Iredell_Well Abandonment_20240116

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. T,1_ leNorth Carolina Department of Environment mtci.Naturai Resources-�aDivisionf Water Quality
''' `:i S ATION#
�, - R CERTIFICATION it
°�• '':�- WELL CONTRALTO
•�'.--'. 6. ' in.
WEL1.CONTRACTOR: WELLDETAiLS: ft- Diameter. ; ---
a.TotalOepth
_ /
b.Water Level(Below Measuring Point):�-
Well C tractor{indivi al Name! Measuring point is ;:_..
above land surface.
5
m an Na a Length Diameter
Well Contractor C p y 2 6, CASINt3:
/ -,2 _lit.
a.Casing Depth(if known): r �_in.
Street dd', 1 f —�W-.----
b.Casing Removed:
• State, Zip Code Z
City or To n
7. D181NFECT�ON:
� � - " l• forite used)
•
� --����,,�, (Amount of 65%7570 calcium hypos h
Area code Phone number ' •
y,WELL INFORMATION: 8. SEALING MATERIAL:
SITE WELL ID# (if applicable) N8r31GEmCDt Salt ament
Cement _lb.' Cement lb.
(If applicable),-------- gal. Wate_r scat.
STATE WELL PERMIT# pp ) Water_—_
COUNTY WELL PERMIT #Of applicable}_ , BenMUS:
DWQ or OTHER PERMIT #(if applicable) 8entontte
06 lb. ` _c ��" '`
,+L if
�Restdenttal Slurry{�l PeOsts
WELL USE(Check applicable use) Monitoring Type gat. JA N j
r►cultural Water ('j 2Q24
0 MuhicipallPublic 0 in dustdaliCommercial Aft t>j;vrr,^'a.
OWL __ -o r i 1�,r.s. __
Cl Recovery injection U Irrigation p �• ,.� '� ,
Type material
tst use).
%7 other p' Amount
3,WELL LOCATION:
UNTY :1_ QUADRANGIE NAME 9. EXPLAIN METHOD OF
NEAREST TOWN: 6'"' s EMPLACEMENT OF MATERIAL:
-
J
�ion,Lot No.,Parcel,Zip Code) i ,.I
(StteeURoad Nance.Number,Community.SubdN
TOPOGRAPHC/LAND SETTING: P
0 Slope (Check Valley 0 Flat a Ridge Other_____.------ 1p, WELL DIAGRAM:Draw a detailed sketch of tteeli on the cba Y)
approp to setting) f this
form showing total depth,depth and diameter of s screens(fan)remainingea n
in the welt,gravel Interval,,intervals of casing perforations,
; _ 'OMS OR�.x._—x��D types of fill matedaistised
nd
LA NorruITuDE Ss, OMS OR7x �-
LONGfTUDE7�'r�"�
pS OTopographtc map : 11. DATE WELL ABANDONED
of a source WAS ABANDONED IN ACCaRDANCE.
(location of well must be shown on a USES topo map andattached to 1 Do HEREBY CERTIFY THAT THIS WELL this form if not using GPSj : WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
he businesswt�ere the well is located.Complete 4a i : THIS RECORD S BEEN PTVIDED TO THE WELL OWNER.
— ^
4a.FACILITY-The name ort DATE
(f aILI residential well,skip 4a;complete 4b,wed owner intomutior►oniyJ IE WELL CTOR
FACILITY iD#(if applicable) : SIG A R F
NAME OF FACILITY DATE
STREET ADDRESS ) : SIGNATURE OF PRNATE WELL OWNER ABANDONINI WELL
residential well
(The private well ownerrrwst be an Individual v iie
State Zip Code : in accordance with 15A NCAC 20.0113.)
Cityor?own �.U..Yr "r ./��l�aun s _
LL OWNER ABANDONING THE WE t1
4b.CONTACTPERSONMIE }� t;r Ic. 4 OLvctip PRINTEDNAMSOFPERSONABANDON
NAME -a^c}cxa�D}ara Y;tta. 41in
STREET ADDRESS 1 O�1C 5i'i r a l DD t Form GW-3A
to the°voter and the original to:Division of Water Quality
Information Processing' Rev.5110
Submit a copy
SetrviceCenter,Raleigh,NG 276ti91617,Phone t(999)i3Q7;f3300 ; ? `
1817 Mail ,

•• '.WELL ABANDONMENT:RECORD': : z. For lntemal:Use.ONL Y:
'1'.Well Contractor Information:' ' - •':' WELL ABANDONMENT DETAILS '• • • -
••Gate Simcox •Gory 7a.For Geoprobe/DPT •or •Closed-L Iop.Geothermal Wells having the same
Well Contractor Name(or well owner personally.abaandoning well on his/her property)_' well construction/depth;only)GW-3Q is needed Indicate TOTAL NUMBER of
. 294.4-8•. . . ..,. • . . wells abandon d: '. {.
NC.Well Contractor Certification Number • 7b•:Approximate volume of water remainingiri well(s): • (gal.) -
: S&ME,..InC.. : . . : FOR WATERSIIPPLY WELLS ONLY:; - : ' .. • .,
Company Name
7c.Type'of disinfectant used:'• ?'"
2:Well Construction Permit#:' :.
'List all applicable wellconsiruction permits(i.e.•UIC,.County,State'Variance,'etc.)if known ' : . •' ' ' ' :' ' ' . '' 'I • : '
. ..
7d.Amount-of disinfectant useda I.
3:Well use(check well'use):
.. - 'Water Supply Well:, : .. • : . . •- 7e.Sealing materials'used:(check allthat apply):- '
DAgricultural• ,.`• :• _ . - .,DMunioipal/Pnblic •
. : .CINeat Cement Grout • •.. Bentonite Chips or Pellets : ." • : . .
.
• • ❑Geothermal(Heating/Cooling Supply) • .'OResidentialWater Supply(single)'.. '❑ Sand Cement Grout • : . : .- ❑Dry Clay' : -•• .. ..
Olndustrial/Comritercial•• •' . ':' ' ,CiResidential Water Supply(shared) L7,Concrete Grout • • . .. El Drill Cuttings .•• " .
❑Irrigation : . . .' `'•• •:' • : . • -. . -•. • ❑Specialty Grout • •' ' ... • ❑'Gravel • ..
Non-WaterSupply_Well: • ". • ; . _ •0 Bentom Shirr);Slur ❑Other(explain g)under 7 .
uMonitoring•. ❑Recovery f
Injection Well:. .. .• _ 7f._For each.material selected.aboive,,provideamount of materials.used:. - . .
•❑Aquifer.Recharge .OGroundwaterRemediatioti • • . " .,•, i F C') •• •• "
DAgu.iferStorage.andRecovery -..• • . 'DSalinityBarrier
• • 50Ibs 11�
❑Aquifer Test •: ❑Stormwater Drainage'.' .. . ' N 1. .6.:2024 - ' ' • -
• OExperimental Technology.' : • .• ❑Subsidence'Control -- "' • • : " • ' • .. ' • , " • •- 7g Provide a brio ldesertpkion ofrtlte aband.annnt procedure:
•
•❑Geothermal.(Closed Loop)•.'• : ❑Tracer - .• - • •
•
: • ❑Geothermal.(Heating/CoolingRetum) '•.DOther(explainunder.7g)' . - •. Removed. •• - • •te pad'and 'protective cover.. ' .:
.
' • :Filled well casing with bentonite chips to surface
• 12/14/23 '
4.Date.well(s)abandoned:
Hydrated •bentonite ,
- ,5a ..
.Well location::- . • •
Nest Communities
Facility/Owner Name: • • '"Facility IDS/(if applicable) -' .-8:Certification i.. • ..
710 Shinnv lle'Road,.Mooresville, NC 1 z '' 12/23/23":
Physical•Address,City,and Zip .• •Signature of Certified Welk Contractor or Well Owner. Date
Iredell t fy"th
County " : " - : Parcel Identification-No..(PIN) :.
By sighing this form, I hereby cer i I at the tv'ell(s)was:(were)abandoned in
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 lat/long is sufficient), ,• '
' 9:Site diagrain:or additional well details: •''
• 35 39'..20.65j •••N. 80 • 48 39'-06• , .• . w You may use'the back of this page to provide additional well.site details or well .
abandonmentdetails..You may also attach additional:pages if necessary. '.
: CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED . •• • SUBMITTAL INSTRUCTIONS "
Attach well construction records)ifavailable..Formultiple injection or non-water supply wells . ,
• • ONLY with the samee cotistructioti/abandonment;you can submit one form. '.•" • • • • ' . '" ` • • • •• ' • ' • "
6arWell ID#: MVV I - • . ' •abandonment'to thle followingt this form wt - ' ..• • •thin 30 days of completion of well
' - -: Division of Water Resources,Information Processing Unit; - •
66.Total well depth: .33 _ (ft.) • : . Center,Raleigh;NC 27699-1617• • : •.3 ' . . . • Mail'Servi.
.. 2 ' • :: • - _. ' . lOb.For-Injection.Wells;_In addition to sending the form to_the address in I0a .
6c.Borehole diameter. • (in.) • above;.also submit-one"copy of this'onn,within 30•days of completion of well
• . - abandonment the'following - .
. . . . :. -
6d.Water level.below ground surface: Dry . : •: (ft.) Division of Water*Resources•,-Undergro•und Injection Control Program, . .
• igh,NC 27699-1636 1636 Mail Servrce Center Rale
•
6e.Outer'casing length(if known):.. (ft.) • lOc:For Water.Suanly&Injection Wells::In addition to.sendingthe 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 .'
6f.Inner casing/tubing.length(if known):" •• (ft •
.). abandoned.
:Screen len th if known)g g ( (ft.)..
•
.6 • • • .
•• Form GW-30 ,. ' . :.• • ', ' :• • ' • :North Carolina.Department of Environmental Quality-Division of Water Resources .?. . . Revised 2-22-2016 '

