Iredell_Well Abandonment_20240119

•
•
•
' ,47. WELL ABAI�IT +O�'���E1�1T
• ( RECORD
....i :North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATYON # 2.656-A _
1.WELL CONTRACTOR: 1
15. WELL DETAILS;
D�V i C a.Total Depth:3 t
Well Contractor(Ittdivid a)Name p —fi'Diameter: in.
2 I•
b.Water[.eve)(Below Meas.urng Point):_ ft.
Well Contracts C mpanW'�at el BOr i n` --- t • Measuring point is I!ft.above land surface.
'
. STREETADDRESS1481 Larry Davis Rd •
1 6. CASING: Length Diameter
I Lawndale, NC 28090 • ! .
City or Town State - Zip Code a Casing Depth(if known): }� �•.
it
b.CasingRemoved: 11. __ /(? in.
( 7G4)• 276-3434
Area code-Phone number t4 i j e
7. DISINFEC'TtON A'�d
2.WELL INFORMATION: (Amount of65%-75%calciwri hypochlorite used)
SITE WELL ID#(if applicable)
8. SEALING MATERIAL:
STATE WELL PERMIT#ri pplicahle) I�lt;at Cement 1
� ` JQ3� 1 /} Sand(emeniiCOUNTY Wp �� •
Cement lb. Cement o.
Water gal. I'• Water
gal,
DWQ or OTHER PERMIT 4(if applicable) _ r ,:1,
1 a-.
Bentonite R 4
WELL USE(Check applicable use): 0 Monitoring Resfdentiai '
Bertonite lb.
l, ,I
[] Municipal/Public ❑ IndustriaVCommerciaiI' JAN 1 9 2024 Agricultural Type:❑Slurry. OPellets,
0 Recovery 0 In'cetionWater• _ , ,
1 0 Irrigation Sai. III;.;Tire DTI P:'^;: ,)!ng Ure
•
COtlter(list use)
— Other I • �:`°
•
Type material t.
3.WELL LOCATION ---
' iW Amount
COLNTY 'JADRANGLHNAME
1E.A, 'STTQ'alN; 1 �
` / •
9. EXPLAIN ETROD OF E ILA NIENT(OF MATERI L.
(Street/Road Name,Number,Community,Sabdivisie::,Lot No.,Parcel,Zip Code) .' �, 1,,__. .. �Y � � //d/
TOPO D•APH1C/LAND SETTING:ING: - _- ` � `.� ti
�.Ale . r , .� '
1_;�lepe L Valley ❑Fiat f]Ridge Other_�r
(Check appropriate setting) 7/ � M +� ` �---
I i
•
- I0. WELL DI,tGR ` 1 ��
I.ATIT1iD "° ®� I May be in degrees, Drzw a d<.piled sketch of the well on the back o f t't=s
�y minutes,seconds, r in a ! l form showing total depth,depth and diameter of screens(if
�l�j I- I decimal fotaat 11 i in the welt,gravel interval,intervals of casing and remaining
LONGITUDE 6 perforations, depth,and
Laritude,'IongStudesoerce; GPS I types of fill;materials lisnd. . I
[Topographic map
(Lacafion ojta well must he shown on a USGS;apv map and 11. IRATE WELL ABANDONED/ F"'
attached to this font?r,f not using GPS.)
•
I DO
4a.FACILITY.The name,ofthe bus;ness where the well is located.Cemple^.e 4a and4u. WITH S•
HEREBY
NCACE2C,WELL CONSTRUCTION STANDARDS,US WELL WAS AND THAT A COPY OF
If a residential well,skip 4a:complete 4b,well owner inf nnenon oniy. 1
( �) THIS REC RD HAS SEEN Pb;UYDED?i�THE WELL OWNER,
FACILITY TD.#(tf applicable)
P1AME OF FACILITY______ - L? 1 �.,, _ � -1-5f
STREET ADDRESS � I l
I City or Town State Zip Code • i SIGNATURE OF PRIVATE WELL OWN•
i R ABANDONING THE WELL DATE .
---
( 46. CONTA ' RSONlV4'ELL OWNER; (The private well owner must be an individual ti•ho personally abandons hts'he residential well
` f in accordance with ISA NCAC 2C.0113.)
