Wake_Well Abandonment_20241115 (4)

WELL ABANDONMENT RECORD rInternal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:) S
WELL ABANDONMENT DETAIL
Cafy 4, . )/
5cILev- 7a.Number of wells being abandoned:
Well Con ctor ame(or well owner personally abandoning well on his/her property) For multiple injection or non-wafer; supply wells ONLY with the sane
y�f1) construction/abandonment,you can s ubmii one form.
J NC Well C tractor Certification Number 7b,Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name
P y •7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well permits(i.e.Count};State,Variance,Injection,etc.)tfknoun 7d.Amount of disinfectant used:
AJ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural ❑Municipal/Public Neat Cement Grout l`. Y > Benfonrte Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout N' l] f`ry Cky
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout N O v 1 2@-LMrill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
,Nqp-Water Supply Well: ❑Bentonite Slurry !t : =^ ' "''01otiier'(e9plain under 7g)
onitoring ❑Recovery
njection Well: 7E For each material selected above,provide amount of materials used: �/
❑Aquifer Recharge ❑Groundwater Remediation 6545, `�4-mil lr/QS 1 lit �IL�G'9 4arAw e.
❑Aquifer Storage and Recovery ❑Salinity Barrier e,
L
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide n brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer L �f / J❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) v �fi GG l
4.Date well(s)abandoned:
7_�w�'v_��� di , 4A ter-7 t•..h,4t +vtlas
52.Well location:
rapt G
Facility/Owner Name Facility ID#(ifapplicable) g-CertiTie on:
/ I �� J
���' 1����'1 t �U,�' IOU� A l Il
Physical Add s.City,and Zip S re of Certified Well Contractor or Well Owner Date
`IUl•8v►' By signing this form, !hereby certify that the wells)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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 0 9.Site diagram or additional well details:
-2 ) i-Qt p"( ® 510,36W 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 ifnecessary.
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)Yavoflable. For multiple Injection or non-water supply
wells ONLY with the satne construcirnlabandomnenr,you can.submit one fonn. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: r
V�- �j abandonment to the following:
i;
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
Li 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: (in.) abandonment to the following:
6d.Water level below ground surface: 461 (f Division of Water Resources,Underground Injection Control Program,
_` (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
1
6g.Screen length(if known): D (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Weelll Contractor Informati-oln: WELL ABANDONMENT DETAILS
V N f r �SChPJ` - 7a.Number of well being abaado ned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-`water supply wells ONLY with the tome
33 constructionlabandonment,you can submit oneform.
NC Well Convect r ificetion Number 7b.Approximate volume of water remaining in well(s):
�. GS [7d.
R WATER SUPPLY WELLS ONLY:
Company Name Type of disinfectant used: /V
2.Well Construction Permit tl:
List all applicable well permits(i.e.County,State,Variance,Injection,etc..)if known
Amount of disinfectant used:-
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ell that ap I'
OAgricultural ❑Municipal/Public Neat Cement Grout Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout -❑ ry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑Concrete Grout-kn t:.: '? ;•d 1 Q Drill Cuttings
Mir' ation ❑Specialty Grout 1 c [02� ❑ Gravel
n-Water Supply Well: l7 Bentonite Slurry ❑Other(explain under 7g)
onitoring ❑Recovery ,._ _ r,M„
jection Well: - 7E For each�n'atetial't;eletfed.a6tiye;provide amount of materials used:
L=
❑AquiferRecharge ❑GroundwaterRemediation Cir ��s �� yjS ' 1"�L�1/PtI®��itPltl°
OAquifer Storage and Recovery ❑Salinity Barrier '©A3, -r� Q�l /I ,/' � �$��f jj✓ ��
❑A uifer Test ❑Storrnwater Drainage
Experimental Technology ❑Subsidence Control
7g.Prov'de a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer �,�M� / e#
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) LLT 0w1�P PJ. 41 t(jt` S �U " �•_"t] �k t f'o
q1 ZN die o lay 0 il� e�t ' v t o �es�r���' r cyjly
4.Date well(s)abandoned: h�Gl�e �Art�t,! p� jpt .
