Onslow_Well Abandonment_20220718

WELL ABANDONMENT RECORD Fur Internal Use ONLY
(,Well Contractor Information: WELL MIANQONSWNI'DF7•ADS
William Ewing 7a-For CcaprobrlDP7•or Closcd•Loopt Geothermal Wells having the same
Well Contractor Num(or well owed pemnally ahandomeg well on luv xr property) well consuuetioNskplh.only 1 GW-30 L4 nsl led. Indicate TOTAL NUMBER of
wells abandoned:
3110
7b.Approximate volume of water rem iiriing in well(s): �
NC well Con=loc Cmin"tian Nuvt@ I'
Crawford Environmental Services FOR WATER SUPPLY W`ELIS ONLV:
Curnpany Nwna 7c.Type of.disinfcetant used:
2.Well Construction Pertull 6: Unknown
list all cppfwuble well cwarrucrinn prrmtit(te.uie,Cooay.$rare,Voriance.ric 1 if tnuwn. 7d.Amount of disinfectant used:
r
3.Well use(check well use):
' Water Supply Well: 7e.Sealing rtnterinls rued(cheek all that apply):
❑Agncuhnral ❑MunicipaVPublic 6\Neat Cement Grout ❑Bentanitc Chips or Pellets
OGcathemtal(licatinglCoohng Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
"+ Dlndnal/Comnxrcial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
ust
l•i ❑Imi "on O Specialty Grout ❑Gravel
Von•Water Supply Well: 0 Benionitc Slurry ❑Other(csplain under 7g)
1111 Klomlocing ORccovery-
Injection Well: 7f.Far each material selected nbovq provide amount of materials used:1
i, ClAquifer Recharge OGmundwater Rernedlalion !.1 A rho.✓ ��--f
} ❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test OStormwater Drainage
OF.xperimcnisl Technology OSubsidence Control 7g,Provide a brief description of the abandotarrent proccdurc:.
OGeothermal(Closed loop) OTracer
CGcothermal(Ncatin JCoolin Return) 00dux(explain under 7 ) 7e��
J.Date well(s)abandoned:
So.Well location:
Scotchman 945(GPM 3045) UST 0-020164
S:Certification:3//p ri(r•`-�'�I` =�
Facdiry1Orrxr Nm ae Facility IDM(if applicable) `` (''1JN1
2347 Catherine Lake Road, Richlands, NC r� '•�''i
-Zv Physical Ady-ms.Cuy,and Tip Signature f Ccaified Well actor or Well Owner Date
Onslow 031083 By signing this form I hereby certify that the well(s)was(were)abandoned in
county Parcel lderitification No.(PIN) accordance wills 15,11 NCAC 02C 0100 or2C.0200 Well Cotutru-Man Standards
and than a copy of this record has been provided to rite well onner.
Sb.Latitude and longitude in degrmVitainuicslsccands or decimal degrees:
6f well fxhl.one btflmg is sufficieaU 9.Site diagrum or additional well details:
34:828266 77.578272 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 DF'r\IIS OF WRLL(S)BEING AIIAND(JIVED SUBMITTAL INSPRUCT'IONS
rV:sch well conrrructim record(r)ifaw,Oble.Formultiple Wecrion or non-water supply welts
ONLY kith the cam.:canstrucaan/ahsmkmmrrs.)»u can submit one forrrc
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the'following:
6a.Well 1114: /0"
Division of Water Resources,Information Processing Unit,
1617\tail Service Center,Raleigh,NC 27699.1617 '
66.Total well depth: �_ Z ((L)
lob.For.Injection Wells: In addition to sending the form to the address in l0a
6a Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
/ abandonment to the following:
6d.Water level blow ground surface: fP (IL) Division of Witter Resources,Underground Injection Control Program,
1636 Mail Service Cenice,Raleigh,NC 27699.1636
6e.Outer casing length(if known): A) 10c.Far Water SImmIV S Injection Wclls: In addition to sending the form to the
adtln•ss(cs)above,also submit one copy of this forms within 30 days of completion
of well abandonment to the county Health department of the county where
6f.Inner easingftubing length Gf known): (rL)
abandoned.
I
fig.Screen length(if known)i (ft.) '
farm GW30 North Cooling Dvgamoentof linvironsrenml Quality-Division of water Rcsourxa Revtscd 2-22.2016
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WELL, ABANDONMENT RECORD Pm Ictemal Uwe ONLY
1,Well Contmclur Informaliou: WELL AI1,INDONAII?hT DETAI1IS
William Ewing 7u.For Gcoprobe/Dvr or Closed-I Itup Geothermal Wells having the same
Well Contractor Nano tm well owner peracmally ahandomne well on hisRter property) well construction/depth,only I OW-30 rs needed. Indicate TOTAL NUMBER of
wells abandoned:
3110
NC Weil Contractwt Ccrt,rlcauon Numbs 7b.Approximate volume of wnter remaining in wefl(s): 3,� (gal.)
I
Crawford Environmental.Services FOR WATER SUPPLY WELLS ONLY:
I
Corr pop Name 7e.Type-or disinfectant used: .
L Well Construction Permit 0: Unknown
List aA applicak-L xa11 consrwL;n p:mtats(i.e_UIC.Coamv,Stare,Yartance.ere)If kmmwt
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e-Sealing materials used(check all that apply):
❑Agricultur,.l OMunicipaVPuhlic Neat Cement Grout ❑Qentonite Chips or HIM
❑Geolltemuil(Ileating/Coaling Supply) ORL�udcntial Water Supply(single) O Sand Cement Grout ❑Dry Clay
Olndusuial/CortimerrW OResidenual WatecSupply(shared) ❑Concrete Grout O Drill Cuttings
�� atian O Specialty Grout 0 GMvCl
1. Non-Water Supply Well: ❑Oentomte Slurry ❑Other(explain under 7g)
IMMonitoring ORecovery
5 Injection Well: X For each material selected above,provide amount of materials used:
O uifer Rech/� arse OGrounJwwcr Remcdiauon �yl�Z!OD���
. OAtiuil'er Storage and Recovery OSaltmty f)atrier 1
❑Agtnfer Test OSlormwater Drainage
OEaperinicatal Technology OSubstdence Control
CGeothmtmtal(Clasal Lap) OTracer
7g.Provide o brief,description of the abandonment procedure:-
OGeothemtal(Heatin `Conlin Retum)_ OOther(explain under 7 ) Riz kule SO 13.T �
iS11 P 4� V tj
4.Date well(s)abandoned:r0 �—
rt tt A R M?