NAME + I .X • Tony R. Davis_1:
STR ET ADDRESS Ij � ►. i PRINTED NAME OF PERSON ABAVDONIIVC;THE WELL~ I
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. I
919
Attn:Information/Management, 1617 Mail Service Center-Raleigh,NC 27699-1617. Phone No,(919)?-¢3-'Ol;ex r1'5 FRn3. Rev Form OW-30
5/06
.
I ;

(Ara hihs 34( PT. C6t.SEci 141,7teg
20 N well Ct;t-tru7' 75 2 4"
IL1,5 E-c1 A- 90 ,, BoR c
tNa. BukET"--- 7,-;
Vat PLZ. 7?1E VAT- f 4 /J A) 77 z 4., 6 37 or
7T4 is t() fa
efr.g6 Diod LE1if
FULag #4 ii* %
E'sA Otxr L K.
• •
0 1/41 PTV 2-N-sP rcrii2 DA rii),eZIE i 0 wPERtn6.
i4Lo NIG. 1.,) irg 1•41R •2;y-zoom 's f; c1Q is EA
1`112. S g fPF.,9vzci 77-6,47 14 r e 6 1.? 4c-,‘ ri26 ,e
CO 1%1TZETE iki 774 c, 77.p 1-9 g ER is p Li
.......„----..... •
•
11 00_ R ("D 41.4,1,

•
WELL ABANDONMENT RECORD 3
For Internal Use ONLY: i
i
1.Well Contractor Information: i
WELL ABANDONMENT DETAIi.S
RANDY OWNBEY
7a.For Geoprobe/DP'I'or Closed 1,lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW130 is needed. Indicate TOTAL NUMBER of
3214A wells abandoned: 1 1
NC Well Contractor Certification Number 71).Approximate volume of water remaining in well(s): (gal.)
AIR DRILLING INC
FOR WATER SUPPLY WELLS:ONLY:
Company Name
2.Well Construction Permit II: 2023-40485 7c.Type of disinfectant used: HTH
•
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.):r t known 2 CUPS
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(cheek all thatI
DAgricultural ❑M ec apply):
Y)�
unicipal/Public 0 Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) MIResidential Water Supply(single) 0 Sand Cement Grout
' 0 Dry Clay
CJlndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout
•❑Irrigation 0Drill Cuttings
Non-Water Supply Well: 0 Specialty Grout 0 Gravel
0 Bentonite Slurry I(9 Other(explain under 7g)
❑Monitoring ❑Recover
injection Well: y •
7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑GroundwaterRemediation 150 LBS HOLEPLUG'
DAquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑Stornwater DrainageI
❑Experimental'Technology ❑Subsidence Control
7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothennal(Heating/Cooling Return) DOther(explain under 7g) POURED 150 L B S H O L E P L U G
';',ra L,gym; '9 r.qj
4.Date well(s)abandoned; 12-8-23
JAN 1 9. 2024
5a,Well location:
STUTTS RD INVESTMENTS,LLC ' ^ ^^
Facility/Owner Name 1 !J\e,:Q/L5 (3.
Facility UM(if applicable) 8.Cell' lion:
405 STUTTS RD,MOORESVILLE,N.G. 28117
Physical Address,City,and Zip _ 12-8-23
I RE DELL Signature of Certified Well Contractor or Well Owner Date
4636611334
County IJy signing this Am. 1 hereby certrjy That dre well(s) was (were) abandoned in
Parcel Identification No.(PIN) accordance with /SA NCAC 02C.0100 or 2C.0200 Well Coit (,uction Standards
• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy(Olds record hers been provided to the well owner.
(if well field,one IuVlong is sufficient)
35° 33.084 ° 9.Site diagram or additional well details:
N 80 53.457 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
.11!uc'hN'ell!'iiWdi'i'(jwt l'e('oi'I(ti)%JOYGrlable. For ntlfl(ihiebi%L'('(iwi orq(At-tvatC'/'si,pp/J'are/Is SUBMITTAL INSTRUCTIONS I •
ONL 1'with the same cnnstructio/t/nhnit[lnnutelu•tot,can submit one Arm
i0a. For All Wells: Submit thisi form within 30 days of completion of well
6a.Well ID/I: abandonment to the following: ,
L
Division of Water Resources,Information Processing Unit,
fib,Total well depth: . (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Injection Wells: In addition to sending the form to the address in IO:t
6c.Borehole diameter: 2 (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: I'
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): (ft.) 10e,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 easing/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 1.-7.2-20 I 6

i '
WELL. ABANDONMENT RECORD —
For Internal Use ONLY: �1
I.Well Contractor Information:
WELL ABANDONMENT DETAILS
CHAD HARTNIESS
7a.For Geoprobe/DP'I'or Closed-1 o I p Geothermal Wells having the same
Well Conantor Name(or well owner personally abandoning well on his/her property) well consh•ltciion/depth,only I G3U\V- is needed, Indicate TOTAL NUM131'.12 of2901 A wells abandoned: 1..__. .. . _
NC Well Contractor Certification Number 7b.Approximate volume of water�,emaining in well(s): (gaI.)
