Iredell_Well Abandonment_20220923

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Norman Travis Costello 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
2251-A wells abandoned:NA
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 150 (gad)
TNJ Brush Cutters, LLC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:_Chlorine Granules
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.)ii known 1 6 ounces
7d.:amount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Coo svuap ry IfgsiAll— Rater Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial �tesidet$iatWater Supply(shared) ■Concrete Grout ❑Drill Cuttings
Olrrigation !, ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: — ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring '>r,. Uftc
Injection Well: `j1t ro,•',�jvt 7f. For each material selected above,provide a mount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4 cubic yards
❑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
S3ME measured water levels and than added chlorine.The above grade concrete casing was removed and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
the soil was removed around the well.The concrete was then added until it manifested
4.Date Hell(s)abandoned: 8/2 5/2 0 2 2 at the surface and was allowed to overtop and fill the surrounded area to cap off the well
5s.Well location:
Williams Development Group LLC
Facility/OHnn \amc Facility ID#(ifapplicable) X.Certification: jlrsrv� /
East Barkley Road, Statesville, NC 28677 8/26/2022
Physical Address,City,and Zip Signal=of Certified Well Contractor or Well Owner Date
Iredell 4753276245.000 By signing this form, /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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lavlong is sufficient) 9.Site diagram or additional Nell details:
35.759522 N —80.847225 M 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)iifavailable.For multiple injection or non-water supply wells
ONLY with the some construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: NA abandonment to the following:
Division of Water Resources,Information Processing Uuit,
6b.Total Nell depth: 30.4 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 24 (ill.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.NN ater level beloN ground surface: 24 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if knim n): NA (ft) 10c.For Water Supply&Infection 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
6E Inner casing/tubing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
ICHD - Environmental Health Division - Private
Drinking Water Well Permit

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September 15, 2022
Division of Water Resources, Information Processing Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Reference: Well Abandonment
Barkley Road East
Statesville, Iredell County, North Carolina, 28677
S&ME Project No. 22690241
To Whom it May Concern,
As requested by Earnhardt Grading Inc., S&ME, Inc. (S&ME) abandoned a well on the property owned by Williams
Development Group LLC located off of East Barkley Road in Statesville (Iredell County), North Carolina.The
property was under construction at the time of the well abandonment. Historical aerial imagery indicates that the
property was previously a residential property, and the well was associated with the original residence.The
referenced well was abandoned in general accordance with current NCDEQ regulations Subchapter 02C—Well
Construction Standards - 15A NCAC 02C .0113 Abandonment of Wells. Additionally, Ms. Danielle Weiberg, a
representative of the Iredell County Health Department (ICHD),was present for the abandonment.We have
attached a Well Abandonment Location Plan,the NCDEQ Well Abandonment Record (Form GW-30 Form), and the
ICHD— Environmental Health Division—Private Drinking Water Well Permit to summarize the work.
If you need any additional information, please let us know.
Sincerely,
5&ME, Inc.
John S. Scott P.E. Frank Morris, P.E.
Project Engineer Project Engineer-Manager
Enclosures: Well Abandonment Location Plan
GW-30 Form
ICHD—Environmental Health Division—Private Drinking Water Well Permit

III
Well Abandonment Location Plan

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