Halifax_Well Abandonment_20240918

WELL ABANDONMENT RECORD , For Internal Use ONLY: i
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 7a.For Geoprobe/DPT or CloslL'oop 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
3270 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.35 (gal,)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: 1 V 1�'/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ijknown
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery I
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 301bs
[]Aquifer Storage and Recovery []Salinity Barrier Grout 15 I bs
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control i
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer 7g.
as placement'
El Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) r--
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4.Date well(s)abandoned: 06/10/2024 J C+ P
8 2074
5a.Well location: i
U-Filler Up #26 00-0-0000010657
Facility/Owner Name Facility ID#(if applicable) 8.Certification: ,.
101 Smith Church Road, Roanoke'Rapids, NC 06/10/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Halifax 0906093
By signing this form, I hereby cert�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:
35.768617 N 80.853228 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
Attach well construction records)ijavailable.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS'
ONLYwith the same construction/abandonment,you can submit one form.
n A,A r 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• 'V'V V—1 abandonment to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: 21.00 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: 12.57 (ft) Division of Water Resources,'Underground Injection Coritrol`Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): 0 (R•) loc.For Water Supply&In•ecti m WeuS: 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
6E Inner casing/tubing length(if known): (ft.)
abandoned.
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY: ll
1 �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford I
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 I GW-30 is needed. Indicate TOTAL NUMBER of
3270 wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.75 (gal,)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,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 s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
CMonitoring []Recovery
Injection Well: M For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRcmediation Bentonite 30lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier❑Aquifer Test ❑StormwaterDrainage Grout 15 I b$
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tr acer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal eating/Cooling Return) ❑Other(explain under 7g)
Pour as placement
4.Date well(s)abandoned: 06/1-0/2024
S E P 1 R 2024
Sa.Well location:
U-Filler Up #26 00-0-0000010657
Facility/Owner Name Facility lD#(if applicable) 8.Certification: l
101 Smith Church Road, Roanoke Rapids, NC v 06/10/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Halifax 0906093 By signing this form, I hereby certify'that the ivell(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:
35.768617 N 30.853228 Rt 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 WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same`co�tn'struction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• 'V'V V—2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24.00 00 1617 Mail Service'Centvr,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: 13.08 (fL) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service;Center,Raleigh,NC 27699-1636
6e.Outer casing length(if(mown): 0 M.) 10c.For Water Suualy&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
6£Inner casing/tubing length(if known): 9 (ft.) abandoned.
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016
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