WELL ABANDONMENT RECORD: Fq�Intemal:Use.ONLY
1. •
Well_Contractor Information:. -. - • . .. WELL ABANDONMENT DETAILS" "
7• 7 Closed-Loop • h ".. • •• •. • • • .. • a.For Geo robe/DPTor Geothermal Wells' avin the same . '
Well Contractor Name(or well owner personally.abandoning-well on his/her property) well constru tion/depth,only 1 GW-3b is needed: Indicate NUMBER of '
. • :: 2944_6 -- :. : '
is abandoned: r
wel coned•
NC.Well Co'ntractor Certificat
ion Number ': • • 7b.Approx r rimaining in well(s): 0 (gal.)- imate volume of water
•: - : S&M E,:I nC..- : .•• • ; . FOR WATER'SUPPLY WELLS ONLY: -:-
Company Name . '.. "
. 7
c..Typeof disinfectant tsed:'.. i- ..
-List all applicable well construction permits(i.e.•UIC;.County,State;Variance,'ete)if known '' '' -- ' ' . ' . '• . • . • . .
• 7d.Amount'of disinfectant used:.
.
3:Well use(checkwell use): .'.: ..
Water Supply Well::: ,. -:• •".• ' •.• : . .. ". : . 7e.:Sealing materials used:(check all that apply):
.oAgricultural. :.• i'•.• :- :" : -,OMunicipal/Public• -". • : ❑Neat:Cement Grout - .. •: :.a'Bentonite Chips or Pellets .• '
• .❑Geothermal(Heating/Cooiing Supply): .DResidential Water Supply(single)' . '❑ Sand Cement Grout_" •• ❑Dry Clay:: • -.
DIndustrial/Commercial' ' •.. •=' .-' ' : .oResideritial Water:Supply(shared). 0 Concrete.Grout- • ❑Drill Cuttings "
.❑lriigation • . ❑ Specialty Grout • ❑Gravel
•Non-Water Supply_Well: ' ' • 0 Bentonite'Slurry .. ''. O Other(ex•plain undef 7g) :
" ®Monitoring,"" ' ❑Recovery -
. . Injection Well::.. .• • . . . • 7L•For each.material selected:above,,provide of materials used:.
❑Aquifer.Recharge .. .❑GroundwaterRemediation• -. "�`'--,r. ' ' - '
"Aquifer•Stora 'e and Recovery;. c Salini"Barrier• .,h. 4 , _
65Ibs ;..
❑Ali uifer Test : •. . . " ❑Stormwater Drainage• • • • ' . ' "- . • - "
- ❑Experimental Technology: :. ,. .• "DSubsidence'Control.•.- ' : • • .. •' ; • " - U CU14 -'
7g.•Provide.a brief descriptioQ of theabandonntent procedure: • •
•❑Geothermal.(Closed Loop).. • :• ❑Tracer":• ' • : . ' • " . Ill 'r r riie ll ;)!- .
- ' .❑Geothermal.(Heating/Cooling Return) • ❑Other(explainunder7g) : • Removed concrete•p .•arta r G: - -• 'cover.:
• ar
. ••
ith ben chips to Filled well casing w tonne surface;
1"2/14/23 r
4.bate.well(s)abandoned: e i
: Hydrated bentonit ...,.
: . 'Sa.'Welllocation::
Nest:Comrnapities .• : • : : • ••
: •Facility/Owner Name '•• • • '' . : • '' : • Facility ID#(if applicable) "
8:Certification: .
: :
71 O.•Shinnville:Road,. Mooresville, NC - . . li
.. Physical.Address,.City;and Zip ' ' - Signature of Certified Well Contractor or Well Owner Date' ' . -
lredell :' C •
_ • •" '• • - '• " By signing this form;I hereby-certifyi that-the"well(s) was(were)abandoned in •
County • : • .Parcel Identification No..(PIN) • •. accordance,with I SA NCAC.02C..0100 or-2C-.0200 Well Construction Standards- " '
- - • and that a copy of this.-record hos been providedow to the well ner.".. - •
5b.Latitude and:longitude in degrees/minutes/seconds or decimal degrees:
•'- :(i£well field,one.lat/long is sufficient)• '
.
o . t.. it o . t. n dia Well a 9:Site gram:or adilitioual 1 det tls:
35 39.•18.72. - 80 �48 44.33 - • -- • You may use'the back of this page to provide additional well.site details or well-
. _. :• _ . . abandomnent'details:._ . W ' . You ma also
o attach addiioa tnl•pages if necessary:.;:
.. .CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED . -•' SUBMITTAL INSTRUCTIONS
Attachri�ellconstructionrecordfs)ifavailable..For multipleinjectionornon-water supplyirells .
' " - 'ONLY with the same construction/abandonment you can submit one form: .' '' " ' • ''
• . • ... ' • 10a.'For All Wells:. Submit.this form:within'30.days of completion of well .
; '•6a.'Well ID#:• M W-2 ' "• • • ' ' • • • - abandonment to the following • • • •
• • ' 'Division of Water Resources,.Information Processing Unit;
41.0 1617 Mail'Service•Center,Raleigh;NC27699-.1617 '
6b.Total well depth: • _• {ff.)" : "
. !Ob.For Iniection'Wells: •In addition to sending the form•to:the address in l0a-
6c:Borehole diameter:'2 - • • (in)• • above also submit one copy of this form•within 30.days of completion:of well
.abandonment to the:following: .
' • - ' D n ces,Under g round Injection Control Program, ' 'ivisio of Water Resour
6d.Water level.below ground surface: �ry . {ft.) ,g
. 1636'Mail Service•Cen ter;Raleigh;NC 27699,1636
-• 6e.Outer •
length(if known):.. . . . ' . (ft) 10c;For Water,Supply&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 .
6f Innercasing/tubing.length(if known): -(ft.) 'abandoned. • - •
•
6g:Screen length(if known): '. (ft.)
' Form GW-30• • North Carolina.Department of Environmental Quality-Division of Water Resources - . Revised 2-224016
.

, WELL ABANDONMENT RECORD For Internal Use ONLY: ;
rn
'
1.Well Contractor Information: WELL ABANDONMENT DETAILS
GarySimcox
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-3 is needed. Indicate TOTAL NUMBER of
2944-B wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '75 (gal.)
S&M E, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: I.
List all applicable hell construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: I`
3.Well use(check well use): '
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural DMunicipal/Public 0 Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout i 0 Gravel
Non,Water Supply_Welh _ 0 Bentonite Slurry _B a- .t_ �❑Other(explain under 7g)
I1
Monitoring ❑Recovery t - - -
Injection Well: 7f.For each material se" lectcd 9bAk pf'oVide�amou t of materials used:
DAquifer Recharge ❑Groundwater Remediation 60 lbs JAN 1 G 2O?4
DAquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage !nfr r:r4- irn Prr-,,-.4: r,1 1!r•.
DExperimental Technology 0 Subsidence Control DV Qi OG
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Removed concrete pad and protective cover.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Filled well casing with bentonite chips to surface.
4.Date well(s)abandoned: 12/14/23 Hydrated bentonite. '.
5a.Well location: ,
Nest Communities
Facility/Owner Name Facility ID#(if applicable) 8.Certification: i
710 Shinnville Road, Mooresville, NC ...Z./ 12/23/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Iredell
By signing this form, I 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
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° 39' 21.48" N 80° 48' 46.98" 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-3 • abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 37.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
1
6d.Water level below ground surface: 32.43 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636 l
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&IniectionWells: 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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
f

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Simcox 7a.For Geoprobe/DPT or Closed-L lop 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
2944-B wells abandoned: E
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.0 (gal.)
S&M E, Inc. FOR WATER SUPPLY WELLS ONLY:
I.
Company Name 7c.Type of disinfectant used: I.
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 0 Neat Cement Grout U Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout • 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
__ Non-- ater_Supply Well: __ _ ______ _ Slurry_Bentonite Sl _ __ j 0 Other(explain under 7g)
UMonitoring ❑Recovery f --'; ---,: ,
Injection Well: 7f.For each material selectedrabove,:prgvijfe'gn'qjin-of I<na erials used:
❑Aquifer Recharge ❑Groundwater Remediation 65 lbs t1
❑Aquifer Storage and Recovery 0 Salinity Barrier 'l4 N 1 6 2024
❑Aquifer Test ❑StormwaterDrainage tR . T.y �� ` 7� +' �y
❑Experimental Technology 0 Subsidence Control r
•n.. l..eh.. Ui
7g.Provide a brief description of thC'ab"a�tilot► iettt procedure:
❑Geothermal(Closed Loop) OTracer
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed concrete pad and protective cover.
Filled well casing with Bentonite chips to surface.
4.Date well(s)abandoned: 12/14/23 Hydrated bentonite.
•
5a.Well location:
Nest Communities
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
710 Shinnville Road, Mooresville, NC �/ 12/23/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Welli Owner Date
redell By signing this form,I 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
and that a copy of this record has been rovided 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° 39' 25.90" N 80° 48' 41.39" `,l, 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)ij'available.For multiple injection ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 43.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 29.14 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centl r,l Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1
WELL s A1�TDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
r` ! J
• &19t i' $/4 1/11/ 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
wells abandoned: • {
ti /
•
NC Well Contra rt atio Number 7b.Approximate volume of Ovate remaining in well(s): '� (gal.)
C
• J0 c//J rI-76 r 75,
FOR WATER SUPPLY WELLS ONLY:
Company Name f"1tJ
� 3, 7c,Type of disinfectant used:
2.Well Construction Permit#: a( 41
1 � ) ��
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc)If known t
7d.Amount of disinfectant used:' t-
3.Well use(check well use):
Water Supply Well: 7e.Sealing material ect�(cheek all that apply):
0 Agricultural nicipaUPublic 0 Neat Cement Grout ''.° .(,,,. -' r•. '. i^Bent�nlaite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout J�N y
Din dustrialCommercial ❑Residential Water Supply(shared) IB'Concrete Grout G fO243 Drill Cuttings
❑Irrigation •. • ❑ Specialty GrcttlfOr,-74i i O iy. 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry Chic Jc J12wT l4tller(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /,, 1 ���
.0 Aquifer Storage and Recovery OSalinity Barrier
DAquifer Test ❑Stormwater Drainage •
❑Experimental Technology ❑Subsidence Control '
7g.Provide a brief description of:the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer /`+�n I J j f,,/ (t)p� t t1 h p ill ,� /i(
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) (� / /J Uv �/
11
4.Date well(s)abandoned: 8. -2 ? v2--? '
5a.Well location: •
• j b
• .0 4i,1 i/Y I' r /e tiAa Ore i,,,, .,e.
Facility/Owner Name Facility p it(if applicable) 8.Certification:
n) f1 'd�J�1 • �i / �� Ii-fiJ� �� J d R7-0
.PhysjwIddregs,City,and Zip Signature of Ohrtified Well Contractor of Well Owner Date
•• D � L!1 By signing this form, I hereby ce;tifi,that the well(s) 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.
•Sb:Latitude and longitude in degrees/minutes/seconds or decimal degrees: I,
(if well field,one lat/lotig is sufficient) 9.Site diagram or additional well,details:
35 �'1 ✓ N .G�� 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 SUBMITTAL INSTRUCTIONS i
Attach well constructionrecot d(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same canrction/chondonment,you can srrbmi!one Arm. 10a, For All Wells: Submit this form within 30 days of completion of well .
6a.Well ID#: .c 1
abandonment to the following:
•
Division of Water Resources,Information Processing Unit,
•
• 6b.Total well depth: J .& 5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
.� 10b.For Infection Wells: In addition to sending the form to the address in 10a
6el Borehole diameter: 6 ' (in.) above, also submit•one copy of this form within 30 days of completion of well
abandonment to the following:
611;Water level below ground surface: 3 (IL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e,Outer casing length(ii known): (ft.) IOc.For Water Sunnly&Infection Wells: In addition to sending the form to the
address(Cs)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(if known): (ft.)
abandoned.
•
.6•g.Screen length.(if known): (ft.)
•
Furor GWa30 • North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY: ,
1.Wel}Contractor Information: �G� � ` WELL ABANDONMENT DETAILS4 .
9,i: n S���p'/ i/ •
7a.For Geoprobe/DPT or Closed-Loop Geotherthal Wells havin the same
Well Co ctorName(or well o nerpersonally abandoning well on his/her property) well construction/depth,only 1 GW-3I is needed. Indicate TOTAL UMBER of
1 _r wells abandoned:
•
Lip
NC W-"contractor CertificationNumber 7b.Approximate volume of water remaining in well(s): (gal.)
• r 114 1/ fll' 5 I V FOR WATER SUPPLY WELLS ONLY:j) •
Company Name • J'7 0 •
i1.� 7c.Type of disinfectant used: •
2.Well Construction Permit#: 0 5'itiAai Rt t d !7 �J /�
List all applicable well construction permits(i.e.UIG'County,State,Variance,etc.)iflotown '!� G'
7d.Amount of disinfectant used: t
3.Well use(check well use):.
Water Supply Well: 7e.Sealing materials used(check all that apply
•
0 Agricultural ❑Mum' ipal/Public 0 Neat Cement Grout Ip'Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 Sand Cement Grout 0 Day Clay
0 Industrial/Commercial ❑Residential Water Supply.(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ' ; 0 Other(explain under 7g)
❑Monitoring . ❑Recovery
Injection Well: 7f.For each material selected above,provide amtiuntof materials used:
❑Aquifer Recharge 0 Groundwater Remediation 6`OP Ir /l4 i ./I i ,7 x 5i../j •
❑Aquifer Storage and Recovery ❑Salinity Bather (� ! L %'
0 Aquifer Test ❑$tormwaterDrainage .%)j}✓.))
0 Experimental Technology ❑Subsidence Control 7g.Provide a brief description of•the abandonment procedure:
❑Geothermal(Closed Loop) OTracer /' in
4 j w Pl'� y//
•
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) (� h7? 7 /1/
�
4.Date well(s)abandoned: 2 3 g , ,.,4.LP'r wpJy )
5a.Well location: t JAN 1 6 2024 •
i•PL•� l•' U� �. /•^"mot• ln5vl i`v+.!w�'.itf�.:^�'..iy n, Vt57
Facili IOviner Name �/ F ility ID#(if applicable) 8.Certification: �, „a `a
/i� �0G•
PhysicalAddress City,and Zip Si ture of Ce ified Well Contractor orwner Date
k , By signing this form,I•hereby certify that the wells) 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 latllong is sufficient) 9.Site diagram or additional well details: :
5- q 9 q N y-�p e ) �' You may use the back of this page to provide additional well site details or well
1 ` c j 1 G�� fJp/ abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells I
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: "Submit this form within 30 days of completion of well
6a.Well ID#: / abandonment to the following:
• Division of Water Resources,Information Processing Unit,
6b.Total well depth: 7 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For 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: 3 7�/ (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): a (ft) l Oc.For Water Supply&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
abandoned. ,
6f.Inner easing/tubing length(if known): #!L (ft.) •
6g.Screen length(if known): /" , (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
I .