52.Well location:
Scotchman#45(GPM 3045) UST 0-020164 V,5� 1 1; {
Facihq-tOarrrs\sate Facility IDA(if epphcablel g.Certification>3.j,[O �- v .,FIR
ri
2347 Catherine Lake Road, Richlands, NC ray — l 2-c) Lf`t
Pbyaaal Address.City,and trip Signituno of Certified Well Contractor or Well Ounar Daw
OnsIOW 031083 0y signing this form I hereby terrify that the well(s)is-as(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Enfilade and longitude in dcgrecslminules/scconds or decimal degrees: and that a ropy of this record has bee n provided to rite well owner.
(if wen rrekl,one Gvtoog iswftcicat) 9.Site diagram oradditional well details:
34.828266 N 77.578212 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
lnachwellcenrrructwnrerord(s)rfawbJabfe. Far multipleirtjeninnornon-enter supplynrllt
ONLY with the some coartrwriorlabandonmem,)au can.wubmit one form. IOa. For All Wells: Submit Otis form within 30 days of completion of well
6a.Well IM- j'yl '✓ abandonment to the following:
Division of Wulcr Resources,Information Proaxsitig Unit,
6b.Total well depth: Z. (ft.) 1617 Mail Service Center,Raleigh,NC 27699.1617
1
10b.For Infection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter. (in.) above,also submit one copy of this farm within 30 days of completion of well
G abandonment to the following:
6d.Water level below ground surface: ( •S S (fL) Division of Water Resources,Underground Injection Control Program
1636,% l Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fL) 10c.For Water Supply S 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
6r.Inner casing/tubing length fir known): (fL) abandoned.
6g.Screen length(if known): (ft.)
I �
Form GW,30 North Carr,lim Depannsnt of I:lrrrrcmntntil Quality-MA Won of Wars Resuvrces j Rev'ued 2-2.2.2016
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WELL ABANDONMENT RECORD Fcr lrffimal Usc ONLY
1.Well Contractor Infurnetion: WELL.AB,\NDQN'NIEN T DF`VAiLS
William Ewing 7a.For Gco rubcfDPT or Closed-L.00 Ccothcrrmtl Wells having the same
P P
Well Conrrnair`tarry hoe well owme personally abandoruea aen on hmgx:r property) welt eanstrt:cuolVdapth,only 1 GW n is needed. indicate TOTAL NUMBFR of
3110 wells absndonw.
NC Well Chftm�ur Cc1611'raen Numtzr Th.Appror(tttate volume of water rcmairdng in tvcll(s): (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLSONtiV:
Company Notre
7c,Type of disinfectant used!
2.Well Construction Permit A: Unknown
Lai oil opplicaNe"If a wt_aoa re-or,tee,UIC Cvuwy,State.Vuname,ere I iftm-xn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
CAgrtcultural GMunicipal/Public 0,Ncat Cement Grout O Bentonite Chips or Pellets
a CGcothcrmal(licau4Cooling Supply) QResidential Water Supply(single) ❑Sand Cement Gmul O Dry Clay
Clndu�triai/Comrneictal C!Residenual Water Supply(shared) C Concrete Grout Cl Drill Cuttings
^frti,ation O Specialty Grout O Gravel
Non-Water Supply Well: Q Bemonite Slurry C Other(explain under 7g)
MManitonng ORccotrry
Injcet(on Well: 7L For each material selected above,provide amount of.ntalerials used:
71 EAquifci Recharge CGroundwatcr Rcmedintion !1 a r 1 v�Gt.+✓J
CAqutfer Storage and Recovery CS-2inity Bamcr
ClAquirer Tact CStormwater Drainage
UrAperimental Technology GSubstdence Control
7g.Provide a brief discription of the pbandonmrnt procedure:
CCrcothermal(Closed Loop) CTracer
OCeothcmtal Mcaun Coolin Return) Collier(ez lam under 7g) /�VpvslJ t✓ rlU�f
a.Nis:well(s)ubandnned:� JUL 1 S 2022
i
SR.Well location:
1 mac_ 1
Scotchman 945(GPM 3045) UST 0-0201.64 1 /�
Facilit [Do(if applicable) g.Certification:
�r/ rr- I�u} sjyy�-,,��(,ti,;ttt`. !)L1+.+tLc�yi S� •.
FacrGty:nwrrr Nami: Y f�
2347 Catherine Lake Road, Richlands, NC / � G Z.;' 2-2—
Phytical Address.City,Lad Zm Signature of Ccnifred Well Contractor or Well Ouncr DaL
Onslow 031083 By signing this form I hereby certify that the well(s)was(were)abandoned in
County Parcel Idemification No.(PIN) accordance with i5A NCAC 02C.0i00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the weft owner.
5b.Ladiude'and longitude in degrres/minutes(seconds or dcclrnal degrees:
(dwell field,one tallong is sufficrem) 9.Site diagram or additional well details:
34.828266 N 77,578272 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 bETAi)S OF WrLI,(S)BEiNG ABANDONED SUBMITTAL fNSTRUCTIONS
Aaach wellrmurnirrion rtcarr1f11 Jamilable For multiple injection or wn-wxaer Supply welts
ONLY with the tame cmurra IiooWabunJnnmcnt.you can Submit ore form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well iDN: m L-1- !/ abandonment to the following
Division or Water Resources,information Processing Unit,
_(ft) 1617 Mail Service Ccritcr,Raleigh,NC 37699-1617
6b..Total well depth:
lob.For iniection Wells: In addition to sending the form to the address in 10a
6a Borehole diameter. (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: g (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
i
6e.Outer casing length(if(mown): (fL) 10c.For Water Supply&lniection!Wells: In addition to sending the form to the
address(es)above,also submit one c6py;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 Of kno"): (M) I
Pure GW-30 Nbnh Catolhna Department of Envnrun tuntal Quality-Divmon of Wairr Resources I Rev d 2-22-2016
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WELL ABANDONMENT RE,CORD t�rtntem�It,xoNLY
i.