AIR DRILLING INC wiz WATER SUPPLY WELLS ONLY:
Company Name
27969 7c.Type of disinfectant used: HTH
2.Well Construction Permit Il: —
List oll uppih ugh•well construction permits(i.e. UlC,County,Slate. Variance,etc.)r•'/'known 2 CUPS
7d.Amount of disinfectant used:
3.Well use(cheek well use):
1 Water Supply Well: 7e.Sealing materials used(check till that apply):
L)Agricultural • CDMunicipal/Public D Neat Cement Grout t l.I Rcnumite Chips or Pellets
LIGeothermal(Heating/Cooling Supply) P3Rcsidcnlial Water Supply(single) Cl Sand Cement Grout 1' C)Dry Clay
1 IlndusIrial/Conunercfal I:_IResitlenlial Water Supply(shared) NI Concrete Grout Is
I) Drill Cuttings
! !Irrigation
I I Specialty Grout I_1 Gravel
Non-Water Supply Well: '
I I n-Wui)riit l I l lienlonlie Slurry I ! Other(esplaim under 7l:)
L I'1Recovery
Injection Well: 7f.For each material selected aboi e,provide amount of materials used:
I-lAquif'er Recharge EtIGroundwater Remediatiott 2 1/2 YARDS
CIAquife•Storage and Recovery flSalinity Barrier a
•
I 'Aquifer est [IStormwate'Drainage
'l ,
f IICxperimental Technology I-ISubsidenec Control
❑Geothermal(Closed Loop 7g.Provide a brief description of the abandonment procedure:
1111cttcf POURED 2 1/2 YARDS OF CONCRETE
f 1Geuthrmal(l letting/C000lf ing Return) C_IOlhcr(explain under 7g)
4.Date wells)abandoned: 06-20723
•
Sa. ,Yell location: jj;vT 9_ —
DAVID PARKER ' CO
Facility/Owner Name Facility IDr/(il'applicable) $,�C e�rt'(icatiotlit.'s cn64'C 'BOG
155 PARKERTOWN RD,MOORESVILLE,N.C. 28115 ( '1 '4.% ;-,11...i.;_,,,..,.......
._.y---,,,,,..,._•-..,.. ,_,6-20-23
Physical Address,City,and Zip
Signature at Cciii lied Well C'ontramor or;Well Owner Date
IREDELL 4659-24-1163 ,.
ljl'.+'n;ning this Arm, l hereby c•c•ril/i•drat the u•r•/i(s) n'(lS Avery) uhturdoitre/in
('oi101) Parcel ldeutitiesutmn Ni,,(PIN)
crc•c•urduttm with /,Sat NC/IC.'02C.0900 or'C'.0200 Well Construction Sicanlurtic
gib,Latitude:t ut longitude in degrees/minutes/seconds or decimal degrees:
urn/that a copy(Obis rec•urd bus been provided to the well manor.
Orwell field.ono Ice/long is sufficient)
35° 38.351 ° 9.Site diagram or additional well petal's:
N 80 50.380 W You may use the back of this page Ito provide additional well site details or well
abandonment details. You may also1auaeh additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach nr!lcou.ctrurtionrccorrl(,c)i/ays//oh/e, Pus nraltipk'itt/mrionru non-water supply itO//' SI111M1TTAL INSTRUCTIONS
` OAt,I'with the sonar construction/abandonment you con avhnrit omit
IOU. I'or All Wells: Submit this'form within 30 days of completion of well
6a.Well ID/I: • abandonment to the following:
1 '
Division of Water Resources,Information Processing Unit,
fib.'total well depth: 20 MOhn 1617 Mail Service Ceter,Raleigh,NC 27699-1617
lab. For Injection Wells: In addition to sending the form to the address in lull
6e.Borehole diameter: 24 (in.) above, also submit one copy of this fi)rnt within 30 days of completion of well
abandonment to the following: ,
6d.Water level below ground surface: (it.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1,
6e.Outer easing length(if known): (rt.) IOc.For Water Supply&Injection Wells: In addition to sending the form to the
actdress(es)above,also submit one copy of this forth within 30 clays ol'completion
of well abandonment to lho county; health department or the county where
61',loner casing/tubing length(if known): (ft.) abandoned.