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JohnnyHart, Jr.
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
I
4446- B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1840 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name granular dry chlorine
2.Well Construction Permit if:
2023-41255 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,Stale.Variance,etc.)if/mawn 60 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
0 Agricultural UMunicipal/Public 0 Neat CementGrotc= _'" •- - A Bentonite Chips or Pellet
OGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) 0 Sand Cement Grout �""1;,x,i,„;-.p 01 f3r lay
❑IndustriallCommercial ❑Residential Water Supply(shared) a Concrete Grout JAN 1 1 9: 0 D routings
❑Irrigation 0 Specialty Grout 6 C QEl4rravet
Non-Water Supply Well: ❑Bentonite SIu ±On'rin=..;;;'$Il fy,,,,,q I ❑Other(explain under 7g)
❑Monitoring ❑Recovery Dv..,,� •-'lT-u:afl URN,
Injection Well: 7E For each material selected fd S?Sve,'+}�wwide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete Grout-9 cu. ydS
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite Chips-39 bags
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Well depth was measured with tape to verify depth.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Correct amount of chlorine was introduced via pouril
4.Date well(s)abandoned: 12/21/2023 material&also mixing with water&pouring. Bentor
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility ID/I(if applicable) . Ce ifieation:
124 Green Morris Lane, Mooresville, NC 28117 \ y
""IiI,4 ! l',
Physical Address,City,and Zip Signs\ofCcrtifi i•Well Contractor ell Owner Date 1
lredell 4626631898.000
13y signing this form, I 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
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:
N W You may use the back of this page to provide additional well site detail or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS -
Attach nwell constructionrecord(s)ifavailable.For n,ultiple injection or non-siatersupply wells
ONLY with the same construction/abandonment,you can submit one form.
Well#21 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDt': abandonment to the following: I
Division of Water Resources,luformation Processing Unit,
1617 Mail Service Center;Raleigh,NC 27699-1617
6b•Total well depth: 760 (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
8 and 6 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
I
abandonment to the following:
6d.Water level below ground surface: 54 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
Ge.Outer casing length(if known): 88 (ft.) 10e.For Water Slimly&Infection 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
6f.Inner easing/tubing length(if known): none (ft.) abandoned.
6g.Screen length(if known): none (ft.) .
Form G W-30 North Carolina Department of Envitontnental Quality-Division of Water Resources Revised 2-22.2016

lredell County, North Carolina November 15, 2023
CWS Well #21 - 124 Green Morris Lane
= „ . •
W Callicutt Trail
226
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.
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---------
Tax faap Anformation
I Print map scale is approximate.
•PIN 4626631898.000 I I
Address 124 GREEN MORRIS LN - -
_ i Critical layout or measurement
• -- ,
•Account II Acct 77398814 activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC OF .
•Milling 500 W MONROE ST STE 3600 this resourCe.
Address MAP tF.O,R RERECANCE LON V-\Y
• CHICAGO,IL 60661 'NOT AtLEGAL100 COMR NW
•GIS Owner CAROLINA WATER SERVICE INC
•Deed Info 1438/1254-WD-20030502 Kaden County,North Cardina makes no claims and no
•Tax Acres 2.083 AC warranties,expressed or Implied,concerning the validity or ,
•Lot II 10 WELL accuracy of the GIS data presented on this map.
•Description LAKE FOREST ESTATES WELL PB41- Geometry updated 11/15/2023
131 Data updated 11/14/2023
•Zoning RA
•Old Parcel/I
1 •Bldg Value $0
I
•OBXF Value SO
•Land VaJue $75000
•Total Value $75,000
' •Defer Value SO
•Tax Districts -ALLCNTY FIRE--
a
•

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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
4446 - B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1720 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
granular dry chlorine
2.Well Construction Permit#: 2023-41258
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)If/mown 52 dunces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ElMunicipal/Public 0 Neat Cemen),Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Ceme4t Grout j= • `,yti ,FDry Clay
•0 Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 7 '❑Drill Cuttings
❑Irrigation 0 Specialty GroutJAN I 61024 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry '0 Other(explain under 7g)
❑Monitoring ❑Recovery 1nfour-x u f1 Prci:,,• : ':+� ,g
Injection Well: 7f.For each material R'Ihtterialri%e,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-8 cu. yd$.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips-27 bags
I
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well depth was measured with tape to verify depth.
Correct amount of chlorine was introduced via pourii
4.Date well(s)abandoned: 12/27/2023 material & also mixing with water& pouring. Bentor
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility IDif(if applicable) 8.Certification:
153 West Callicutt Trail, Mooresville, NC 28117 `�G
Physical Address,City,and Zip Signa a of Cmt red Well Contracto or Well Owner Date
lredell 4626631898.000 1.
By signing this form, I 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
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:
N 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. i
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 same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: Well#22 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the form to the address in 10a
Ge.Borehole diameter: 8 and 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Gd.Water level below ground surface: 81 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Ge.Outer casing length(if known): 53 (n,) 10c.For Water Sunniv&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
6f.Inner casing/tubing length(if known): none (ft.) abandoned.
none
6g.Screen length if known): {ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

•
Iredell County, North Carolina ; November 15, 2023
CWS Well #22 - 153 West Callicutt Trail •
f4 I - _ __.— G ._�._ 195
140
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=O ;; ;,1•"=126:69529615446805 ft .
7axMx>tldMarmation
I 1 `J
Print map scale is approximate.
•PIN 4626631898.000 q Critical layout
oYt or measurement
•Address 153 W CALLICUTf TRL - —
_ - 1 `1 I
•Account f Acct77398814 — --- this
should not be done using
•Tali Owner CAROLINA WATER SERVICE INC OF ahis resource.
•Mailing 500 W MONROE ST STE 3600
Address MAP FOR x REFERENC ONLY
• CHICAGO,-IL60661 'NOTdAL'£G,AiLID.O.CUN1ENT
•G15 Owner CARO LINA WATER SERVICE INC
•Deed Info 1438/1254-WO-20030502 Ueda County,North Carolina makes no claims end no ,
I •Tax Acres 2.083 AC warranties,expressed or Implied,concerning the validity or
•Lot# 10 WELL accuracy of the GIS data presented on this map. I
•Description LAKE FOREST ESTATES WELL P841- Geometry Updated 11/15/2023
131 Data updated 11/1412023 1
•Zoning RA
•Old Parcel/I
•Bldg Value $0
•013XF Value $0
- •Land Value $75,000
I
, •Total Value $75,000
•Defer Value $0
•Tax Districts -ALLCNTY FIRE--
I

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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
4446- B wells abandoned: f `
I.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1700 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfeetani used: granular dry chlorine
2.Well Construction Permit 0: 2023-41261 ;'
List all applicable well construction permits(l.e.UIC County,State,parlance,etc.)/)known 50 Ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural a Municipal/Public 0 Neat Cement Gr. uh Ig Bentonite Chips orPellets1
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement G li�"" ; E c ay
❑Industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout /t ,CTDri!l uttings
❑Irrigation 0 Specialty Grout JA N 1 Gravel
Non-Water Supply Well: 6 202�
0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery intt i7411v:?:^.41 77r C snit s3 Ull_1
Injection Well: 7E For each material selegltdiajr3movide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-8 cu. ydE,l'
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage Bentonite Chips-81 bags
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well depth was measured with tape to verify depth.
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Correct amount of chlorine was introduced via pourii
4.Date wells)abandoned: 12/29/2023 material& also mixing with water&pouring. Bentor
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility 1Db(if applicable) 8. er'notion: I
132 Magnolia Farms Lane, Mooresville, NC 28117 .• 4).,'
Physical Address,City,and Zip Signe f Certified ell Contractor or ell Owner Date
I redell 4626648796.000 ;
By signing this form, 1 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: I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N. W You may use the back of this page to provide additional well site detail 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)ifavailable.For multiple Infection or non-watersupply wells I
ONLY with the sane construction/abandonment,you can submit one form. I
10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: Well#23 abandonment to the following: ,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
and 6lob.For Injection Wells: In addition to sending the form to the address in l0a
Sc.Borehole diameter: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: `f
22 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): 65 (ft,) loc.For Water Sunnly&Infection 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
6f.Inner casing/tubing length(if known): none (ft.) abandoned.
6g.Screen length(if known): none (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

Iredeli County, North Carolina November 15,i2023
CWS Well #23 - 132 Magnolia Farms Lane i
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• ,Textulap4nformation "—— I
i Print map scale is approximate.
•PIN 4626648796.000 Y. I. Critical layout or measurement
•Address 132 MAGNOLIA FARMS LN - L I 1,
•Account/ Acct77396814 activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC OF
•Mailing 500 W MONROE ST STE 3600 this resource,
Address 111/1AP FOR fit EFERENCE IONLY
• CHICAGO,IL 60661 NOT A LEGAL tDOC43MENT 1
•GIS Owner CAROLINA WATER SERVICE INC 4
•Deed Into 1438/1254-WD-20030502 Iredell County,North Carolina makes no claims and no
•Tax Acres 1.113 AC warranties,expressed or ImpLed,concerning the validity or ,
•Lot 4 43 accuracy of the GIS data presented on this map.
•Description LAKE FOREST ESTATES WELL P641- Geometry updated 11/15/2023
131 Data updated 11/14/2023 '
•Zoning RA 1 '
•Old Parcel 9
- •Bldg Value SO
•OBXF Value $0
•Land Value $45,000
•Total Value $45,000 I
•Defer Value $0
•Tax Districts -ALLCNTY.FIRE--
t
1

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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 ceded. Indicate TOTAL NUMBER of
4446- B wells abandoned: 1 I
f 1 2030
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name granular dry chlorine
7c.Type of disinfectant used:
2.Well Construction Permit ii: 2023-41265I
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)IIfknown 60 ounces dry ehlorin7_
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural uMunicipal/Public 0 NeatCemerprQpt •_ _ e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) 0 Sand Cemclit grant'I 1^ '-1.p FollyClay
❑industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout I ❑Drill Cuttings
❑Irrigation 0 Specialty Grout JAN 1 6 2024, 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ; 0 Other(explain under 7g)
❑Monitoring ORecovery itlftorir,,W:^.fl PrczczA gzo Ifs
Injection Well: 7E For each material elckl f' 'brY provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout- 10 cu.yds. '
,
❑Aquifer Storage and Recovery ❑Salinity Barrier Bentonite Chips-205 bags
❑Aquifer Test ❑Stormwater Drainage
1
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer Well depth was measured with tape to verify depth.
OGeothermal(Heating/Cooling Return) ❑other(explain under 7g)
Correct amount of chlorine'was introduced via pouril
4.Date well(s)abandoned: 1/5/2024 material &also mixing with;water& pouring. Bentor
5a.Well location: placed by hand&concrete,was poured from truck.
Carolina Water Service-NC NC0149185
Facility/Owner Name Facility ID#(if applicable) 8.Ce Mention:
1556 Brawley School Road, Mooresville, NC 26117 \\. 4 i �. .'a�
Physical Address,City,and Zip Signatu of Certifier /ell Contractor or ell Owner Date
Iredell 4626713870.000 J
By signin this form,I hereby certifr that the well(s)was(were)aba oned 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:;
N 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)Ifavailable.Formulliple injection or non-trater supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDII Well #31 abandonment to the following:
1,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1300 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
8 and 6 10b.For Infection Wells: In addition to sending the form to the address in 10a
Gc Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: i
65 Division of Water Resources,Underground
und Injection Control Program,
6d.Water level below ground surface: (ft)
1G36 Mail Service Center,Rideigh,NC
27G99-1636
6c.Outer casing length(if known): 1 fl3 (ft.) 10e.Jror Water Sunnly&Injection Wells:j,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
none abandoned. 1
6f.Inner casing/tubing length(if(mown):_ (ft.) 1
1
none
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of EnvironmentalQuality-Division of Water Resources Revised 2-22-2016
� , i

•
•
Iredell County, North Carolina . November 15,12023
CWS Well #31 - 1556 Brawley School Road
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Tax Map information .... _—..---
Print map scale is approximate.
•PIN 4626713870.000 ir Critical layout or measurement
•Address 1556 BRAWLEY SCHOOL RD r
•Account it Acc t 77398814 activities should not be done using
•Truc Owner CAROLINA WATER SERVICE INC OF •.-' this resourCe.
•Mailing 500 W MONROE ST STE 3600 l' '
Address .1v1AP FOR.fREFERENCE,ONLY
• • CHICAGO.IL 60661 NOT A LEGAL 130,CLIPIENT
•GIS Owner CAROLINA WATER SERVICE INC OF
NC Iredell County,North Carolina makes no claims and no
' •Deed Info 1874/2178-WO-20070808 warranties,expressed or impUed,concerning the sadly or
•Tax Acres 1.01 AC accuracy of the GIS data presented on this map.
•Lot 4 273 WELL
Geometry updated 11/15/2023
•Description FARMS P2 M1 WELL-31 PB43-93 REV I Data updated 11/14/2023
PB52-96-Zoning RA
•Old Parcel ti '
•Bldg Value $0 .
•OBXF Value SO •
•Land Value $45,000 l
•
•Total Value $45,000
,
•Defer Value $0 .
•Tax Districts -ALLCNTY FIRE-- .
r
Ii
1 .
I '