1.Well Contractor Information: NTi,L ABANDONATF.rT Dr•.TAiLS
William Ewing ! i
7a.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same
Well Co:utactm Name(or well owner petsomily abandaning«ell on his/her property) well construction/depth,only 1 9W-30 is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
I I
t
NC well Cont at=Cen,fication Numlx,• 7b.Approximate volume of water remaining in we11(s): 0-27 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
CRnT}Vtay Nd[r>; �
( 7c.Type of disinfectant used:
F 2.Well Construction Permit#: Unknown
t List all arpFwble well comim-awn perm,tr(Le.VIC.Count)•,Srate,Variance,efc)i14a—n
i 7d.Amount of disinfectant used:
1 3.Well use(check:well use):
1VWer Supply Well:
7c.Scaling tn:ttcrials used(check all that apply):
r,
n CAgricultural 0-MunicipaUPublic Neat Cement Grout C Bemonitc Chips or Pellets
CGcothem)al(UcatingfCooling Supply) OResidential.Water Supply(single) O Sand Cement Grout i. O Dry Gay
Clndustrial/Commercial CResidential Water Supply(shared) 'O Concrete Grout ❑Drill Cuttings
Clm.ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: O Bentonite Slurry C Other(cvplain under 7g)
RMonnoring CRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
afer CAv Recharge e
,( • 7 OGroundwater Rcmexliation 9((
CAquifer Storage and Recovery OSalinity Barrier - f
4'
CALluifcr Tcst OStormwater Drainage
❑ExperimenudTechnology OSubsidenceControl
(Closed Loop) OTmcer
7g.Provide n Is 'ef description of the abandonment procedure:
pGeutlmerrttnl �
CGcothermal(TleauntJCoolins Rctum) COther(cx lainunder7 ) �/"� 4J�rs f `p, �O,-/i✓— �l+�Y) -fir)T ti,Ce p
t"...tT
4.Date well(s)abandoned: 02�
5a.Well location:
Scotchman;#45(GPM 3045) UST 0-020164 raf?? 111 El 1 i
F=ibtytthv=Narrs - Facility,ID#(if applicable) 8:Certifications lt'Q� i) i'Ui 11ra�11V'i't itG J1` I
2347 Catherine Lake Road, Richlands, NC -Z Lt-
Phys,vat Addrau,City,and Zip Signature of Cenificd Well Contractor or Well Owner ,Date
Onslow 031083
By signing this form,1 hereby certify that the avelf(s)was.(were)abandoned in
County Parcel Idea ietcation No.(PTN) atrordance with 15A NC,1C 02C.0100 or 2C.0200{Yell Construction Standards
and that a copy of ilus reconi'has been provided to the w•efl owner.
56.Latitude and longitude in degrecs/minutcs/seconds or decimal degrees:
(if well field.one latilong is sufficient) 9.Site diagram or additional well details:
34.828266 N 77.578272 `� You may use die back of this page to provide additional well site details or well
abandonment details You may also ataeh additional pages if necessary,
CONSTRUCTION DfTA1LS OF WELLS)BEING ABANDONED SUBMITTAL.INSTRUCTIONS
Anaehwtlieomrructionreeord(s)ifmallable.For multiple injection ornon-wviersupply netts - -
ONLY w*h the tame contimvitorJabandonment.you can submit one form 10a. For All Wells: Submit this form within 30 days of dompletion'of well
6a.Well IDN: M lv _7 abandonment to thGfollowing-
Division of Water Resources;Information Processing Unit,
6b.Total well depth: 2. Z A) 1617 Mail Service Cciitcr,Raleigh,NC 27699.1617
lob.Far 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:
6d.Water level below ground surface ��• r L� (ftJ 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 Suooly&injection'Wells: in addition to sending the form to the
address(es)above•also submit one cop of this form within 30 days of completion
of well abandonment to the coun�y �ealth department of the county when:
6L inner easinghuhing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) i
Korth Carolina i Form GW'-?0 - Departarnt of Envuonrrenial Quality•Uivi4lan at Water Resources � i Re—ed 2-22-2016
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WELL ABANDONMENT RECORD For tamrral Us ONLY
t.%Vcl1 Contractor Infbrmation: WELL ABANDONMENT DETAILS
William.Ewing 7a.For GeoprobdDPT or Closed-Loop Geothermal Wells having-the sane
we41 Carn7sclor Name(or well awne ptssorally cboondomog well on hWha property) well construcuonldepth;only I GW-30 i�,n 'dad. Indicate TOTAL NUMBER of
wefts abandoned:3110
NC Well Coevectrx Cenillcauan Nvmhx 7b.Approtimate volurtm of venter mnmirung in well(s): t� L�
Crawford Environmental Services FOR WATER-SUPPLY WELLS ONLY: --
Company Name - .
0 7c.type or disinfectant used:
2.Well Construction Permit 9: Unknown
List o ,r,p ccmr il ruable+-Il rrarrtan pemuts Re UIC.Cnm Stela Variances etc)iffJm `
t un •7d.Amount of disinfectant used;
F. 3.Well use(check well use):
Water Supply Well.. 7c.Scaling materiuls.used(check all that apply):
y' OAe iculu tnl O tunlcipaVPublic AN at Cernent-Grout ❑Bentomte Chips or Pellets
t,
OGLothermal(fleamng/Ctwling-Supply) ❑Residential Water Supply(single) O Sand Cement Grout O Dry Ctay
'Olndustrial/commeiclal OResidential Water Supply(shared) O Concrete Grout ❑Drill Cuttings
�_IIrri -on- ❑Specialty Grout ❑Gravel
Non-Worter Supply Well: y, Cl Bentonite Slurry, Other(explain under 7g)
Vhfaniwring - ❑Recovery
Injection Well: 7E For each material selected above,provide amount or materials used:
OAqueferRecharge OGmundwaterRcmeiiation �C(165 D�jyt�GLe++�t~
j F
i QAqur[er Starngc and Recovery i35alinity Barrier
OAqutfer Test OStonnwater Drainage
❑Experimicntai Technology OSubsidence Control 7g.Provide a brier description of the ubaailonmenl procedure:
OGeothersonJ(Closed loop) OTraccr
OGcothermal(Heatin Coolin Return) OOlhsv(ex lain under 7 )
// ��;�_
4.pate svcll(s)abandoned: f9 lV Z
7
52.Well localiiitr:
Scotchman#45(GPM 3045) UST 0-020164
Facility IDM(if applicable) 8,Certification:
FociGty/Owrrt:rNans �.;rt ,�,n•, F'� "' e I-
�� lrcr� ,r �r a71.,ts�1�'!G Ui�l
2347 Catherine Lake Road, Richlands, NC -Zc�� z-l—
Physical Address.City.and Zip Signaltae of Cenifled Well Contractor or Well Owner Date
Onsjow 031083 By signing this form. I hereby cerrifi�dour the weB(s)8.as(urre)abandoned in
County Peal identification No.(PEN) accordance with 15A NCAC 02C.0100 or 2C 0200 Well Construction Standards
and that a copy of this record has been provided to die well owner.