t
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department or Environmental Quality-Division of Water Resources ket iscd:....,_::_,
.5 to

Tv IIJJtJ1J fin/Ink/UIN NM I' iti{JCORll
For Internal Use ONLY:
• I. Well Contractor Information: r I
\1 LLL ABANDONMEN I llETAILS
NEILL PARDUE
7a.For Geoprobe/UPT or Closed-Loop Geothermal Wells having the same
Well contractor Name for well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate'I O'I'AI.NUMBER of
2609A mils abandoned: JI
N('Well contractor certification Number 7b.Approximate volume of water remaining in well`s):
AIR DRILLING INC I (gal.)
FOR WATER SUPPLY WELLS ONLY: `+
C'ompam Name
7c.Type of'rlisinfectant used: 1 ,I TH
2.well Construction Permil'II:
IA/all npplicrrble well construction permits(Le. WC,County,State, Variance.err.)ff known ' 2 C UPS
7d.Amount of disinfectant used:`
.1.Well tse(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
! !Agricultural LIMunicipal/Public Ll Neal Cement Grout
II 13cnloni(c Chips or Pellets
i ICieothermal(limning/Cooling Supply) I.IResiclential Water Supply(single) LI Sand Cement Grout •
I I Dry Clay
AInclustrial'Commercittl I:IResidential Water Supply(shared) LI Concrete Grout
LI Drill Cuttings
I !Irrigation ' 1:1 Specialty Grout L I GravelNon-Watertor Supply Well: P' Y
hI Bentonite Slurry 11 Other(explain under 7g)
'Monitoring ['Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
( ;\qui(i:r Recharge FIGrounclwater Remediation 75 BAGS
I:\quiff...siora,;e:uul Recovery I-ISalinity l3ata•icr
'Aquifer Test I ISlorntwater Drainage ;
'l
: '.I:xperintental Technology I iSubsidenee Control --
I iGcuthcrnurl(Closed Loop) 7g.Provide a brief description ol'j the abandonment procedure:
Il IlOI•heer 75 BAGS BENTONITE CHIPS POURED
IG oll,ernrttl(I Ic:iling/Cooling Return) I.IOlhce(explain under 71;)
c ,e ~�Goa
I.Date well(s)abandoned:
06-01-2023 z '' �`' '' oaf L.. ,;1
JAN 1 9 '2024
5a.Well location:
SPIVEY CONSTRUCTION S--- i'��: '
C)r: C. :,.-1?a
Facility/Owner N;une Facility IOU(it'applicable) 8.Carlin ratio
167 LUGNUT LANE,MOORESVILLE,N,C. 28117
J
Physical Address.City,and rip — .— __ -- — 06-01-2023
rant •o ct c 'Dolt, or a 49, • Or bate
IREDELL +'' '
['auntyI
,:• By.vigning I/i/sArm, 1 hereby cerdlje that the tvell(s) was (leer(:) abandoned in
Parcel Identification No.(PIN) accordance with 114 NC AC 02C.0100 or 2C.0200 Well Construction Sianrlru•t/v
ih.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy(Olds record has leer provided to the well owner.
Orwell lieu One latilone is sufficient)
9.Site diagram or additional well.details:
350 33.916 N 800 54.302 W You may use the back of this page to provide additional well site details or will
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OFWl•:1,1,(S)BEING ABANDONED
:lumlrnr//en(urr(u-ounrecord(.,yt/'nrni!«h/e. %irrmultiple in%errionuruarh••urucre'rgrph'trc'N•r SUBM1'1'TALINSTRUCTIONS.
ONLY with the same cunsp'tu•rio(eiahmulorrmenr,you can submit one form. I. ' .