Well Data from NCDEQ Records and from CWS
8" 6" Estimated Estimated Iredell Co
Site Well Well Well Depth Well Pump Well Yield Casing Total Well Total OZ Cubic Yds Permit Actual Static
Well No. Depth Depth Depth Pump Set Dia HP (GPM) Grout Depth Gallons Chlorine Concrete Number Depth Level
Well 1 1000 1000 0 294 8 15 Building to be demo 2610 78 13 2023-41230 1000 44 200 Bay Harbour Road
Well 2 900 900 0 399 , 8 10 45 Rock Well Cover 2349 70 11.7 2023-41232 1055 47 110 Sunrise Circle
Well 3 765 765 0 420 8 10 64 Building to Remain 1997 59 9.9 2023-41233 775 17 Chuckwood Road Lot 74
Well 4 705 , 705 0 315 , 8 10 70 Building to Remain 1841 55 9.2 2023-41234 705 50 1540 Brawley School Road
Well 6 825 85 740 _ 525 8 5 25 85 Rock Well Cover 1310 39 6.5 2023-41235 800 43 Polpis Drive-Lot 515
Well 7 1000 250 750 252 8 5 30 121 Rock Well Cover 1755 52 8.7 2023-41237 1000 48 Poplar Circle-Lot 565
Well 8 900 900 0 525 8 7.5 28 52 Rock Well Cover 2349 70 11.7 2023-41239 880 44 Brawley School Road-Lot 4
Well 9 900 900 0 525 8 7.5 28 60 Rock Well Cover 2349 70 11.7 2023-41240 900 51 Brawley School Road-Lot 6
Well 10 800 90 710 525 8 5 20 90 Rock Well Cover 1279 38 6.4 2023-41244 800 29 Quaker Road -Lot 30
Well 14 800 66 734 378 6 _ 3 22 66 Rock Well Cover 1252 37 6.2 2023-41245 780 42 207 Wild Harbor Road
Well 15 800 77 723 441 ` 8 5 25 77 Rock Well Cover 1264 37 6.3 2023-41246 800 48 109 South Fork Road
Well 16 800 _ 85 715 - 462 8 10 39 85 Rock Well Cover 1273 38 6.4 2023-41247 800 .49 110 South Fork Road
Well 17 800 52 748 441 8 3 12 52 Rock Well Cover 1236 37 6.2 2023-41249 800 57 142 South Fork Road
Well 18 800 ,. 500 300 462 8 7.5 38 70 Rock Well Cover 1746 52 8.7 2023-41250 520 50 143 South Fork Road
Well 19 800 500 300 357 I 8 15 55 81 Rock Well Cover 1746 52 8.7 2023-41252 800 34 109 Jack Pine Court
Well 20 800 550 250 - 483 8 10 55 53 Rock Well Cover 1803 54 9 2023-41254 800 63 215 South Fork Road
Well 21 760 760 0 378 8 20 100 88 Rock Well Cover 1984 59 9.9 2023-41255 '760 54 124 Green Morris Lane
Well 22 800 480 , 320 378 _ 8 10 _ 39 53 Rock Well Cover 1724 51 8.6 2023-41258 800 81 153 West Callicutt Trail
Well 23 800 455 345 441 8 10 40 65 Rock Well Cover 1695 50 8.4 2023-41261 800 22 132 Magnolia Farms Lane
Well 31 1300 103 1197 357 8 5 103 Rock Well Cover 2029 60 10.1 2023-41265 1300 55 1556 Brawley School Road

I
WELL ABANDONMENT RECORD
For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 7g.For Geoprobe/OPT or Closed-Loop1Gcotherinal 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
4446 - B wells abandoned: I
NC Well Contractor Certification Number • 7b.Approximate volume of water remainingi in well(s): 1220 (gal.)
McCall Brothers, Inc. I
FOR WATER SUPPLY WELLS ONLY:I
Company Name 7c.Typeof disinfectant used: granular dry chlorine
2.Well Construction Permit#: 2023-41245 j
List all applicable well construction permits(i.e.UIC,Comely,State,Variance,etc.)if know; 36 ounces dry chlorine
7d.Amount of disinfectant used: 1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural •Municipal/Public 0 Neat Cement Goat, {. -^^; r�I U.Beri?tt,onite Chips or Pellets
❑Geothermal(Fleeting/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement daft L,..-`',4 r . a r (+'�k C1,l)'Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 202 Drill Cuttings
❑Irrigation 0 Specialty Grout JAN 1 Gravel •
Non-Water Supply Well: n
0 Bentonite Sl �i` pr�.,,�,,. •',,p Glbi�'(explain under 7g)
❑Monitoring ❑Recovery tit.0'.r;�.'^"� ,;, ``L`'SS
Injection Well: 7f.For each material selececu aim c provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete Grout-6 cu. yd$. '
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips -22 bags '
❑Experimental Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Well depth was measured with tape to verify depth.
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
Correct amount of chlorine was introduced via pouril
4.Date well(s)abandoned: 12/27/2023 material & also mixing with water& pouring. Bento►
5a.Well location: placed by hand.&concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
207 Wild Harbour Road, Mooresville, NC 28117 \\'4,4. `-%but
Physical Address,City,and Zip Sign of C ed Well Contrac or Well Owner Date
Iredell 4626718897.000
By signing this form,I hereby ceri05.,that the well(s) was(here)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: „ •
N 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 SUBMITTAL INSTRUCTIONS
Attach well consirection record(s)ifavailable.Formultiple infection or non-water supplywells i
OA'LYwith the same construction/abandonment,you can submit one form.
Loa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Well#14 abandonment to the following:
1
Division of Water Resources,Information Processing Unit,
6b.Total well depth 780 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in l0a
8 and 6 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
4 ,
42 Divisions of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
• I
6e.Outer casing length(if known): 67 (ft.) toe.For Water Supnlv&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
6E Inner casing/tubing length(if known): none (ft.) abandoned. I
6g.Screen length(if known): none (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016

Iredell County, North Carolina November 15,2023
CWS Well #14 - 207 Wild Harbor Road
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riaxitap a ntorm at i on I Print map scale is approximate.
; •PIN 4626718697.000 zr
•Address 207 WILD HARBOR RD ,
ut or measurement
—- —
Critical layo'..:,.
•Account II Acct 77398814 :_ activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC OF - this resourcie.
•Mailing 500 W MONROE ST STE 3600
Address IIVI AP FCR IRC-r-EREN.CE ONLY .
• CHICAGO,IL 60661 NOT AIL.E.GALIDOOLIMENT .,
•GIS Owner CAROLINA WATER SERVICES INC
i •Decd Info 1422 I 618-WD-20030318 Iredell County,North Carolina makes no claims and no '
•Tax Acres 1.11 AC warranties,expressed or implied,concerning the validity or ;
•Lot 1/ 357 accuracy of the GIS data presented on this map. .
•Description THE POINT P3 MI.WELL LOT REV Geometry updated 11115/2023
P641-37 Data updated 11/14/2023 • 1
•Zoning R20
I .
,
•Old Parcel 41 ,
I •Bldg Value $0
' •OBXF Value SO I
i
•Land Value $135,000
•Total Value $135,000 t I
•Defer Value $0 •
•Tax Districts -ALLCNTY FIRE--
,

•
WELL ABANDONMENT RECORD • For Internal Use ONLY:
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on Iris/her property) • well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4446- B • wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1260 (gal)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: granular dry chlorine
2.Well Construction Permit#: 2023-41246
List all applicable well construction permits(Lc.UIC,County,State,Variance,etc)"known 38 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural CMunicipal/Public ❑Neat Cement Grout' •� �.�'Vlento tte Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Satid Cement Grout l7 Dtay
❑Industrial/Commercial OResidential Water Supply(shared) II Concrete Grout JAN 1 G 2024 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite SltlftrgJf &f71 7rC,t;K df3 explain under 7g)
❑Monitoring ORecovery D4` yin
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-6 cu. yd:,
❑Aquifer Storage and Recovery ❑Satin ity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips-30 bags ;.
0 Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Well depth was measured with tape to verify depth.
OGeothermal(Heating/Cooling Return) ❑other(explain under 7g)
Correct amount of chlorine was introduced via pouril
4.Date well(s)abandoned: 11/28/2023 material &also mixing with'water& pouring. Bentor
5a.Well location: placed'by hand &concrete was poured from truck.
Carolina Water Service of N NCO149185
Facility/Owner Name Facility IDS(if applicable) 8.Certification:
109 South Fork Road, Mooresville, NC 28117 1-\0-a`}
Physical Address,City,and Zip Sig re ofCe c Well Contras r or Well Owner Date
lredell 4626729954.000
By signing this form,I hereby certify that the wells,)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA 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:
N 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)Ifavailable.For multiple injection or non-water s:,pplywells
ONLY with the same constractlon/abandonarent.you can submit one form.
10a. For All Wells: Submit this form within 30 days of completionIof well
Well#15
6a.Well ID#: abandonment to the following.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699.1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter 8 and 6 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
48 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 77 (ft.) 10c.For Water Supply&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
61.Inner casing/tubing length(if known): none (ft.) abandoned.
6g.Screen length(if known): none (ft.)
Ii
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

Iredell County, North Carolina November 15,2023
CWS Well #15 - 109 South Fork Road q
i _,_
910
m 35 WELL
k� I
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9'
'1 e7° 1•'=126.69981684850607 ft k
Tax04aptntmrmation --•` Print map scale is approximate.
•PIN 4626729954.000 g Critical la out or measurement
•Address 109 SOUTHFORK RD lay
Out
Acct 77398/314 -- �-- activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC OF this resource.
•Mailing 500 W MONROE ST STE 3600
Address !MAP FO.R fgEF ,Ef11PE'ONLlY
• CHICAGO,IL 60661 iIOT A-LEGAL;D0CL3MlENT I
•GIS Owner CARO LINA WATER SERVICES INC I.-Deed..into 1325/973-WD-20020306 Iredell County,North Carorma makes no claims and no
•Tax Acres 1.185 AC warranties,expressed or implied,concerning the validity or I
•Lot# 907 WELL accuracy of the GIS data presented on this map.
•Description THE POINT ON NORMAN WELL LOT . Geometry updated 11/1512023
P639-92 Data updated 11/14/2023
•Zoning RA I
•Otd Parcel#
r •Bldg Value $0 1
•OBXF Value SO
•Land Value $70,000 i
•Total Value $70,000
a •Defer Value $0 .
•Tax Districts -ALLCNTY FIRE--
•
•