5b.Latitude and,longitude in degreeshminutes/sewnds or derimal degrees:
(if well field,one lat11ong u sufficient) 9.Site diagram or additional well details:
34.828266 N 77.578272 Iv You may use die back of this page to-provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS S OF WELL(S)BEING Al1ANDONF.n SUB�IITT,U.INSTRUCT-IONS
rUrachwell construction recordfr)ifavailable:For mulapte injection orwn-warrrrupplynt!Ib - ,
ONLY wfth the same cogitrurtian/abandann enl,you cm mbmlr one fora 10a.For All Wells: Submit this farm within 30 days or completion of well
_6 abandonment to'thc following:
6s.Well ID#:r
Division or Water Resources,Information Processing Unit,
6b.Total well depth: �- Z (rt.)• 1617 Mail Service Center,Raleigh,NG 27699.1617
10b•For lniection Wells: In addition to sending the form to the address in 10a
j tic Borehole diameter. (in) above,also submit one copy of this,farm within 30 days of completion of wall
abandonment to the following:
6d.Water level below ground surface: k-6 '2- (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ccnter,Raleigh,NC 27699.1636
6e.Outer casing length(if known)- (ft.) 10c.For Water Supply&Iniection'Wclls: In addition to sending the form to the
addresses)above,also submit one copylof this fort within 30 days of completion
of well abandonment to the county health department of the county where
6r.Inner casing/tubing length(if known): (ft.) abandoned.
i
6g.Screen length(if known): _ _ (IL)
Form GW-.10 North Carolina Departacnt of Ery uonm:ntal Quality-Divnion of Water Resources Resked 2-11-2016
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WELL ABANDONMENT RE,CORD For Itim-nal Use t7NLY
1.Well Contractor Ild'Ormation: WELL ABANDo,-,;NmrN'T Di?TAIhS 1
William Ewing 7n-For GeoprobdDPT or Closed-Loop Geothermal Wells having aic s nie
Well'Comuncror Name tot well owner perwnalty,s_bandomas vweli on hivbcr property) well construction/depth,only OW 30 is nLded. Indicate TOTAL NUMBER of
3110 wells abandoned- t
p
NC well C:i Ior Cerdficarom Nw ilzr. 7b.Approximate volume of water remaining in well(s): (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONL I Y:
- Cotrtnay Nnmv
7c Type of disinfectant used:
2 Well Construction Permit 0, Unknown
Lan all applicable wrll=muructmn perrun/i.e UIC County.Srom Yaruun-r,etc)i/lnnxx "
7d-Amount or disinfectant used:
3.Well rose(cheek well use):
Witter Supply Well: 7e.Scaling materials used-(check all that apply):
OAg:-icultural ❑.lunicipal/Public 06cat Cement Grout 0 Bentonite Chips or Pellets
U -lGeotherntal(licaunp/Cooling Supply) CResidential water Supply(single) 0 Sand Cement Grout 0 Dry Clay
!I' PubdustritdlComn�rcial 0Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Olrrt atitnt 0 Specialty Grout 0 Gravel
)I Non•Waier SuPP( Well:
O.other(explain under 7g)y
kMMunnnnng ORccovery
g Injection Well; 7f.For each material selected above,provide amount of materials used:
OAtimfcr Recharge ❑Groundwater Remcdiation l 7—
CC
7Arluifrs Storage and Recovery OSalinity Barrier
° 0Aqusfer Test GStormwate r Drainage
CExNrli=nW Technology OSubsidence.Control
7g.Provide a brief description of the obandonmcnt procedure:
u C]Gcwlhcrm-al(Closed Loop) 0 Tracer
elGeotherm l(Flcadrt Coofing Return) ❑Other(explain under 7 )
o _ C n ems-a
4.Date well(s)abandoned: � 'I�" 2 Z '� r `a 9 t"P•fie
So.Well location: JUL 8 2022
Scotchman#45(GPM 3045) UST 0-020164 p
FecilitylG.ner Nome Facility applicable) Si Certification: J IDM(if a I/O A
2347 Catherine Lake Road; Richlands, NC ;1 Q,el�i;�sl ai�Zu C I. )J�E
�a
Physical Address,City,and Zip Signature o[Certified Well Contractor of Wcll Owner Date
Onslow 031083 By signing this form. I hereby rerrify that the well(s)was(were)abandoned in
C,„,,,,y Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0160 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 degrceslminules/seconds or decimal degrees:
(f well CWK one ladloog is sufficient) 9.Site diagram or additional well.detuils:.
34.828266 N 77.578272 1V 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 W6LL(.S)BRING ABANDONED SUBMITTAL INSTRUCTIONS
Auach"llcimiruclwnncord(s)ffamihible For multiple injection orno n-wnrersupplywellr
ONLY with the some consinxtion/abandonment,you can submit one form 10a. For All Wells: Submit this farm within 30 days of completion of well
6a.Well ID#: s~ abandonment to the following:
Division of Water Resources,Iiiforination Proccs'sing Unit,
6b.Total well depth: I (ft.)
1617 Mail Service Center,Raleigh,NC 27699.1617
101).For Inicction Wells: In addition to sending the form to the address in 10a
6e-Borehole diameter-. (in.) above,also submit one copy of this fort within 30 days of completion of well
abandonment to the following:
6d.Water level below grgund surface: 7 (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fit) loc.For Water Supply&Inicction Wells: In addition to sending the form to the
addresses)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 Of known): (fl.) abandoned.
i
6g.Screen length(if known): (ft.)