- 10;t. For All Wells: Submit this lornt within 30 days of completion of well
6a.Well IDIl: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 305 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
l
10b. For Injection Wells: In addition to sending the form to the address in I0a
6e.Borehole diameter: 6 (in.) above, also submit one copy of tilts:form within 30 days of completion of well
abandonment to the fallowing:
i
6d.Water level below ground surface: (ft.) 1)i'l5in11 of Water Resources,Uuldergrouad Injection Control Program,
1636 Mail Service Getter,Raleigh,NC 27699-1636
6e.Outlet-casing length(if known): (1•t.) 10e.Nor 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
79 GALV of well abandonment to the county health department of the county where
•
6f. Inner casing/tubing length(if known): t•t• abandoned.
6g.Screen length(if known): (ft,)
•
Form(ill.30 North Carolina Department orEnvironntcnial Quality-Division of Water Resources)
Revisal:?-''''"'n I A

WELL ABANDONMENT RECORD
Ivor Internal Use ON1..1. I I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NEILL PARDUE I
7n.For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the same .
Well Contractor Name(or well owner personally abandoning\veil on his/her property) well construction/depth.only 1 GW-30 is needed. Indicate'I'O'l'AI.NUMBER of
2609A wells abandoned: 1__.._
N( well Conir mor Certilientinn Number 7b.Approximate volume of water}remaining in well(s): (gal.)
AIR DRILLING INC I'
FOR WATER SUPPLY WELLS ONLY: '
c'ongnuw Name
7e.'I'ype of disinfectant used: HTH
2.Well Construction Permit it:
Lin all applicable well eons/ruction permits(i.e.U/C,County.Stare,Variance,etc.)r k"own 2 C I nS
7(I.Amount of disinfectant used:
3.Well use(cheek well use):
Water Supply Well: • 7e.Sealing materials used(check all that apply):
1!Agricultural LIMunicipal/Public 1:1 Neat Cement Grout ' IA Bentonite Chips or Pellets
;Geothermal(heating/Cooling Supply) ,A Residential Water Supply(single) Li Sand Cement Grout I LI Dry Clay
• I Ind ustriaECor tnereial f}Residential Water Supply(shared) I'I Concrete Grout II LI Drill Cuttings
i Ilrri aU°ta I'I Specialty Grout IA Gravel
Non-Water Supply Well:
f-1 llentonitc Slurry CI Other(ex lain under7?11Monitoring LIRecovery I �)
Injection Well: 7f.For each material selected above,provide amount of materials used:
I IAquili:r Recharge DGroundwater Remediation 1 20 LBS
i
I}Aquifer Storage and Recovery ElSnlinity Barrier
I !Aquifer'lest [IStorntwater Drainage
I II xperimental Technology LlSubsidence Control I!
I IGcothrrmatl(Closed Loop) Gl'I'racor 7g.Provide a brief description of the abandonment procedure:
(a'ollier:natlIIleating/Cooling Return) L101her(explain unde•7l;) 120 LBS BENTONITE CF LPSAPC) . .'i
4.Dale well(s)abandoned: 06-01-2023 _.
5a.Well location:
ln
LAKEVIEW BUILDING GROUP CIA r rr�" ?!'zg u
f37,7
Facility/Owner Name Facility IDtl(ffapplicable) 8.Cerli tt.. , o )
131 STUTTS RD,MOORESVILLE,N.C. 28117 .�•�
. i t: : ice. 06-01-2023
Physical Address,City,and Zip `
ig551ttn of Certi fled Well Contractor orl Welt Oner Date
IREDELL
By signing this farm, 1 hereby cert'i/i'that the well(s) was (were) abandoned in
('scnay Parcel Identification No.(PIN) accordance with/S.d NCAC 02C.000 or 2C.0200 We'll Construction Standards
Sh.Latitude and longitude in degrees/(minutes/seconds ordecimal degrees: and that a copy alibis record has 1)cen provided to the inch owner.
fir well field.one lot/loan is sofficion°
0
0 9.Site diagram or additional well details:
35 34.005 N 80 54.105 ,, You may use the back of this pageito provide additional well site details or well
abandonment details. You may also'attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED i
:Reich:roll raa.srrnrtionree•oreK.c)i!•arailable. earmultiplein/ectioaor•ami-unrersupph'trell•,• SI113M1TTAL INSTRUCTIONS
lh\'/,1'with the sane consfravaaNahandanment,you cnu.submit One.%arnt,
IOa. For All Wells: Submit thisIform within 30 days of completion of welI
6n.Well ITN!: abandonment to the following: I,
!'