,r 0��
Sa.Well location: �$66/& Ott9i°t�/)Pe���/?tLrsv(�p1�., �•el/ l411-$
Facility/Owner Name Facility ID#(ifapplicable)
S.Certifica
Physical Address,City,and Zip Sig t of Certified Well Cont or Well Owner Date
W'�U`'e' By signing this form,!herebp cerl6 that the wells)was(were)'abandoned in
County Parcel Identification No.(PIN) accordance with ISA NC4C 01C.0100 or 2C.0200 Well Consiruction Standards
I 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:
3 a 7 9t ]A 14 N p 0 �-v r�J You may use the back of this page;to provide additional well site details or well
r�J l! 3 I W abandonment details. You may also;attach additional pages if necessary.
i
CONSTRUCTION DETAILS OF WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well consiruciion record(s)If available. For nurltiple injection or non-water supply I;
wells ONLY with the scone constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
( -6a.Well](Dtl: abandonment to the following:
I.
Division of Water Resources,Information Processing Unit,
6b,Total well depth: (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617 .
t1 10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of thA form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
fu� / 10c.For Water Supply&Iniectron Wells: in addition to sending the form to
6e.Outer casing length(if known): T� (ft.) 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 -
6E Inner casing/tubinglength if know ft. where abandoned.
g C 4) ( )
1
6g.Screen length(if known): a (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

1 •
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well ``tractor„InnfformaY : WELL ABANDONMENT DETAIILS
( �• 7a.Number of wells being aband on I .
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection ar non-water supply wells ONLY with the same
constnrctionlabandonmenr,you can suMiit one fort.
NC We1lptraptotCerti bl� o�
7b.Approximate volume of water remaining in well(s):
����1ILL JJ fU/j�j� FOR WATER SUPPLY WELLS ONLY:
Company Name •7c.Type of disinfectant used: t%"
2.Well Construction Permit M
List all applicable well permlis(I e.County,State,Variance,Injection,etc.)ifknown ' �V
7d.Amount of disinfectant used:
-#
3.Well use(check well use):
Water Supply Well: 7 Sealing materials used(check all that arlDry
y):
❑Agricultural ❑Municipal/PublicNeat Cement Grout Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ✓✓✓✓✓✓❑ Sand Cement Groat -' %->>^'; ,Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Cl Concrete Grout '=' L °i '3,4561i Cuttings
❑lrri lion ❑ Specialty Grout NOV t;�O Gravel
N -Water Supply Well: ❑Bentonite Slurry lJ '❑F Other(explain under 7g)
..>S
onitoring ❑Recovery ir,`..--•:..=.-:• ;a;;�,W^:;;-;: j
njeetion Well: 7E For each material selected,above,'pravid9 amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation �f� �� t •�; r tJ�S GLr.�
❑Aquifer Storage and Recovery ❑Salinity Barrier �t❑Stormater Drainage TestP— i
❑Experimental Technology ❑Subsidence Control 7 ,provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �l'! 1 L � ,ll lL
�- b
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
4.Date well(s)abandoned: _ � yy�� jj df ELF
lU—h
Sa.Well location: _ " ' - O �,-4e_
S.Cer ific
Faceility/Owner Nam�/� j J Fac�ili�ty[D#(ifapplicable) 11AA
it/tit
Physical ddre ity,and Zip SigatyWoMertified Well Contractor or Well Owner Date
Gr a By signing this form, I hereby cergo,that the wells)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 lattlong is sufficient) 9.Site diagram or additional well details:
`�g� u��I �� CT®� You may use the back of this page to provide additional well site details or well
7 J N t J W abandonment details. You may also attach additional pages if necessary.
I.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For nu duple injeezimm or non-mazer supply
wells ONLY with the sane con
pstructio
n/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
tr Yt'
6a.Well ID#: I o t —q abandonment to the following:
( Division of Water Resources,Information Processing Unit,
66.Total well depth: � (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
�ll 10b.For Infection Wells: In addition-to sending the form to the address in IOa
above,also submit one copy of this form within 30 days ofcompletion of well
6e.Borehole diameter: (in.) abandonment to the following:
II
�✓ Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: ii (it.) 1636 Mail Service Cei ter,Raleigh,NC 27699.1636
! 10c.For Water Suooly&Infection Wells: In addition to sending the form to
fie.Outer casing length(if known): (ft.) 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
6f.Inner casing/tubing length(if known): ''� (ft.) where abandoned. i
I
6g.Screen length(if known): o (ft.)
. i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I,