1 Form GW-)0 - North Carolina Department of Environmental Quality-Division of Water Resources_ - — Revised 2122-2016
I

I
WELL ABANDONMENT RECORD For Internal We ONLY
1.Well Contractor Information-. WFLI,ABANDONMENT DETAILS
William Ewing 7a For GeoprohclDl'T or Closed-Loop Gcothcrmal Wells having the same
Well CorarWor Narrc rs tar well owr=peonally abandoning,well on htslhcr property) well eonstructioNnlepth,only I GW-30 is n eded. Indicate TOTAL NUMBER of
3110 wells abandoned:
�—
NC Well CaramewrCeruficatwn NumUcr 7b.Approximate volume of water remaining in well(s): 5 (gol•)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
mpa y
Ca n Yatrc 7G'Iypc of disinfectant used: �
L Well Construction Permit p: Unknown
Cut all appta ab/e well mvrmetian pumas(Le tAC.C owr`..State.Yariame.ere)if hlov n
7d.Amount of disinfectant used:
g 3.Well use(check well use):
WatorSupply Well: 7a Scaling materials used(check all that apply):
CAgriculturdJ CMunicipaMblic IYNcat Cement Grout C Bentonite Chips or Pellets
CGeothLsrrtal(Ileating/Cooling Supply) ❑Rcsndential Water Supply(single) C Sand Cement Grout O Dry Clay
01ridustnnllCommerctal QResidential Water Supply(sharul) O Concrete Grout C Drill Cuttings
❑Irrinntion ❑Specialty Grout ❑Gravel
1. Non-Writer Supply Well: C Bcntonite Slurry ❑Other(explain under 7g)
y• ®19onitrmng CRecovery
j injection Well: 7f.ror each material selected above,provide amount-of materials used:
DAquifer Recharrp CGroundwater Remediauon
t CAquifer Storage and Recovery ❑Salinity Barrier f J
CAquifcr Test ❑Stormwater Drainage
CEeprnmenat Technology CSubsidence Control 7g.Provide a brief description of the abandonment procedure:
GGeothermal(Closed Loop) CTmcer
CGenthermal(Hea&glCoolin Return) ❑Other(explain under 7 ) r c—
IV
4.Date wcil(s)abandoned:G
Jlll 1 � 207_?
Sa.Well location:
Scotchman##45(GPM 3045) UST 0-020164 � r�r
tie�yr _. l � ��
FaciEr}'Oaroar Narric racihty 00(if applicable) B:Certification:3llU 111;)r+t�,�.9a-TI�A Pp'oc'l nil'vG UNIT
fivtR7+v7rrr i
2347 Catherine Lake Road, Richlands, NC
Fhysial Adana,City.trod Zip Signature ofCenifled Well Cottiracter or Well Owner Date
ODSIOW 031083 By signing this form, 1 hereby cerrify that the well(s)was((sere)abandoned in
Coualy Parcel Identification Na(PlIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Cohsirucrion Standards
and Thar a copy oJ'this record has been provided to the well owner.
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(if well field,ax taulong is wf inerit) 9.Site diagram or additional well details:
34.828266 N 77.578272 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 me ssary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED, SUml%in-A1,INSTRUCTIONS
.lnachwrflconytracrianrernrd(j)Ijaraifable Forrwltiple injection ornan-wnrerrupplyaeftr _
ONLY with the name conrlructlarJabarufann,nt.yw can rubmrr one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID0- �' i^' Z/ abandonment to die following.
Division of Water Resources,information Processing Unit,
66.Total well depth: ?It. (f4) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lniection 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.
6d.Water level below ground surface: (�' / (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1I
6c.Outer using length Cf known): (ft.) 10a For Water Suaoly R 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 cu-inglWbing length(if krroRn): (fL) abandoned-
6g.Screen length fir known): (rL)
i
Forts GW-30 North C=lusa D,parmcm of Envs,-anm;ntal Quality-Division of Water Resources Reused 2-22-2016
i
i
i
g

• i
WELL ABAND01WENT RECORD For t5ermlUmNNIN
1.Well Coatmctor Istfaroatiea: WELL ABANDO."IMNT D6"1'All C``
William Ewing 7a.For GeoprobdDPT or Closed-Lotip Geothernud Wells hating the saute
w'7 Coitirx cn Mama for-ta ewrea pCrsac3Gy ftb=n ZJ:es ae11 an h vbcr property) well cansmicdorildepth,only I G4V-30iit needed. Indicate TOTAL NUMBER of
3110 tvcM abandoned: 1
Nu aicr 7b.Approximate volume or water reiimining in wcll(s)- °` / (gal.)
Crawford Environmental Services FOR WATLR SUPPLY WELLSONLY:
7c.Type of disinfectant used:2-.Well Constractian Permit&: Unknown
Lu;,�ry:r-;�-�-te,sc',/m"�rvr.c,�perm,•'tr it e L7C.Ccrety.Sratp.l'ar:x-r.e:, 1JLv:�a
7d.Atrrount of disinfectant used:
3.Wru use(check web use):
Water Sapply Iti'edl- 7e.Scaling materials used(check all that apply):
oAgricul=ral OMunicipallPubfic r9kXeat Cement Grout O Benronite Chips or Pellets
G=1112�_ (}ieaunglCoaLng Supply) DResidential Water Supply(single) Q Sand Cement Grout D Dry Clay
GL rstn CoamtxrcW CRendential Water Supply(shined) G Concrete Grout G DnB Cuttings
G 0 Specialty Grout O Gravel
Noe-Wafter Supply Well: G Benionite Slurry Cl Other(ezpWu umk-s 7g)
6"1"�-gig ORccovery
Iajectioa Well. 7f.For each material selected above,provide amount of materials used:
0Aq:;-':'er Recharge GGroundwater Rcrnediation ) /
ifcr tied R q<r l O S �.>y.r�. ✓e e•
' A4` Stnra� Recovery GSasfiniry Barrier -
CA lCc-r'rev ❑Stormwater Drainage
GEvperirnr_-.W Technology GSubsiderrce Control
7g.Pro vi
tud; de a brief description of the abando amen t p �urei p� r
Gecrmal(Closed Loop) 7Tracer lY F�
O7C<wthcr al(Hcarin oohs Return) ❑Other(explain.under 7 ) Ti9r n ..,'r✓ i/t r 5 rLs t•? �<— �%f�
1v s /:;. JUL 1 S 2022
4.Dose vtcll(s)ubaxidnnrd: -
rnrarl Q�,f`-rl
St.Wcu location;
Scotchman 945(GPM 3045) UST 0-020164 '' ?1 pi-1,OCESvIN IJNI,
Fa L!r4X*er.,Nz= Facility[Da(if applicable) S.CertYication:3 I1
2347 Catherine Lake Road, Richlands, NC
Pticsi=l A!Grast.City.ead L7 Signature of Certified Well Contractor or Well Owner Dare
Onslow 031083 0y signing this form. I hereby certify that the rvell(s)ens(were)abandoned at
County Parrot identification No-(PN) accordance frith 15A NGIC 02C.010t7 or 2C.0200 Well Construction Standards
and that a copy of thin record has been prmided to the well ox•rer.