Division ot'Water Resources,Information Processing Unit,
61).'Fittal well depth; 105 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
1.
IOb. For Injection Wells: In addilioi) to sending the fiord]to the address in IPa
6e. Borehole diameter: 2 (in.) above, also submit one copy of thi;c form within 30 clays of completion of well
abandonment to the following; f
i '
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
lie.Outer casing length(if known): (f•t,) 10c.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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Perm CiW-30 North Carolina Pepsi-Intent of Environmental Quality-Division of Water Resources
Revised 7.-7.2-7.01 6

WELL ABANDONMENT RECORD
For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NEILL PARDUE
7a.For Geoprobc/DI''l'or Closed-Lot p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW.130!is needed. Indicate TOTAL NUM131•:R of
2609A wells abandoned:
NC\Veil Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
AIR DRILLING INC
FOR WATER SUPPLY\VI:I,LS O\I,Y:
C ompimy Name
2023-23929 7e,Type of disinfectant used: FIT
2.Well Construction Permit il:
l.icr ill applicable well ronsiruction permits(i.e.U/C,County,State, Variance,etc.)(I'knutrn 2 C U PS
7d,Amount of disinfectant used:
3.Well use(check we'll use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural LUMunieipal/Publie LI Neal Cement Grout i•' Bentonite Chips or Pellets
LiGetnhennal(Heating/Cooling Supply) IJResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
Lllndustrial/Commercial ❑Residential Water Supply(shared) CI Concrete Grout I-1 Drill Cuttings
i!Irrigation Cl Specially Grout CI Gravel
Non-Water Supply Well:
0 Bentonite Slurry ❑ Other(explain )under 7g
lMonitoring CIRccovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
IJAquiler Recharge ❑Groundwater Remediation 200 LBS
ClAquiler Storage and Recovery ❑Salinity Barrier
I !Aquifer Test LIStormwater Drainage I
I:Ilixperimental Technology LlSubsidence Control i
1 Gcolhcrmal(Closed Loop) 7g.Provide a brief description ol'the abandonment procedure:
f_l'1'ilier POURED 200 LBS BENTONITE CHIPS
LIGeothermal(Heating/Cooling Return) LlOther(explain under 7g)
%
�.Date,vellcs)ahandunec,. 05-15-2023 _ � T'`'�'
5a.Well location: JAPE 3 9 Z024
SPIVEY CONSTRUCTION tn,vr�1 ,y�,,,.: .::I7;:I
Facility/OwnerNamc Facility ID//(if applicable) 8.Cerlif i ;`, J`�'Z�
1273 BRAWLEY SCHOOL RD, MOORESVILLE,N.C. 28117 05-15-2023
Physical Address,City,and Zip —_ _ _-- ---
Signature of Certified Well Contractor orAVell Owner Date Date
IREDELL 4636156655
By signing this torn,, I hereby ceri(/1',that the well(s) was (were) «bu«donc l in
cranny Parcel Identification No.(PIN) accordance with LSA A' /IC(I?C.'.(JIDO or 3C.020(I Well C'uaavr«cv(uu.S7a«rlurrL'c
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has bec'n,prot'idc'd to the well owner.
(Jr well field.one tat/Tang is sufficient) 9.Site diagram or additional well details:
350 33.490 N 800 54.405 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.
1
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
a«ac•lravtlrunruvrr(wrrecard(.r)i/ut'an«ble. For multiple iq/eaionoruoa-tr«ter supply crel/c SUBVII7"1'AI,iNS'l'12[1C'1'iONS i,
ONLY with the suns,cnas0•rret(ar,'abaudanareal,you run submit one farm. I.
(Oa. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID//: i abandonment to the Iollowing:
fl Division of'Water Resources,Information Processing Unit,
6h.'I'otal well depth: 95 (no1617 Mail Service Center,Raleigh,NC 27699-1617
2 1/2 1(lb. For Injection Wells: In addition to sending the Ibrm to the address in !Oabe,Borehole diameter: (in,) above, also submit one copy of this (farm within 30 days of completion of well
abandonment to the following:
i
l; .