1
' WELL ABANDONMENT RECORD For Internal Use ONLY:
1
1.Well Contractor Information: WELL ABANDONMENT DETAILS '
Johnny Hart, Jr. 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
1 !
wells abandoned:
4446-B 1275
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name granular dry chlorine
2023-41247 7c.Type of disinfectant used:
2.Well Construction Permit#: .
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)if known 38 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
I Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural RMunicipal/Public ❑Neat Cemeni6rogt`:--- �-, - g f;*-s0Behtonite Chips orPellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand' Cement d oiit—(.a=g.—i "rs' IL..❑iiDsy7 Clay
❑Industrial/Commercial OResidential Water Supply(shared) s Concrete Grout J�N 1 ' 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 6 2024❑Gravel
Non-Water Supply Well: 0 Bentonite Slu they(explain under 7g)
im.d.TIn.-.tt t�f %,-4).:- ..MtA ( P
:Monitoring ❑Recovery ��-- 4 ;t T
Injection Well: 7f.For each material serieed 9tibire;"prtivide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-6 cu. yd5'
❑Aquifer Storage and Recovery ❑Salinity Barrier Bentonite Chips-56 bags
0 Aquifer Test ❑Stormwater Drainage
DExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Well depth was measured'with tape to verify depth.
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Correct amount of chlorine',was introduced via pouril
4.Date wells)abandoned: 11/28/2023 • material &also mixing with water& pouring. Bentor
5a.Well location: placed by hand&concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility IDb(if applicable) 8.Certification:
110 South Fork Road, Mooresville, NC 28117 kt\q \rkg) ,). \
Physical Address,City,and Zip Si re of Ceded Well Contracto r Well Owner Date
Iredell 4626830288.000
By signing this form, 1 hereby cent*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:
N 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavoilable.For multiple injection ornon-water supply wells
ONLY with the saute construction/abandonment,you can submit one forts.
Well#16 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: ,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
106.For Injection Wells: In addition to!sending the form to the address in 10a
8 and 6
6c.Borehole diameter: (in.) above,also submit one copy of this forms within 30 days of completion of well
abandonment to the following:
I
Gd.Water level below ground surface: 49 (ft.)
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer easing length(if known): 85 ({t) 10c.F'or Water Stumly&Injection 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
6L Inner casing/tubing length(if known): none (ft.) abandoned.
6g.Screen length(1f known): none (ft.)
Fonts GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Iredell County, North Carolina November 15,2023
•
CWS Well #16 - 110 South Fork Road
G' •''tali , , \ a53
°r
•
I 175a `
4 , `_, f .,�
',? op u
1
al I o !f •
• >L 51a6a
•
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,
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'1 SiAb .io ! !I I
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ry i
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1). 57__ •
•
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101 I
SOT ••I.. 271 ♦ -
. WELL 109
t. I `\
I • I.
,�o • I,
�� t1 , \
ao I.
.\
t.\-' - 36S ,\l,
•1516,=, -
`...Z;.\
iyyir ,: - \ 1 1"=126.69866457570323 ft
sw
Tawa/lap.Information .'._."""`.'.
-n Print map scale is approximate.
•PIN 4626830288.000 Critical layout or measurement
•Address 110 SOUTHFORK RD ' _ _ '
•AccountII Acc177398814 - - - activities should not be done using
•Tax owner CAROLINA WATER SERVICE INC OF -
•Mailing SOO W MONROEST STE 3600 this resource.
Address iiMAf3 FAR IREF.ERE11ICE ONLY
• CHICAGO.IL 60661 Nor AIUEGALID,OC.UMENT
•GIS Owner CAROLINA WATER SERVICES INC
-Deed Info 147612662-WD-20030825 Iredell County,North Carolina makes no claims and no
•Tax Acres 1.444 AC warranties,expressed or Implied,concerning the validity or
•Lot 11 PT910 accuracy of the GIS data presented on this map.
THE FARMS P1 M2 SHT2 REV P843-46- Geometry updated 1231512023 +
Description 47 DOT1664-1763 Data updated 11/14/2023 j 11
•Zoning RA S
•Old Parcel .
R
•Bldg value SO
•OBXF $0
Value
•
•Land S70,000 I I
Value
•Total Value S70,000 j i
1 •Defer $O `
i
i

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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 OW-30 is needed. Indicate TOTAL NUMBER of
4446 - B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1236 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: granular dry chlorine
2.Well Construction Permit#: 2023-41249
List all applicable well construction permits(i.e.UIC,County.State,Variance,eta)ifkntown • 37 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural eMunicipa1/Public 0 Neat Cement Grout.
t,,It,.1�1 tConlaitye Chips or Pellet
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand CemenRtb v 1
❑lndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 6 ❑Drill Cuttings
❑Irrigation 0 Specialty Grout JAN 1 2U240 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 _Other(explain under 7g)
❑Monitoring ❑Recovery ( —fr`�„r �I1 w=;••. • �6B
Injection Well: 7f.For each material seletedadil,pto'vide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-6 cu. yd:
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Bentonite Chips-30 bags
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) l7Tracer Well depth was measured with tape to verify depth.
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
Correct amount of chlorine,was introduced via pourit
4.Date well(s)abandoned: 11/29/2023 material &also mixing with water&pouring. Bentor
5a.Well location: placed by hand &concretOwas poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility ID#(if applicable) Ce tifreation:
142 South Fork Road, Mooresville, NC 28117
Physical Address,City,and Zip Signa re of Corti ad Well Contractor Well Owner Date
iredell 4626733584.000
By sign ig this form,I hereby certify that the well(.)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:
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(S1 BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well contraction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same consiruclioniabandonutent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
Well#17
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
8 and 6 lob.For 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:
j
6d.Water level below ground surface: 57 (D,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 52 (ft) 10c.For Water Sumdv&Injection Wells:'i 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 healh'department of the county where
f.Inner casing/tubinglength(if known): none abandoned.
6 g ). (it.)
' I
6g.Screen length(if known): none (ft.)
Fonts GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
•

•
Iredell County, North Carolina November 151 2023
CWS Well #17 - 142 South Fork Road
7g bCo4 r, ff�� o t I J i 1'�
.9 Tr moo{ / e7d/ '—����
130 n / r •145:1J�
p 120 id • 4-Call/ 1 l3o rr !/ ^p!•
uti
! 1061 2 .
i•-- 1 ' 70•30A - t30 I /;
5FE l'
._.-...__ ..__.___.. _- i 14 - C3IlCVq '.130 r
202 250 Trdll _ '
- 1,
39 -
1.66 '-112. 1 173 I
MU {\ U n?'ray
, '1 241 102- •-
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278
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102 ':' - "`j�;. • may` •\
142
-.. i•: 159 4 463 ` •106 - / 2 ,�a I `�
6•1 _ 276 I )
1
266 71-CO5 ``~ ' 36 ! 1D0 1 q,Sy/�//
Fork / 41
Rd ra r 57 / `.9
�-231 /
S Fork Rd /'' 1 265
I / I
224 ® ?03 262 •-.`01 i•'35 1
-.------- 208 CO- SF '53 �..;...•
orkkf
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d93
267 r _ \- 170
2L0 °� . - SForIC -�
--- _ WELL !e .40 - Rd i.
7 107 :`/ cos It2221
//
_ h i 1"=126,69730047315666 ft s
•
Tax Map<Intormation ^--`^—'—`--
Print map scale is approximate.
•PIN 4626733584.000 ill Critical layout or measurement
•Address 142 SO UTHFORK RD — - ' y
•Account# AccI 77398814 —— activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC OF - this resource.
•Mailing 500 W MONROE ST STE 3600
Address 1MAF'FOR 2£FERE1ilCE.O.RiLY
• CHICAGO,IL 60661 NOW A ILEGALLDO.OI!UMENT
•GIS Owner CAROLINA WATER SERVICES INC
•Deed Info 1325/973-WD-20020306 Iredell County,North Carolina makes no claims and no ` .
•Tax Acres 2A27 AC warranties,expressed or Implied,concerning the validity or
•Lot II 909 WELL accuracy of the GIS data presented on this map.
•Description THE POINT ON NORMAN WELL LOT Geometry updated 11/15/2023 '
••Zanln RA P1339-92 Data updated 11/1412023 1 •
'
9
•Old Parcel it
•Bldg Value S0 -
•OBXF Value $0
•Land Value 682,500
•Total Value $82,500 .
•Defer Value $0
•Tax Districts -ALLCNTY FIRE-- i
•

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
•
Johnny Hart, Jr. 7a.For Geoprobe/DPT or Closed-Loup 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
4446- B wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water re i aii ing in well(s): 1730 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name granular dry chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#:
2023-41250
List all applicable well construction permits(7.e.UJC.County,State,Variance,etc.)Iknown 54 ounces dry chlorine(
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
_-''
❑Agricultural eMunicipal/Public CI Neat Cement Gra'6;= r� 0 I Jd 1h bhite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout 1" '��"--r b`❑�D 'i;Id)
4'�' Y
❑Industrial/Commercial ❑Residential Water Supply(shared) !N Concrete Grout JA N 1 r;2 rill Cuttings
❑Irrigation ❑Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slur T,"::::'F.I1 P171—C 4t&. d r$Ctxplain under 7g)
❑Monitoring ❑Recovery • Dtre Q o ti3
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-8 cu. yd5
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips- 110 bag
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well depth was measured with tape to verify depth.
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Correct amount of chlorine was introduced via pouril
4.Date well(s)abandoned: 1/29/2023 material&also mixing with water& pouring. Bentor
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility ID#(if applicable) .Certification:
143 South Fork Road, Mooresville, NC 28117 WA
Physical Address,City,and Zip Sign of Cc ified Well Con clot or Well Owner Date
Iredell 4626732176.000
• By signing this form, 1 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
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:
N W Youaba may use detthe back
You of this pageso proandonment a . may al attachto additionavideadditionall pageswell if necessarsitey.detils or well
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach nwell construction record(s)ijm'ailable.For multiple.infection or„on-watersupplywells
ONLY with the same constr ctioniaba„donment,you can submit one form. '
Well#18 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well no: Well to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
8 and 6 lob.For Infection Wells: in addition to,sending the form to the address in l0a
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 50 (ft.)
Division of Water Resources,Undergl ound Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 70 (ft.) 10b,For Water Supply&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
6f.Inner casing/tubing length(if known): none (ft.) abandoned.
6g.Screen length(if known): none (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised -22-2016
1 1

Iredell County, North Carolina November 15, 2023
CWS Well #18 - 143 South Fork Road
C 246 N
i�Q
I 27a.. t
40
t
- - R . - 159I 4 a63,J� ilU6
v 1 i q2 -1
7, V •. C7 1 t
�• 1
m
L b,y 276 , I i
S
1
- 190 267: r''�^..�
S F 266 71-005 -ti.._ 36 'I / I �1013
ork Rd ( /52
•
iC S F°k�a •V.133
265Gf Rd i 1
y 224 ® np39 _ 262 1-_�`di 35
91,
s2
L 268 coo SPorkRd isa' {
1
,� 1 -107 250
• �.
V. cos®
•
_ 267 "� - `27 �`•,_
fee • S p°r; .
vat ti7 tea d- 1 .
_ - 270
..:"1 n 1,13 coo •
'113,i d -``
a •,„.... 21
2.`.6 Zee -----
257
-
---.. 250 ,.d In7
123%= ^. y1
, . .,..5,j-.
n i
254 i
265.264A - `•.
5FE
1
306 1
1
/' 3 r
'` '/ 1S16s�
o141�02\
,y ,yo
t 2522 w
;4
-..• .A."=126.6,990170563924 ft
T
Tax Map information Print..—..—--. 1
Z] Print map scale is approximate.
•PIN 4626732176.000 a 1
•Address 143 SOUTHFORK RD -- - Critical layout or measurement
•Account s Acct77398814 - -- - - -` activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC OF this resource.
•Mailing 500 W MONROE ST STE 3600
Address MAP FOR IFF ENCE{ONLY
• CHICAGO.IL 60661 ili.QJ-,A,f EGAL-0_OCI,IEN�r
•GIS Owner CAROLINA WATER SERVICES INC k
•Deed Info 1325/973-WI)-20020306 Iredell County.North Carolina makes no claims and no
•Tax Acres 1.573 AC warranties.expressed or implied,concerning the Validity or I
•Lot 3{ 908 WELL accuracy of the GIS data presented on this map.
•Description THE POINT ON NORMAN WELL LOT
Geometry updated 11/35f2023
•Zoning RA39-92 ' Data updated 11/14/2023
•Old Parcel k
•Bldg Value $0 •
•OBKF Value $0
•Land Value $70,000
•Total Value $70,000
•Defer Value SO
•Tax Districts -ALLCNTY FIRE-- j
t

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr, f
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
4446- B wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water remai I inlg in well(s): 1745 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Typeof disinfectant used:
granular dry chlorine
2.Well Construction Permit#: 2023-41252 I.
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.)iflmown 55 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check ail thatiapply):
❑Agricultural eMunicipalIPublic ❑Neat Cement Grout --- _ 1 e Bentonite Chips or Pellets
•
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement G ot�t ` ,:.N f• r y� g PP Y) PP Y( g ) �-,t�;�r �'1� la
❑industrial/Commercial ['Residential Water Supply(shared) It!Concrete Grout ',I I.tril Cuttings
❑Irrigation 0 Specialty Grout J'9 N 1 6 2u240 Gravel
Non-Water Supply Well: ❑Bentonite S u ❑Other(explain under 7g)
❑Monitoring ❑Recovery I, "`r�til { :` n';.
r4.�,-,,,,: :1URA
Injection,Well: • 71.For each material sclt c ed ithovearovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-8 cu. ydE I
❑Aquifer Storage and Recovery ❑Salinity Barrier Bentonite Chips - 95 bags
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well depth was measured with tape to verify depth.
OGeothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Correct amount of chlorine was introduced via pourii
4.Date well(s)abandoned: 12/21/2023 material & also mixing with water& pouring. Bentol
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility ID#(if applicable) S Certification:
109 Jack Pine Court, Mooresville, NC 28117 , \, ��_ A
Physical Address,City,and Zip Signal of Certifi d1):
ll Contract or Well Owner Date
Iredell 4626624805.000
By signing this fonts,1 hereby certf 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: I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:'
N 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formnitiple injection or non-water supplywells
ONLY with the same construction/abandonment,you con submit one form.
Well#19 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well W#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I'
10b.For injection Wells: In addition to sending the form to the address in l0a
above,also submit one copy of this form Within 30 days of completion of well
6c.Borehole diameter: 8 and 6 (in.)
abandonment to the following:
6d.Water level below ground surface: 34 (ft.)
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,RalIleigh,NC 27699-1636
6c.Outer casing length(if known): 81 (ft.) 10e.For Water Suppiv&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
6f.Inner casing/tubing length(if known): none (ft.) abandoned.
none I
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of WaterResources Revised 2-22-2016