5b.Uthudc and longitude in degrees/minutedsecunds or decirmtl degrees:
(if well fickL a<e taall=g is sufficient) 9.Site diagruni or additional wrll•detiails:
34.828266 N 77.578272 W You may use the back of this page to provide additional well site detailc.or well
abandonment details. You may also atpich additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMTI'TAI.INSTRUCTIONS
tcrxhxrl(consrrucrirmrerar!/t/iJa:arlable. Farrudripfein�ecuonarnon-xorertupplyxeflt ONLY wnh the came canar¢ctlur✓abandaramera:you cansubmir one form. 10a. For All Wells: Submit this form within 30 days of completion of well,
6a Well IDg: Wt r✓ ! abandonment to the following:
Division or Water Resources,Information Processing Unit,
66:Total c*eB depth: {ft). 1617 Mail Service Center,Raleigh,NC 27699.1617
106.For Inicclion Wells- In addition to sending the form to the address in 10a
6e.Borehole diameter- (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.• r C _(ft.) Division of Water Resources,Underground Injection Control Program,
1636,NWI Service Centcr.:Palcigh.NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Sunaly&Inicclion 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 I health department of the county where
6L Inner ensingftubing length(ir known): (f6) abandoned.
6g.Screen length(if known): ([L) I
I
Form GW-30 Nonh Cs lica Deportment of Eawroarrental Q©fity-Division of Water Rv ourm i Revised 2-22-2016
I

WELL ABANDONMENT RECO" For lntcmil Use 0NLY
1.Well Contractor Inrormation: WELL ABANDONNTrI-17 DFTAIiS{
William Ewing 7a.For GcoprobdDPT or Closed-Loop Geothermal Wells having the same
\Nell Comuactar Name(or vcll owrr.•r personally abandoning well on hidher property) well co astnution/depth,only I GW-30 is ceded. Indicate TOTAL NUMBER of
11 0 wells abandoned' � I
33 Well Cnnunctrn Cmnfi.atwn Nurntcr 7b.Approximate volume of water remaining in well(s): D (gal•)
Crawford Environmental Services FOR WATER SUPPLY WELLS OtiLY:
Company NatrN '
7c.Type of disinfectant used:
7-Well Construction Permit S: Unknown
Lot all oppl:rahle-rU cnnrrrvcrimn permias n.e.UIC Cwmre.Stora•Variance.err.)if knrwrt
7d.Amount of disinfectant used:
3.Well use(check well usr)t
Water Supply Well: 7e.Scaling materials used(check all that apply):
CAgr-cultural ❑NtunicipaUPublie �,-Ncat Cement Grout ❑Bentonite Chips or Pellets
,-3Ccoftrm2l(Hearing/Cooling Supply) C1Rcsndcndal Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
00ndustnal/Commcrcial OResidenlial Water Supply(shared) O Concrete Grout ❑Drill Cuttings
Olniradon O Specialty Grout ❑Gravel
{ Nan-Water Supply Well: ❑Bentonite Slurry O Otlus(explain under 7g)
l EI.Mcnitering ❑Recovery
Injection Well: 7f.For cuch material selected ahov/q provide amount of malerials used:
GAquifcr Recharge ❑Groundwater Rentediation q'i/6,
�! OAqui(cr Storage and Recovery `JSslinity Barrier _r
l QAquifer'Tesst ❑Stormwatcr Drainage
li ClEzperirrcnud Technology OSubsidence Control
7g.Provide a brief description of the abundonment•procedurc:
CCcnthcnrud(-Clo-icd Loop) OTracer y
i C OsarMJ,�/PJi �J �✓Tor.l`. /�v.... crc .�
Gendtermaf(1Teadn f Coolnng Retumj Cbther(cz lain under 7 ) � ; � sa=Vz�
St.R r9�r
4.Detewell(s)abandoned: JUL 1 2022 ID
So.well location:
Scotchman l#45(GPM 3045) UST 0-020164 ,��±
Fmcibty/Owncf Narne Facthry IDd(if applicable) '-- g•Certification: 3 I Irir•C �„^,�1 I(,sl PRO TSSING UNII
2347 Catherine Lake Road, Richlands, NC � - G-Zv-I- --
Ph�y xzl Ad6ms.City.and&p Stgmtiuc of ccnifted wcodiunctor or Well 0--mr Dare
Qnslow 031083 By signing this forrn, I hereby rerrify rhat the well(s)was(were)abandoned in
County Parcel Idemificauon No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been'pravided to the well owner.
Sb.Latitude and longitude in dcgms/minulcs/secronds or decimal degrees:
(if n..elt Gdd,one IxJtamg is sufficient) 9.Site diagram or additional well details:
34:828266 N 77.5578272 W You may use the back of this page to'provide additional well site details or well
abandonment details. You may also atinch additional pages if necessary.
CONSTRUCTION DFTAIi S OF WFI-I,(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
,L-4cAweUca.strucrionrecardfr)/mzritable.For mtriple injection ornan-wvier supply wells
ONLY tidt the samecartrrucrirr✓abandanmerr.,ynvcaasubmirone/orm. 10a. For All Wells: Submit this forth within 30 days of completion of well
6n.Well IDd: f"t' " L abandonment to the following:
Division of Water Resourcm Information Procesing Unit,
rib.Total well depth:
2 /" (d't-) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Irtieetion 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
�j abandonment to the following:
I / (fL) Division of tauter Resources,Underground Injection Control Program,
Gd.Water level below ground surface: 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A) 10c.For Water Supply C Inicction Wells: in addition to sending the form to the
address(,,,)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
6L inner casing/tubing length(if known): 60 abandoned
i
6g.Screen length(if known); (ft.)