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cnier,Raleigh,NC 27699-1636
he.Outer casing length(if known): (ft.) llle.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
6C Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form ow-30 North Carolina Department ot'Environmental Quality-Division of Water Resources Revised 7-2..7.-?.11 l o
•
'

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NEILL PARDUE I
7a.For Ceoprobe/DPT or Closed-hoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her'property) well construction/depth,only I OV/t-30 is needed. Indicate TOTAL.NU\'l 3liR ul
2609A wells abandoned:_____ ....
NC well Contractor Certification Number 71).Approxin»tte volume of wale remaining in well(s): (gal.)
AIR DRILLING INC FOR WATER SUPPLY WELLS ONLY:
Company Name
2023-17078 ITH
7c.Type of disinfectant used: I
2.Well Construction Permit li:List ill applicable wellcons•truclias permits(i.e. (//C,County,State, Variance,etc.)((known !2 CUPS
7(I.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
:.:1Agrieulwral 0Municipal/Public 1:1 Neat Cement Grout Ll Bentonite Chips or Pellets
LUGeothermal(Heating/Cooling Supply) VResidcnlial Water Supply(single) 0 Saul Cement Grout ❑ Dry Clay
❑Industrial/Commercial El Residential Water Supply(shared) U Concrete Grout I, LI Drill Cuttings
1llrrigation El Specialty Grout LI Gravel
Non-Water Supply Well: Cl 13entonitc Slurry J Other(explain under 7g)
1.IMoniloring DRecovery 1`
Injection Well: 7f.For each material selected above,provide amount of materials used:
,Aquifer Recharge UGroundwater Remcdiation PORTLAND CEMENT
:"A,,,,iler Storage and Recovery EiSalinity Barrier i'
I :Aquifer'lest LIStormwater Drainage
I I per mental technology (:)Subsidence Control 1!
7g,Provide a brief description ufithe abandonment procedure:
IJ(kothci-mal(Closed Loop) tJlraer POURED 51/2 YARDS PORTLAN,D CEMENT
!_)Geothermal(Llcating/Cooling Return) LlOther(explain under 7g) F '_;
,
y _ --r-,--r-,..
d.Date well(s)abandoned: 04-20-23 r JAN 1 9 2024
I.
5a.Well location: i§
CANDITO CONSTRUCTION i u.�
;�0G
i acility/Owner Name Facility IN(il'applicnblc) 8,Certifies, on.` e I' ' ! 1
276 TURNERSBURG HWY,STATESVILLE,N.C, 28677
.`
rr` /' ' 04-20-23
Physical Address,City,and Zip
Si,'wore orCertiticd Well Contractor Or Well(wail'' Date
IREDELL 4745378891
lip signing this fornt, I lunc'hy ce)•ri/i'that the well(s) was (treuc') abandoned in
County Parcel Identification No.(PIN) ' accordance with /Sit NCIC 02C)0/00 or 2C.0200 Well Construction•Shuu/urds
and that a copy(Olds record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(il'well till.one tat/Iona is sufficient) 9,Site diagram or additional well details:
35o
49.077 N 800 52.543 `,1, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pares if necessary.
CO.V5'1'RUCI'ION DI•"I'AILS OF NW:1,L(S)I3EING ABANDONED S1113iV11'1"I',11.iNS'1'11[1("1'10NSt I(weh well consu•urti,nnenar,l(s)1/'ur•,tiluhle. forma iple0i)m'(ionornon-,rarersupplrwclls p ,
ON/.1'with the same ronxtrurtiat/ah,rndonnn'm.you can submit one,form. d
10a. For All Wells: Submit this form within 30 days'of completion or well
6a.Well 11)11: abandonmentto the totlowing: I.
I
Division of Water Resources,Information Processing Unit,
6b.'l'otal well depth: 44 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
24rt l0h. For Injection Wells: In addition to sending the!farm to the address in lira
(ic.Borehole diameter: (lga,) above, also submit one copy of tlliti form within 30 days of completion of well
abandonment to the following: r '
, I
Division of Water Resources Underground Injection Control Program.
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC:27699-1636
I
Ille.For Water Supply&injection\\tells: In addition to sendin) thr linen to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit onc1,ctipy of this form within 30 days or completion
of well abandonment to the county health department ul' the county where
of.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
form i 1V-_Itt North Carolina Department of Environmental Quality-Division ul•Water Resources Re'isal 2-:!.'....to I„
4