II
Iredell County, North Carolina November 15,2023
CWS Well #19 - 109 Jack Pine Court
171 ..�Jstla/e Trail - !26 rfr 202 J- Ka4y
Y v Trei/ �l F y
-fa- -. C •
I .'y i
`- C n 713 ,. J j
-„ r .: I1 15 '! �' '?o! RaDsda/P Trail
j ry .113 /•:
s° •
P052.174 •ry 224 +, f
Sa C Pa.13.35 225 / � /\./
Jjrr 21
127
O ry 15
4. .:
JJJ :d /f 4 r
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,c,22J+. 59 % 226 V.
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. °.7 : °` �100 263
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1 1 -pi L
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!S,
�r
'
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1
� 1"=126.70054666543648 ft$ 23f f
Tax..66apinformation -.-.—'--`"-'-"'
Print map scale is approximate
•PIN 4626624805.000 Critical layout or measurement
•Address 109 JACK PINE CT -k_:
•Account N Acct 77460856 - activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC I
•Mailing 500 W MONROE ST STE 3600
this feSDWrce.
Address itti'*P iROF2IR FERENGEtO,NLY .
• CHICAGO,IL 60661 Ai.OWAILEGAL'(DODIiIMENT 4 .
•GIS Owner CAROLINA WATER SERVICE INC OF
NC ' Iredel County,North Carolna makes no claims and no
•Deed Info 1502/224-NW-20031112 ' warranties,expressed or implied,concerning the validity or
•Tax Acres 0.952 AC accuracy of the GIS data presented on this map.
•Lot If TR3 n Geometry updated 11/15/2023
•Description SOUTHFORK RD PROPERTY WELL Data updated 1//14/2023 i I
P842-13 I
•Zoning RA s .
•old Parcel it i I i
•Bldg Value S0 a
•OBXF Value $0
• •Land Value $45,000 I
•Total Value $45,000 f
•Defer Value $0 1
•Tax Districts -ALLCNTYFIRE- •
-
• t -- a

WELL ABANDONMENT RECORD Far Internal Use ONLY:
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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
4446 - B wells abandoned: I
I I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1800 I (gal.)
1I
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
CornpanyNatno granular dry chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#:
2023-41254
List all applicable well construction pennies(i.e.U/C,County,Slate,Variance,etc.)if known 54 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
I•
Water Supply Well: 7e.Sealing mnteri d i sed.(cygEk all that apply):
❑Agricultural GMunicipal/Public ❑Neat Cement Grout:,, 1 t 4 BPntonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout �I ❑-er.Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) RI Concrete Grout JAI N 1 6 202 Drill Cuttings
❑Irrigation 0 Specialty Grout Gravel
Non-Water Supply Well: 0 Bentonite Slurry 'r'` "�r1 T .,.;,,;-C-4 , rr(explain under 7g)
❑Monitoring ❑Recovery r,,WQ-';;jt �' ''(
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑AquiferRecharge ❑GroundwaterRemediation Concrete Grout-9 cu. yd£
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips-9 bags ;
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Well depth was measured with tape to verify depth.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Correct amount of chlorine was introduced via pouril
4.Date well(s)abandoned: 12/21/2023 material&also mixing with water& pouring. Bentor
5a.Well location: placed by hand &concrete was poured from tuck.
Carolina Water Service.of N NC0149185
Facility/Owner Name Facility ID#(if applicable) S. ertifieatioa:
215 South Fork Road, Mooresville, NC 28117 1k 4 .1-lQ.a�
Physical Address,City,and Zip Sign Certified ell Contractor or ell Owner Date '1
Iredell 4626539500,000
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1.5.4 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 1at/long is sufficient) 9.Site diagram or additional well detail :
N W You may use the back of this page to provide additional well site details or well
abandonment.dctails. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructionrecords)ifarailable.For multiple injection ornon-water supply wells -
ONLY with the same construction/abandonment,you can subudt one form.
10a. For All Wells: Submit this form within 30 days of completion of well
Well#20
6a.Well DM: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
8 and 6
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: 63 ({t) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 53 (ft.) 10c.For Water Supply&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 I department of the county where
6f.Inner casing/tubing length(if known): none (ft.) abandoned. I
none
6g.Screen length(if known): (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
1
i
3

•
Iredell County, North Carolina November 15, 2023
CWS Well #20 - 215 South Fork Road
y
o\ 74 '+o N, 93
I 37 t'' \�"
/ ! 70 (�
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'9-,e1' cos' %
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rj __ 102 �i 67-9A SF;--
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26' W
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l,
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93.54 L7 1N . 175 - 25 _ ___1/5__. i ___ 722 , 7(1
r•a4J-1C4 _ '- v i
Ragsdale Trail Ragsdale Trail Ragsdale Trail -
Ragsdale Trail
_--- ----_ _ -' - lzd
zza
1:4-- -- - 137 --- .. Ragsdale Trail
f N 4 i' i/
` //. 2t9 lig - 7 I `1
C�-t657 /216 .• •'ti j/ lA5
—=�'
, l ----`f " sv2 I,M1, 1"=126:69767509050807 ft
217 1 `
Tax Map 6nfolmation -"' .---
T Print map scale is approximate.
•PIN 4626539500.000 �]
•Address 215 SOUTH FORK RD - , Critical layout or measurement
•Account II Aca177460856 --, activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC - this resource.
, •Mailing 500 W MONROE ST STE 3600 I,
Address d1!IAP F 1ONL'Y OR REFERENCE
• CHICAGO,IL 60661 nor AiLEGAL 0», i:ac r
, •GIS Owner CAROLINA WATER SERVICE INC OF
NC Iredell County,North Carolina makes no claims and no
- •Deed Info 1502/224-NW-20031112 warranties,expressed or Implied,concerning the validly or
•Tax Acres 1.232 AC accuracy of the GIS data presented on this map.
•Lot p TR2 Geometry updated 11/15/2023
•Description O E FARMS P2 M2 WELL REV PB44- , Data updated 11/14/2023 '
•
•Zoning RA ,
• •Old Parcel IS ,
•Bldg Value $0 1
•OBXF Value $0
•Land Value $52,500 '
•Total Value $52,500
` •Defer Value $0
•Tax Dlstricts -ALLCNTYFIRE-- f
t
{!lliFF
. y
{ I

it
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the lame
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTALNUMBER of
4446- B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2486 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
granular dry chlorine
2.Well Construction Permit#: 2023-41230
List all applicable well construction permits(i.e.UIC,Canty,State,Variance,etc)ifkiowa 78!ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materiair�ss--uu�s.ed(check all that apply):
El Agricultural •Municipal/Public 0 Neat Cement GroVlrt;2 r^,: rl„ a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ,''„'IrWe t„ ' ,: I$yt, y
❑Industrial/Commercial ❑Residential Water Supply(shared) IA Concrete Grout Jq N ❑"55nl uttings
❑Irrigation 0 Specialty Grout 1 6 2022 Gravel
Non-Water Supply Well: ❑Bentonite Sltriry5rin.is 0 Other(explain under 7g)
'rl f' r,. !.F
❑Monitoring ❑Recovery ,L, Sr0.411t
Injection Well: 7f,For each material selecctehliovQj ovi a amirunt of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-10 cu.yds.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormweter Drainage Bentonite Chips-46 bags
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Well depth was measured with tape to verify depth.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Correct amount of chlorine was introduced via pourilf lg dry
4.Date well(s)abandoned: 1/4/2024 material&also mixing with water&pouring. Bentonite pellets
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility ID6(if applicable) 8.Certification:
1
200 Bay Harbour Road, Mooresville, NC 28117 `,ko.ay
Physical Address,City,and Zip Sig\tturc of Ike ified Well ntractor or Well Oivner Date
Iredell 4626602489.000
By signing this form, 1 hereby certt&that the wells)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 lar/long is sufficient) 9.Site diagram or additional well details:
N 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 SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)ifavailable.For multiple injection or non-water supplywells ,
ONLY with the same construcilo labs ndanme,t,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
Well#1
6a.Well ID#: abandonment to the following:
•
Division of Water Resources,Information Processing Unit,
1000
6b.Total well depth: (ft.) 1617 Mail-Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
8 and 6
6c.Borehole diameter: (in.) above;also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
1
6d.Water level below ground surface: 41 -(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center, I Raleigh,NC 27699-1636
unknown IOc.For Water Supply&fnicction Wells:I In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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
6f.Inner casing/tubing length(if known): none (ft.) abandoned.
6g.Screen length(if known): none (ft.)
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

•
Iredell County, North Carolina November 15,2023
. CWS Well #1 - 200 Bay Harbour Road
+ 2 2
•
A N• o •
t .yam^9 y�..1' I !
••y '' ��p0 A ,,10,I. .
r
161 qt `�
•
a I ?rm
• e a ! a
L]6r
•
'1 I p'. J
• c
. V. 1, 1 7
Spp _ �� I ' �t0.� i0-:
a
lj7 g5 ` ga'I
!- 97
.y• .y 8' I d
LlJaOSCr.9.9ME. �OJtR .
GZ.7 iY }tA.1�•3t
t 5.6 1 gad
WELL SITE
017"�
1 OOJt I
J1
RoUrrld 726 - d I.
, aQ Hatbopt `�.
.;yc ,rss Bay Harbour Rd BM 111 i �j...
..
r
404- ' • ,
c '- t2s._ I
i. _ •
12s lee
t. rl
e 119
215 '' .1$
9
1 2 3
`+ ors Lam^--
55 ,'1-0y
E
COL"aOn 4 J i
r f iD3 3 i
• f� r,
-fr. Jc4
- 7z's i ' -- 1"=126.71069683298981 ft
Tax Mapanfonstatlon --•--_ --
�I Print map scale is approximate.
•PIN 4626602489. • I Critical layout or measurement
•Address 200 BAY HARBOUR RD -_- ____1
•Account N Acct 77399696 - + activities should not be done using
•Tax Owner CAROLINA WATER SERVICES INC this resource.
OF
•Mailing 2335 SANDERS RD iA lic.P• RJR F.ER.ENICEORILY
Address INOTAILEG:,ALiDDO.IJ;1V1E11T '
• NORTHBROOK,IL 60062
•
•GIS Owner CAROLINA WATER SERVICES INC Iredefi County,North Carolina makes no claims and no
•Deed Into . 1158/976•WD-19990818 warranties,expressed or Impfied,concerning the validity or
•Tax Acres 1.01 AC accuracy of the GIS data presented on this map.
•Lot N 94 WELL i
Geometry updated 11/152023
•Description 115
THE HARBOUR P1 MA PB24-114- Data updated 11/142023
a
•Zoning R20
•Old Parcel 1702F12000A094
1 •Bldg value $0
•OBXF Value $0 I I
•Land Value $125,000
•Total Value $125.000 ! I
•Defer Value $D , l�
•Tax Districts -ALLCNTY FIRE--
1

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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
4446 - B wells abandoned: I I
I
NC Well Contractor Certification Number2621 7b.Approximate volume of water remaining in well(s): (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
granular dry chlorine
2.Well Construction Permit#: 2023-41232
List all applicable well coustntclion permits(r.a.U/C,County,State,Variance,etc.)ifbmwn 80 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use): .
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural CMunicipal/Public 0 Neat Cement Gr - _ �r r e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Glouls L.Lp I 1.1 0-Dr Cjay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout Cr ri1Y uttings
❑Irrigation 0 Specialty Grout J4 N 1 b 2O I Gravel
Non-Water Supply Well: 0 Bentonite SI ❑Other(explain under 7g)
❑Monitoring ❑Recovery 3Fr-•,�? .-1:�r :^r 9 llnX
Injection Well: 7E For each material seleP4.11 ovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-11 cu.yds.
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips-55 bags
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Well depth was measured with tape to verify depth.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Correct amount of chlorine was introduced via pouring dry
4.Date well(s)abandoned: 11/27/2023 .material&also mixing with water&pouring. Bentonite pellets
5a.Well location: placed by hand & concrete was poured from truck.
Carolina Water Service of N NC0149185 •
Facility/Owner Name Facility lDk(if applicable) 8.Certification: ,
110 Sunrise Circle, Mooresville, NC 28117 r-P-ati
Physical Address.City,and Zip Signs
Certell Contractor Well Osvner Date
Iredell 4625594981.000
By signing this form,I hereby certify that:the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA 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:
N ,y 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 '
Attact,well constructionrecord(s)ifavailable.For multiple injection or non-water snpply wells
ONLY with the same construcrionfabandonment,you can submit one form.
Well#2 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
1055
Gb.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
•
10b.For Injection Wells: In addition to sending the form to the address in 10a
8 and 6
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: 47 (ft) Division of Water Resources,Underg I and Injection Control Prjram,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
Ge.Outer casing length(if known): unknown (ft.) 10c.For Water Sumtly&Inicction 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
6E Inner casing/tubing length(if known): none (ft) •
abandoned.
6g.Screen length(if known): none (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016