I
Farm GW-30 North Carolim Deparumni of linvironormal Quality-Division of Water Rerouscts I Revised 2 2Z-2016
i
I

WELL ABANDONMENT RECORD For!dean!Use ONLY
1.Well Contractor Information: N'IiLI.Af1ANDON�iENT DETAl1 S
William Ewing 7a.For Geoprobdl)PT or Clod-Loop Geothermal Wells having the same
Well Cmiumtor\anr for w w•rcie well or p emily abvidomnb aril on hnllrt pWrly) well construction/depth.onV l GW30 is,n i died. Indicate TOTAL NUMBER of
3110 wells abandoned:
NC w"UI Coar=ar Crntfi lmn Natter 7b.Approximate volmne of water re I rang in wcll(s):�y(gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
corranny:Nana
t 7a'Type of disinfectant used:
2.Well Construction Permit Y: Unknown
L_rt elt..r?ca'^'a,a:a�vur�ctr::z p<rmits(Le.UlC Cunm Slate,Valiance.etc./tJlzom
tb' 7d.Amount of disinfectant used:
j 3.Well use(check well use):
i Water Supply Well: 7e.Scaling materials used(check all that apply):
:Agricultural CMunicipal/Public iQNcat Cement Grout 0 Bcnwnite Chips or Pellets
CGecLhermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout O Dry Clay
0"Irdut mucorroacm ad ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
G'Im ,uan ❑Specialty Grout Cl Gravel
Non-Wnter Supply Well: ❑Bcntonitc Slurry ❑Othcr(explain under7g)
R.Manitonng oRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
L Aquifer Recharge CGrouedwnter Remediafion `f ��>S �J✓"c(�L e..w�
f e7Aquifcr Steragc and Recovery CSalinny Barrier
CAqulfer Test CStorrnw•alcc Drainage
OF-xpedract ual Technology CSubsidence Control 7g,Provide a brief description of the abandonment procedure:,
CGeotlicrmal(Closed Loop) (]Tracer
CGeothetmal(Heating/Cooling Return) COther(ex lain under 7R) Z+ ^" ! 4 f F✓`v .r .
la
a.Date well(s)abandoned:
So.Wen Ioution:
Scotchman#45(GPM 3045) UST M20164
8.Ccrtilleation. (�f r n S4{�;i p��C, UN111
F-aci!ity/0%=Nitine Facility1DVpfapplicable) tAii(l.,ta
2347 Catherine Lake Road, Richlands, NC (�_ 2 v- 2'L_
Ph)siral A&ress.City,aW Tsp Signature of Certified Well Contractor 'Yell Owner Data
Onslow 031083 By signing rids form 1 hereby certify.hefts fire well(s)was(ii•ere)abandoned in
Couay Puccl ldenuficalion No.(PIN) accordance wirli 15A NCIC 02C.0100 or 2C.0200 Well Construction Standards
anti drat a copy of this-record has been provided to the well ovner
5b:Latitude and longitude in degreeslminutes/seconds or decimal degrees:
Cif well field,are tatltona is sutficica) 9.Site diagram or additional well derails:
34.828266 77.578272 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 DL+TAILS OF WI?LL(S)BrING ABANDONED SUBMITTAL INSTRUCTIONS
Aaathwzllcanatracttmtrer�rdfr/i/avarlobft,for mulliple injection ornon-wwurvpplywrfis -
OA'LY with the tame canrtrucno Jabs tQanrnrnf,)au can submit one form. I Oa. For All Wells: Submit this form within 30 days of completion of wen
6a.Well 1130: n'I t✓— abandonment to die following-
Division or Water Ranurces,Information Processing Unit,
66:Total well depth: A)Z A) 1617 Mail Service Center;Raleigh,NC 27699-1617
10b,For Iniection Wells: In additiop to sending the form to the address in Ida
6c.Borehole diameter. f�Q— (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: 7, 7 .(rL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c Outer casing length(if known): M� (fL) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
addrms(cs)above,also submit one cagy cif this form within 30 days of completion
of well abandonment to the county,hadth department of the county when:
6f.Inner casinijtubing length(if known): N �r (fL) abandoned'
6g.Screen length(if known): N (ft)
Para GR'-19 %%=b CiroGm DciSmrm-e ofCnvcbnnencd Ouabty Di%ision of\Yarn Rcsour= 1L-r,ud 2 22.2016
� I

WELL ABANDONMENT RE1CORD For Internal Use ONLY
1.Well Contractor Information: WELL All AINDOVNuar DFT III SI
William Ewing 7a.For GeoprobdDlvf or Closed-Loip Geothermal Wells having tan same
well Coma Tor Naas(or yell owner tcnoaally ahardentng well on his/her pn,porty) well eonstruelionhdepth.only I GW-30l16 i cetkd Indicate TOTAL NUMBER of
3110 wells abandoned. 1 ff
NC well Couur .tor Celitllcatmn Number 7b.Approximate volume of water re i ining in well(s): D_ S (gal•)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
l'art!puny\aaho
7c.Type of disinfccWnt used:
IWell Construction Permit N: Unknown
l.ui all apaitcahle welt ce urrvctlon permits(r.r UfC.Count)•.Stma Variance,ear)if tnown
7d.Anromri of disinfectant used:
J.Well use(check well use):
Watrr Supply Well: 7e,Scaling materials used(check Lill that apply):
I OAgriculkuml CMunicipal/Public Ncat Cement Grout O Bentonile Chips or Pellets
19 OGcothcmtal(licaung/Coolmg Supply) OR(nidential Water Supply(single) 0 Sand Cement Grout Dry CInY
01ndustial/Commercial ORtsidential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
Distillation C3 Specialty Grout 0 Gravel
Non-Witter Supply
Well-0 Bentortitc Slurry ❑Other(explain under 7g)
lllMoniioring 0RccovLry i
Injection Well: 7f.For each material selcacd.above,provide amount of materials used:
OAquifer Recharge 00mundwater Remcdiation
Mquifcr Storage and Recovery OSalinity Barrier
OAquifer Test CSlomhwater Drainage
Oli-eperimcmal Technology OSubsidence Control
Tg.Provide a brief description of the'abmnduttmenf promduro:
0Gcrotiremlal(Closed LAW) ❑Tracer
OGeadhcmtal Mcatin Cuolin Return) 00ther(ex lain.under 7 ) ��e"
k ^'
P A J�
J.Date well(s)abandoned: I4"��' Z _ J U I 18 2929
5a.Well location:
Scotchman #45(GPM 3045) UST 0=020164 Ya r�II 'd
B:Certification: J� /7— ^��2 � {{Pp'OCESSI'N"G! nI
PactGty%Owtty Naas Futility[Di(if applicable) O li-.i 't7G f'r1 >,r7 7 Jf�l
2347 Catherine Lake Road, Richlands, NC �vZ��.,
Physical Address.City,and Tip Signature o 'fled Well Contractor or Well Owner Date
OnsIOW 031083 By signing this form, I hereby cervify;'that the ivell(s)was(were)abandoned in
County Parcel Watifhcation No.(PIN) accardmnce wish 15A NCAC 02C.OIOQ or 2C.0200 Well Construction Srandards
and that a copy of this record has been provided to the well owner
56.I,ntitudc and longitude in degrecs/minuleslscconds or decimal degrees:
(if-11 fold.one lat/iong is sufficient) 9.Site diagram or additional well details:
34.828266 y 77.578272 1V You may use the back of this page to:provide additional well site details or well
abandonmcnt details. You may also attach additional pages if nece ssxy.
