy 13rvttt
❑ CAWMI
C7 Benbooite Starry
❑Other (®cplaiu under 7g)
ar dwaterRemediatiar
DAgntfrr Storage and RaCo„es3, L sa1initY hiss
Test isS>
.l.iedmolosy [7SC.oatrol
peal (Closed Loop) a Tracer
_❑C,e l 1'mg RelFtm) QO w (explain under 7g)
IL Ante wen(a) abandoned:
5a. well Ioeafien:
FscFity+'Owtrslvsme gacigtyll�(ifappltcabb)
Pl i�l C , and TIP
COUBW Paled id=6fic+tion M. (I'II3)
R, L.tude MW longitude iD &V--&d-9WM=>MS or ded-a decrees' .
(ifwell bald, am hdkog is safficiet)
3- 4'0N�`�a°'35 = W
II .
Attadtawllcea0ln[o4itni-041)Y--Wta PerseuUtpia�eedaaWnam'NatersreppJyurns
ONLYwftit tltsaunre coa�raekotYabmtdo
1
tin. Well1D#. - -
6b. Total well deptig 9 (B•)
6& water kvf i bdow Vvand share: to It
7E For each msterisN seleded above, probe a MUUt of mstedals used:
7q. provide a brief description Of the abanddnment procedoree
L tins
Mid- en carfacbw or won Owner
BY ins Up, r h.,r e * that the xWWS) war(--) a�t�ea in
&=rdwxv with l5A NCAC 02C .0100 or 2C .0200 Weft Conattuction Sondardc
and that a copy of dds wand has heat provided to the w J7 owner.
9. Site Msgra n or wMItionsl well defxlls:
You may use the buk of fhss page to pravide additional welt site dtails or well
absodonuumt da ails. You nay also mwb eddhionat pages ifnmmarY
10s. For All Wes: Submit this "farm within 30 days -of coagt1860 a of well
abodoMMOU to*e, f0[[0Wh*
M&A. nn of Wite, R.g nrrM iaiarmMtien PnMMXdne TYXkk
1617 Man $erviee Centw, R~6 NC 27699.1617
1pb• : in addition to sending the form to ft address in 10a
abovq also submit otte copy of this form within 30 days of completion 0f well
abandcument to the MOWing:
Divlitlon of Water Resources, IId ][njeedoa Control Program,_
16M Mail Service Custer, Ralf, NC 2709 4636
_�11.) 1Dc. • in addition to sealing the foam t0 the
6e. outer casing length f lmo m): adcheas(es) above, also submit one copy of this form wahm 30 days of coMWtcb0n
of wall abandonment to the wuay health depeatmeot of the Y arlt-
6L Inner caslaWtublng si left& (if NmM): _ -(R) absuilons&
6g. Screen lead Of kw—)- i � r (fP
FormGW-30 Noati<CualmaDepsRsmetd0fHavnnsm®fe1QU ty-DfvSMofWatwROOM= Revised2-227Alb

WELL ABANDON1ViEN RECORD
For at Usa ONLY -
1. Well Contractor Information:
W011 Connactar Name (Or well owncrp�oaa>!y a1'°=douing well oa hiail" pmpesty)
9�l (= a- — j[��A
NCCn WcU contractor Ccrubmdon Nnmb-
ColmpanyNanx
Z. Wen Construction Permit #
List nil applicable —B Construction permits (Le i1IC County. Slate. partrmcc, etc.} [Flvtawn
3. Well use (checlrwoll use):
Water Supply Well:
OAgricultnlal ❑ivlunicipaliPublic
oCkothermai (HeatinglCoolmg Stitpply) C1R mdenttal Water Snooty (she)
Uindustrial/commerciel OResidential Water Supply (shared)
Well:
❑Aquifer Red—ge ❑clraondwaoer Remediation
oAqufer Storage and Recovery ❑Saliltity Batrie3r-
❑Aguif,TTest cStatmwater Dminage
❑Experiiaental Tacbnology ❑Subsidence Control
❑Geothemlal (Closed L lop) OTzacer
4. Date weil(s) abandoned: O
Sa. Well location;
(IN
FasilltyfOwnerNmne Fscitity (
j'
Physical Address. City, and Zip
U &. Cam,-i-,n (
Cm ulty
parcel iderdificatioallo_ (PAT)
5b. Latitude and longitude in degXee H"utealaecoads or decimal degrees:
(if well acid, .1a was is suffic �t)
WELL euetyi) 2Mff T DF.TAELS'
7a. For Geoprobe/DPT or Closed -Loop GettthermA Wells having the same
well const =ttonldepih, only I OW-30 is needed. lnhicate TOTAL 141IMBER of
wells abandoned:
7b. Approximate volnme of water remaining in weB(s):
FOR WATER SUPPLY WELLS ONLY:
7G'1`ype of dlddectant used:
7d. Amount of disinfectant used:
I7m Sealing materials used (checicakl that r ppl
❑ Neat cement Grout to Chips or Pellets
p Sand Cement Gout
❑ Dry ClaY
❑ Conereft GrpA
❑ Drill Cuttings
❑ Specialty Grout
❑ [.navel
0 Bentonite Slurry
❑ Other (explain no 79)
7L For each materiai selected above, provide amount of materials used*-
1k 0 00
7g. Provide a brW description of the sbainddnment procedure:
Y
B. Cie cation:
si a of e ' V Coutraaor or Wall0WM
By signing this form I he7r Certify that dre tvell(s� was (were} abandoned in
aerwrdartce with I.5.4 NCAC 02C .0100 or 1C .0200 Well Construction Standards
and that a copy of dds record has bean provided to the WeU owner.
9. site diagram or additional well details:
You may use the bask of this page to provide additional well site details or well
abandQnmeut details You may also attach additional pages if necessary.
Cp1�T$1•ii�t;"lTD1WDl;TAILS DF __ BEIPT �F• g 3BIVfITTAi.Ii�iS'l'ItUC'Fi�
AuachweuwratraCtlonrecarYi{s}ifavailabt� FormaltlgletnjectfottArnAtr-watersupP13 xrlls
oNLy.ththesameconatrucdan/ab—donmen4Yaacansubmitoitef m
6a. Well Mirk: -N co
6b. Total well depth U C. (ft.)
4
6c. Borehole diameter: ()
6d. Water level below ground surface:
10a. For AU : Submit this,fotn within 30 days -o€ completion of well
abandaamcnt to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Ratetgh, NC 27699-16117
10b. For In We : in addition to sending the form to the address in IN
above, also gubtnit one copy of this form within 30 days of completive of well
abandonment to the following
Division of Water Resources, Underground Injection Control Progrxut,
1636 Mall Service Center, Raleigh, NC 27699-1636
caskng length (if ) 16c. For 1�Vater Snunhr & Injection Wells: In addition to sending the form to the
6e. outer lea known): 00 address(es) above, also submit one copy of this font within 30 days of completion
of wen ahantlommcut to the county hca-1th dcparrmcnt of the vuuutY -h—
abandoned
6f. Inner casingltublug length (if known): pp (� )
6g. Screen length (if known): IN
Prnm GW-30
North Carolina Depmt nW of Envitonasmad Qtmiity - Division of Water Resources Revised 2-22 2016