1
•
Iredell County, North Carolina November 15,2023
•
CWS Well #2 - 110 Sunrise Circle
$. - v- ,4 --4,, ,..--/ ,
. --.€1 ...,,,.
4,-
+ . ' ' •, ,S 95
Tp zal ----...
. i C01.114061
...,
'
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Fr t116
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61
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111 0
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% 4. 6- v-
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0'
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. 47 , •
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- Sunrisa Cir
1.7g
121
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173 .
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Ist-5 1"=126.71887956221055 ft 1,--.L .4.` -. • -
•;S
2.5: 35 • 2: i 41:1
.....-..-.....--
7112/v5/lap toforrnation Print map scale is approximate.
•PIN 4625594981.000 1.7
1
Address 110 SUNRISE CR Critical layout or measurement
•
•Account N Acct 77398814 activities should not be done using
•
•Tax Owner CAROLINA WATER SERVICE INC
this resource.
•Mailing 500 W MONROE ST STE 3600 ;MAP FOEt ft,EFERgtICg ONLY
Address (NOT Atl,EGAJ-Dp.OlittlIT
CHICAGO,IL 60661
•GIS Owner CAROLINA WATER SERVICE INC Iredel County,North Carolina makes no claims and no
,• •Deed Info 1158/968-WD-19990818 warranties,expressed or Implied,concerning the validity or
•Tax Acres 0.98 AC accuracy of the GIS data presented on this map.
•Lot II 49 WELL
Geometry updated 11/15/2023 ,
•Description THE HARBOUR P1 MD PB24-136- Data updated 11/14/2023
137 t
;• •Zoning R20 I ,
;••; •Old Parcel I, 1702F12000A049
•Bldg Value $0
.;4 •OBXF Value $0
•Land Value $100,000
•Total Value 6100,000
•Defer Value $0 ' ,
- •Tax Districts -ALLCNTY FIRE--
I

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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
4446- B wells abandoned: 1 I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining I in well(s): 1888 (gal.)
II
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: granular dry chlorine
2.Well Construction Permit#: 2023-41233
1
Lisiall applicable well construction permits(i.e.UIC,County,State,Variance,eta)'Penmen 60 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural eMunicipal/Public 0 Neat Cement Grant %;—: s-Be t rite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grou'b L.b.p L.In, �1m,1?i Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout JA N 20 44
_0 Drill Cuttings
❑Irrigation 0 Specialty Grout Gravel
Non-Water Supply Well: 0 Bentonite Slurry .. �r ' ' .❑Other,(explain under 7g)
❑Monitoring ❑Recovery fFvrvrr..at l :'-•",.,"'T3l.,N.4
Injection Well: 7f.For each material selectga4,9rovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete Grout-5 cu. yds.;
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑StormwaterDrainage Bentonite Chips- 152 bags
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: I
❑Geothermal(Closed Loop) ❑Tracer -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well depth was measured with tape to verify depth.
Correct amount of chlorine was introduced via pouring dry
4.Date well(s)abandoned: 12/28/2023 material&also mixing with water&pouring. Bentonite pellets
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility ID//(if applicable) 8.Certification:
Chuckwood Road, Lot 74, Mooresville, NC 28117 1 „a'1
Physical Address,City,and Zip Sign re of Certt _10 Well Contra r or Well Owner Date
I redell 4626414326.000
By signing this form,I hereby certl drat the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N 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 SUBMITTAL INSTRUCTIONS
Attach well cautruction record(s)ifavailable.Formrrliiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can subunit one fort,.
10a. For All Wells: Submit this form within 30 days of completion of well
Well#3
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 775 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
8 and 6
6c.Borehole diameter: (in.) above,also submit one copy of this form;within 30 days of completioll of well
abandonment to the following:
6d.Water level below ground surface: 17 (ff.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): 64 (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of ihis 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): none (ft.) abandoned.
6g.Screen length(if known): none (ft.)
I
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Iredell County, North Carolina November 15, 2023
I
CWS Well #3 - Chuckwood Road (Lot 74 The Harbour Phase 3)
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ToxiMap Information Print map Scale is approximate.
•
•Address BRAWLEY SCHOOL RD PIN 4626414328.000 i Critical layout or measurement
•Account 14 Acct 77391173 activities should not be done using
•Tax Owner CAROLINA WATER SERVICES INC this resourCe.
•Mailing Address 500 W MONROE ST STE 3600
• CHICAGO,IL 60661 MAP IFOR f3EFERENQE(ONLY 1 1
•GIS Owner CAROLINA WATER SERVICES INC NOT A'LEGAL iDaOLIMPVir I
•Deed Into 1158/972-WD•19990816
•Tax Acres 1.32 AC Iredell County,North Carolina makes no claims and no
•Lot a 74 warranties,expressed or impaed,concerning the vaSdity or I
accuracy of the GIS data presented on this map.
•Description THE HARBOUR P3 MI PB27-75-77
•Zoning R20 Geometry updated 11/15/2023
•Old Parcel O Data updated 11/14/2023
' •13Idg Value SO '
•0 BXF Value $0
•Land Yalta $125.000
•Total Value S125,000
•Defer Value $0 •
•Tax Districts -ALLCNTY FIRE--
I
, .

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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
4446 - B wells abandoned:
' . 1703
NC Well Contractor Certification Number lb.Approximate volume of water remaining in well(s): (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: granular dry chlorine
2.Well Construction Permit#: 2023-41234
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.)if known 56 ouhces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural RIMunicipal/Public • 0 Neat Cementp uL„ra y;--;1} Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grtuf"" a L.,% y/"❑ijDTt Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) II Concrete Grout JA N 0 Drill Cuttings
❑Irrigation 0 Specialty Grout I 6 L02¢ l7 Gravel
Non-Water Supply Well: ❑Bentonittil41Yr,e.;i4 n pr 0 Other(explain under 7g)
Gi
❑Monitoring ❑Recovery "=' ."
rd' .`e•Z�� 9 U�:fi
Injection Well: 7E For each material selecteii above provide amount of materials used:I
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-6 cu.yds
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips-101 bags
0 Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well depth was measured with tape to verify depth.
Correct amount of chlorine was introduced via pouring dry
4.Date well(s)abandoned: 1/5/2024
material&also mixing with water&pouring. Bentonite pellets
5a.Well location: placed by hand &concrete was poured from truck
Carolina Water Service of N NC0149185
Facility/Owner Name Facility IDk(if applicable) : Certification: '
1540 Brawley School Road, Mooresville, NC 28117 1 ,10 4i
Physical Address,City,and Zip Signs\of Certi e. ell Contractor or ell Owner Date
Iredell 4626720224.000
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C 10200 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:
N 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ijavailable.For multiple infection or non-water supply wells
ONLY with the same construction/abandonment,you,can submit one form,
Well#4 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID/4: abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb.Total well depth: (ft.)(It.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
8 and 6
6c.Borehole diameter: (in.) above,also submit one copy of this form with,in'30 days of completion of well
abandonment to the following: i
•
6d.Water level below ground surface: 50 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Rnleikb,NC 27699-1636
6e Outer casing length(if known): 70 (ft.) 10e.For Water Supply&Iniection Wells: In I ddition 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 iepertment of the county where
6f.Inner casing/tubing length(if known): none (ft.) abandoned,
6g.Screen length(if known): none (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Iredell County, North Carolina November 15,2023
CWS Well #4 - 1540 Brawley School Road
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1"=126,70375560146196 ft
Tex;idap Jnf ormation ----
�! Print map scale is approximate.
•PIN 4626720224.000 dir i Critical layout or measurement
•Address 1540 BRAWLEY SCHOOL RD
•Account# Acct77398814 - --- activities should not be done using
•Tax Owner CAROLINA WATER SERVICE INC -
OF this resource.
•Mailing 500 W MONROE ST STE 3600 MAP FOR 1REFERENCE ONLI
Address CHICAGO,IL60661 NOT.A LEGAL DOCL CI-WENT 1
•GIS Owner CAROLINA WATER SERVICE INC Iredell County,North Carolina makes no claims and no
•Deed Info 1364/2583-WD-20020827 warranties,expressed or implied,concerning the validity or
•Tax Acres 1.268 AC accuracy of the GIS data presented on this map.
•Lot# Geometry updated 11/15/2023
•Description BRAWLEY SCHOOL RD Data updated 11/14/2023
•Zoning R20
•Old Parcel#
•Bldg Value $0
•OBXF value $0
•Land Value $70,000
•Total Value $70,000
•Defer'Value $0
•Tax Districts •ALLCNTY FIRE--
j I

WELL ABANDONMENT RECORD
For Internal Use ONLY: iI
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. i
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/lier property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4446- B wells abandoned: I
i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1350 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:I
. Company Name granular dry chlorine
2023-41235 7c.Type of disinfectant used:
2.Well Construction Permit it: ,
List all applicable well construction permits(l.c.UlC County.Slate.Variance,etc.)Iflatown 50 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well usc•(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural CMunicipal/Public 0 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) II Concrete Grout 0 Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:I
❑Aquifer Recharge ❑Groundwater Remediation --,,
Concrete Grout-6 cu. yds. �" �„-
❑Aquifer Storage and Recovery ❑Salinity Barrier - .�,f�AC. ki in,;7'^:
Bentonite Chips-21 bags . �..,,./
0 Aquifer Test ❑StormwaterDrainage p g JAN
❑Experimental Technology ❑Subsidence Control 1 6 2024
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer
Well depth was measured with tape to f de' the?r-.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) ,. , ••-"'‘,,:;-g(-IN X
rsvv4l oc-3
Correct amount of chlorine was introduced via pouring dry
4.Date'well(s)abandoned: 12/20/2023
material&also mixing with water&pouring. Bentonite pellets
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility ID!,(if applicable) 8.Certification:
Polpis Drive, Lot 515, Mooresville, NC 28117 141 ar'\
Physical Address,City,and Zip Sign re of Carried ell Contract° r Well Owner (Date
Iredell 4625865125.000
By signing this forth,1 hereby certtbt that the tvell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 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:
N 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple Injection or non-watersupplywells
ONLY with the same cot,struction/abandonment,you can submit one form.
Well#6 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
8 and 6 106.For 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: I
ll
6d.Water level below ground surface: 43 (ft.) Division of Water Resources,Undergrou Id Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): 65 (ft.) 10c.For Water Supply&Injection Wells: Inladdition 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
6f.Inner casing/tubing length(if known): none (ft.) abandoned.
none
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division ofWater Resources j ,Revised2-22-2016
'
I .