CONSTRUCTION DETAILS OF WEI,L(S)BEING ABANDONED
SUBMITTAL IN,STRUCI'10\S
Attach well constiuciion record(s)ifuvailable.For multiple injection ornon-tinter supply wells -
ONLY with the same constructka✓abandonment.)wu can submit one fomr. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDS: fiel w— abandonment to the following:
-
Division of Water Rcsourccs,Information Processing Unit,
6b.Total well depth: (fit.) 1617 Mail Service Center,Raleigh,NC 27699.1617
t0b.For Injection Wells: In addition to sending the form to the address in iOa
6c.Borehole diameter: (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: at.) �
( Division of Water Resources,Uniderground Injection Control Program,
1636 Mail Service Ccritcn,Raleigh,NC 27699-1636
6e.Outer losing length(if known)- (ft.) 10c.For Water Sootily S Injection Wcills: In addition to sending the form to the
address(m)above,also submit one copy bf this form within 30 days of completion
of well abandonment to the county 1)calth department of the county where
6L Inner casing/tubing length(if known): (fp) abandoned.
6g.Screen length(if known): 66)
Form CM 10 North Carolina Department of Environrrcntal Quality•Division of Water Resources Revised 2-22-2016
f f
I'

FELL ABANDONMENT RECORD For lnecrosl Use ONLY.
I I E==
1.Well Continctor Information: WELL ABANDONMENT DIlyis i
William Ewing 7a.For Geoprobc/DPT or Closed-Loop)Icothrrnml Wells having the same
Well Cocunctor Name tar well ownsT personally ahaosbnial;well on his/h.r property) well constmctioNdepth,only.I GW-30(�nclpdcd. Indicate TOTAL NUMBER of
wells abandoned-.
3110
�t weu Contractor Cen,rxaunn Number 7b.Approslnmte volume of wntcr re i ining in well(s).- (gal•)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONVYi
I,
Couip"y Name lc.Type of disinfectant used:.
!:WellConstruction Permit#t: Unknown I'
Ilrt all applk.,chte hrU ccncanrrtlon permirr li.e UlC_Cawnm-Stnre.Voriuncr.em),fino m
7d.Amount of disinfectant used:
3.Well use('check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
C4lgri cultural ❑MunicipaVPublic Neat Cement Grout (; ❑Bentonitc Chips or Pellets
CGeiuhenttal(licating/Cooling Supply) CResidential Water Supply(single) ❑Sand Cement Grout C Dry Clay
QlndustriallCummcred GResidential Water Supply(shared) Cl Concrete Grout {; C Drill Cuttings
Oinieation C Specialty Grout C Gravel
r Noe-Wa tr Supply Well: C Brntmtitc Slurry � ❑other(explain under 7g)
t ®Monitoring ORccovcry,
c Injection Well: X For each material selected above,pro
vide amount of materials used:
r OAquiferRecharge Maxaundw•atcr.Remcdiadora
0Aquifer Storage and Recovery OSalinity Barrier
ClAquifer Test CStnnnwater Drainage
CE,perimenW Technology CSubsideru; trot
7g.Provide a brief description of Ute abandonment procedure:
❑t,eottternral lCioscd trap) f7Ttaeer _
7. CCseoftmatl(Eleatina/Coolin Return) C(Othes(ez lain.under7 )
i. 4.Date well(s)abandoned:
r
g Sa.Well location: .1UL 1 8
Scotchman 945(GPM 3045). UST 0-020164 ,
FtritirdOwncr Name - Facility[De(if applicable) 8.Certification. 3/to
2347Catherine Lake Road, Richlands, NC / k RJtI;'d
Phyucal Address.City.and Tsp Signature of Certified Well Coo nTi va-Welrowper Date
QTISIOw 031'083 By signing this form-I hereby certify that the ivell(s)was(were)abandoned in
County Panel Identilicrtion No.(M) accordance with 15A VC,%C 02C.0100+r 2C;0200 Well Ctnstruciion Standards
and that a ropy of this record Iuu been pimided to the well osvnee
5b.Latitude and longitude in degreeYminutes(seconds or decimal degrees:
(if well field.am latlkmg is suf@cirm) 9.Site diagram or additional well details:'
34.828266 IN 77.578272 INYou may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages iCriccessary.
CONSTRUMON DETAILS OF WELLS)BEING ABANDONSB SUBMITTAL INSTRUCTIONS
Amchwellcemstrortionrecard(s)ifmniWie.For nueltfpklnjerlionor non•hulertupplrwrily
OVLy wtih the same rmutrrxri:xtlatiardanme+n,yTn+eon submit one farm 10a.For All Wells: Submit this font within 30 days of completion of well
taa.Well[B t'✓ 2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
a 66.Total well depth: r'Z- A) 1617,Mail Service Center,Raleigh,NC 27699-1617
I
10b,For Inieclion Wells: In addition to sending the form to the address in 10a
6c Borehole diameter: fin.) above,also submit one copy of this roar within 30 days of completion of well
abandonment to the following:
6d:Water level below ground surface: (r 2—S Division of Waiter Un ter Resources, der ground Injection Control Program,
(f►) 1636,Nlail Service Center,Raleigh,NC 27699-1636
6e.Outer easing length(J known):
l0c.For�ester Supply&Injection Wells. In addition to sending the form to the
(ft.) )
adtlmss(cs)above also submit one copy of yhis form within 30 days of completion
of well abandonment to the county tic:ath department of the county where
6f.Inner casing(lubing length(if known): ([(,) abandoned.
6g.Screen length(if known):
F•orrh Gw.)0 Noah Carolina Department of l nvironimntal Quality-Division of Water Resources { Revised 2.22:20I6