Iredell County, North Carolina November 15, 2023
CWS Well #6 - Polpis Drive - The Point Lot 515
8s
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TaxMap Information ----"'--
I Print map scale is approximate.
•PIN 4625865125.000 'I Critical layout or measurement
•Address BRAWLEY SCHOOL RD
•Account it Acc177398814 ..—_— , activities should not be done using
•Tax CAROLINA WATER SERVICE INC OF - " this resource.
Owner
•Mailing 500 W MONROE ST STE 3600 IMAP FOR iREF,ERENCE,DULY
Address NOT'A!LEGAL DOCUMENT 1
• CHICAGO,IL 60661
•GIS CAROLINA WATER SERVICE INC Iredell County,North Carofna makes no claims and no
Owner ' warranties,expressed or Implied,concerning the validity or i
•Deed Info 1177/588-WD-13991214 accuracy of the.GIS data presented on this map.
•Tax Acres 0.949 AC Geometry up dated 1L15/2023
•Lot a 515
THE POINT ON NORMAN PS M3 WELL Data update 11/14/2023
Description PB33-69 PB33-96-101
•
•Zoning R20
•Old Parcel • I i
N
•Bldg $0
Value
•OBXF $0
Value
•Land $162,500
Value 1
a
1

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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 construetion/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4446- B wells abandoned:
j 1755
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
granular dry chlorine
2.Well Construction Permit tl: 2023-41237
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)tfknown 55 ounces dry chlorine
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 0 Neat Cement Grout •Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amou Edf mi alert is used:it yam- .4
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-8 cu. yds �, i';°m'%.ter , ' V rz Le
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips- 13 bags . JAN 1 6 2O24
❑Experimental Technology ❑Subsidence Control x,._
7g.Provide a brief description of the abandonmeilrirFoce3i itE t s tom•:,_•g Un
OGeothermal(Closed Loop) ❑Tracer Well depth was measured with tape to kgi#i'de th.
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Correct amount of chlorine was introduced via pouril
4.Date well(s)abandoned: 12/20/2023 material & also mixing with water& pouring. Bentot
5a.Well location: placed by hand & concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility IDti(if applicable) ..Certification:
Poplar Circle, Lot 565, Mooresville, NC 28117
Physical Address,City,and Zip Sign\,...
re of•Ce`fied Well Con ctor or Well Owner Dale
Iredell 4625852533.000
By signing this form, 1 hereby certifr 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:
N 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. I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)(available.For multiple injection ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Well#7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1000 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 and 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: l
6d.Water level below ground surface: 48 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 121 (ft.) IOc.For Water Son6ly&Infection 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
none abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): none (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016

i
1
Iredell County, North Carolina • November 15,2023
CWS Well #7 - Poplar Circle - The Point Lot 565
•
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i 24, 63 a
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TaxMapdnformation. _ ......, ..,_..t Print map scale is approximate.
•PIN 4625652533.000 7 '
•Address BRAWLEY SCHOOL RD - -- — Critical layout or measurement
•Account IS Acct 77398814 -"" activities should not be done using
•Tax CAROLINA WATER SERVICE INC OF - �'
Owner this resource.
•Mailing 500W MONROE ST STE 3600 MAP FOR REPERENORONLY
Address
• CHICAGO,IL60661 in1A.T, ;I�EGAL'jDA•Cl1.fti1�,111iT.
I
•GIS CAROLINA WATER SERVICE INC Iredell County,North Carofma makes no claims and no • t
Owner warranlles,expressed or Implied,concerning the validity or
...Deed Info 1177/588-WD-19991214 accuracy of the GIS data presented on this map. 1
•Tax Acres 0.98 AC
•Lot It 565 Geometry updated 11015/2023
• THE POINT ON NORMAN P5 M1 WELL Data updated11/14/223
Description PB33-69 PB33-96-101
•Zoning R20 I
•Old Parcel
If
•Bldg $0
Value
•OBXF S0
Value
•Land $220,000
Value '
I

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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 deeded. Indicate TOTAL NUMBER of
4446 - B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water rem`ining in well(s): 2174 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: gran I lar dry chlorine
2.Well Construction Permit#: 2023-41239 I
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.)if known 70'ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(cheek all that apply):
❑Agricultural •Municipal/Ptiblic 0 Neat Cement Grout I U Bentonite Chips or Pellet
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout I, 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout , ❑Drill Cuttings
❑Irrigation 0 Specialty Grout , 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring • ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used;. z-
❑Aquifer Recharge ❑Groundwater Remediation c '4 y.a, , c"'"a
Concrete Grout-9 cu. yd" . ��,�,�,Y,.;; �� a....�'
❑Aquifer Storage and Recovery ❑Salinity Barrier '``�
❑Aquifer Test ❑StormwaterDrainage Bentonite Chips- 131 bag' JAN 1 t; c024
❑Experimental Technology ❑Subsidence Control i �r€o ��
7g.Provide a brief description of the abandonmentced ,ry ;>;turc;-, ;3
❑Geotlmerinal(Closed Loop) ❑Tracer Well depth was measured wit�q'ape tg veh epth.
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Correct amount of chlorine was introduced via pourii
4.Date well(s)abandoned: 12/20/2023 material & also mixing with water& pouring. Bentz)!
5a.Well location: placed by hand & concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility IDi/(if applicable) 8.Certification:
Brawley School Road, Lot 4, Mooresville, NC 2811-/ 04 a\
.cckr
Physical Address,City,and Zip Signal.e of Certifieil Well Contracto r Well Owner Date
Iredell 4625965431.000
By signing this form,I hereby certio+that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the st'ell 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:
N 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
Attach well construction record(s)ifavailable.Formultiple injection ornon-watersupply wells
ONLY with the same cautnrclion/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Well#8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 880 (It.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
8 and 6 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following: 1
6d.Water level below ground surface: 44 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 52 (ft.) 1Oc.For Water Supply&Infection 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
6f.Inner casing/tubing length(if known): none (ft.) abandoned. j
6g.Screen length(if known): none (ft.)
•
I ,
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

Iredell County, North Carolina November15,2023
CWS Well #8 - Brawley School Road - The Point not 4
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J o
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- I' - I~1"=126.72827416204605 ft •1
__ •Y • r •- •-- _ hits -= - _____t:--- --- -gin
Tax.Mop+Infonnation '-�--'�"'"' Print map scale is approximate.
•PIN 4625965431.000 q • I
Critical layout or measurement
•Address BRAWLEY SCHOOL RD _ r y
•Accountll Acct77395202 -- -- activities should not be done using
•Talc Owner CAROLINA WATER SERVICES - this resource:
•Mailing 500 W MONROE ST STE 3600
Address MAP FOR REFEREhICEONLY
• CHICAGO,IL 60661 SNOT A LEGAL POCU•MENT
•GIS Owner CAROLINA WATER SERVICES OF NC
•Deed Info 1090/1636-WD-19980803 Icede3 County,North Carolina makes no claims and no
•Tax Acres 0.82 AC warranties,expressed or Implied,concerning the vaidtty or
•Lot 4 4 accuracy of the GIS data presented on this map. I.
•Description THE POINT ON NORMAN LLC WELL Geometry updated 11/1512023
SITE 8 PB30-154 Data updated 11/14/2023
•Zoning RA CUD
•Old Parcel •
N
•Bldg Value SO
•OBXF SO
Value
•Land Value $200,000
•Total value $200,000
•Defer Value $0 ,
•Tax •ALLCNTY FIRE-- .
I
I

i
WELL ABANDONMENT RECORD • For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
it
Johnny Hart, Jr. 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
4446 - B wells abandoned: i I
NC Well Contractor Certi/ication Number 7b.Approximate volume of water remaining in well(s): 2207 (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY: •
Company Name granular dry chlorine
2.Well Construction Permit k:
2023-41240 7c.Type of disinfectant used:
Lisl all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc)if known 70 ounces dry chlorine
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(chec!['all`thu1 nppl'y
❑Agricultural IMunicipal/Public ❑Neat Cement( outs,,,,`,_.?L...is k' 4^Bt:ntonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout rr,, Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) I Concrete Grout JAN 1 6iO2 Drill Cuttings
❑Irrigation 0 Specialty Grout
Non-Water Supply Well: `•,;1 `I �,:` ;: ." �Y�)
❑Bentonite Slt}P 4•.'+„¢2lZ' 0 Other(explain under 7g)
i .
❑Monitoring ❑Recovery �t"V. "
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete Grout-9 cu. yd;
❑Aquifer Storage and Recovery ❑Salinity Barrier Bentonite Chips - 128 bag
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) Well depth was measured with tape to verify depth.
Correct amount of chlorine was introduced via pouril
4.Date well(s)abandoned: 12/20/2023 material &also mixing with water&pouring. Bentor
5a.Well location: placed by hand &concrete was poured from truck.
Carolina Water Service of N NC0149185
Facility/Owner Name Facility IDN(if applicable) Certification:
Brawley School Road, Lot 61, Mooresville, NC 2811 145 Ati
Physical Address,City,and Zip Signe e ofCe eyirti6 Well Contract° r Well Owner Date
Iredell 4625968348.000
By signing this form,I hereby certrjy that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 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:
N 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavallable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this fonts within 30 days of completion of well
6a.Well ultf: Well#9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 900 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 and 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: 51 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 63 (ft.) loc.For Water Slimily Lk 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
6f.Inner casing/tubing length(if known): none (ft) abandoned.
I
6g.Screen length(if known): none (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1 i

1
1
Iredell County, North Carolina November 15,12023
•
CWS Well #9 - Brawley School Road - The Point Lot 61
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.............--...-.-,.... I .Tax Map information
, Print map scale is approximate.
•PIN 4625968348.000•Address BRAWLEY SCHOOL RD ir 4, Critical layout or measurement
•Account q Acct 77395202VVV-V_ activities should not be done using
•Tax Owner CAROLINA WATER SERVICES this resource.
•Mailing 500 W MONROE ST STE 3600
Address /MAP FOR REFERENCE ONLY I
1
CHICAGO,IL 60661 I I
•GIS Owner CAROLINA WATER SERVICES OF NC hteir.A!LEGALDOCUNIENT I
•Deed Info logo)1636-WO-19980803 Iredell County,North Carolina makes no claims and no
•Tax Acres 1.09 AC warranties,expressed or Implied,concerning the validity or
•Lot II 61 accuracy of the GIS data presented on this map.
•Description THE POINT ON NORMAN LLC WELL Geometry updated 11/15/2023 1 ,
SITE 9 PB30-154 Data updated 11/14/2023
•Zoning R20
•Old Parcel
if
•Bldg Value so
•OBXF SO
Value
•Land Value S210,000
•Total Value $210,000 .
•Defer Value SO
•Tax -ALLCNTY FIRE--
i
1 i

;
WELL ABANDONMENT RECORD For InternalUse•ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS
Johnny Hart, Jr. 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
4446 - B wells abandoned: ! I
I I 1280
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
McCall Brothers, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name granular dry chlorine
2.Well Construction Permit if: 2023-41244 7c.Type of disinfectant used: ,
hist all applicable well construction permits(/.e.UIC,Como;State,Variance,etc)ifknotrn 40:ounces dry chlorine!
7d.Amount of disinfectant used:
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural eMunicipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout , 0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout , ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ' 0 Other..(axplaiin under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amountamateyials us dy - r-- l
❑Aquifer Recharge ❑Groundwater Remediation Concrete Grout-6 cu. yd5 J.>�N 1 - ^•
❑Aquifer Storage and Recovery ❑Satin ity Barrier Y (y e0e.it
❑Aquifer Test OStormwater Drainage Bentonite Chips- 12 bags;
tts o i,-,.it::'<^.n s,- -;„5,-1'•3!" LIN❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment proc&daiiCJ)O;j
OGeothermal(Closed Loop) OTracer Well depth was measured with tape to verify depth.
❑Geothermal(Heating/Cooling Return) ❑other(explain under 7g)
Correct amount of chlorine was introduced via pouril
4.Date well(s)abandoned: 12/28/2023 material &also mixing with water& pouring. Bentor
5a.Well location: placed by hand.&concrete was poured from truck.
Carolina Water Service of N NCO149185
Facility/Owner Name Facility ID#(if applicable) .Certification:
Quaker Road, Lot 30,-Mooresville, NC 28117
Physical Address,City,and Zip Sign re of Ce 'fled Well Co for or Well Owner Date
Iredell 4635071434.000
By signing this form.!hereby cer,*that the well(s)was(were)aba oned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction tarrdards
and that a copy of this record has been proi'ided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well detailsi
N 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)(1available.For multiple Infection or non-water supply wells
ONLY with the same construction/abandonment,you can submit me form.
Well #10 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ILA Well to the following:
1
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
•
10b.For Injection Wells: In addition to sending the form to the address in 10a
8 and 6
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I i
6d.Water level below ground surface: 29 ({I,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if'mown): 90 (ft.) 10c.For Water Supply&Injection Wells:i 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
6f.Inner casing/tubing length(if known): none (ft.) abandoned.
I
6g.Screen length(if known): none (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 122-2016

•
Iredell County, North Carolina November 15,2023
CWS Well#10 - Quaker Road Lot 30
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, f � _+� _.c` '- `- ___-_ ."\_—.—_—_-s-1- i —. --__--- ----Taxmgpiintormation -- ---• i
Print map scale is approximate.
•PIN QUAKE il Critical layout or measurement
•Address
•Account11 Acci77395202 activities should not be done uing
•Tax Owner CAROLINA WATER SERVICES this
•Mailing 500 W MONROE ST STE 3600
h resource.'
Address CHICAGO,IL 60661 IMAP', OR REP.ERENCE,C N.L'Y
•GlS owner CAROUNA WATER SERVICES INC NOT A 1.EGAL:D.4CU.MENT
•Deed Info 1210/2146-WD-20000731 Redd County,North Carolina makes no claims and no
•Tax Acres 1.083 AC warranties,expressed or implied,concerning the validity or I
•Lot if 30 accuracy of the GIS data presented on this map.
•Description THE POINT PIC PB31-127 REV Geometry updated 11/1512023
P835-97 Data updated 11/14/2023
•Zoning R20 •
•Old Parcel B
•Bldg Value $0
•OBXF Value $0 .
•Land Value $150,000
•Total Value $150,000•Defer Value .$0
•Tax Districts -ALLCNTY FIRE--