Mecklenburg_Well Abandonment_20240903

WELL ABANDONMENT RECORD02 'For Internal Use ONLY.
This Thnn can be used for single of multiple netts
I.Well Contractor Information: k^�' WELL ABANDONMENT DETAII ti
Rich Lemire \ JJ 71.Number of wells being abandoned: 1
Well Contractor Name(or well owner p ttsonath:rhanitomng rent on iutilter property) For %interne tntectruti cw num.-looter swop'). watts ONLY frith ..the suet
wtotnertioh--oh; onotent,►low tam nohow one Om.
2593A 7b.Approximate solarise or water remaining in ecll(v)NONE (gal-)
NC Well Contractor Cenificatiai 3'uarbef
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Caarpaity Name lc.Type of disinfectant used:_
2.Well Construction Permit AI imi0301368,
turf all applicable well peenttcyIt.e.(:wren,Sit*,l-urtomcet iniectb at elr.t tfbonen
(I. %mount of disinfectant used:
3.Well um(check well use):
Water Supply Well: 7 e.Scaling materials used(check all that apply):
DAgnenln al Municipal/Public G Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(HcatingjCooling Supply) ORcsidettial Water Supply(single) O Sand Cement Grout 0 Dry Clay
DLudustrlaLCommertial ORcsidctnal Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
D inijation ❑ Specialty Grout 0 Camel
Non-Water Supply Well: L'7 Bentonite Slurry 07 Other(explain under 7g)
latvlonitonng ❑Reco eery
Iafection Well: 7f.For each material selected above.provide outcast of materials used:
❑Aquifer Recharge OGan ntdwater Remediation
OAquifer Storage and Recover ❑Salinity Ranier
Bentonite. :2501b ,Wtr:3al. BENTONITE PELLETS Amount:250
OAquifer Test OStoamsaicr DM)wage
DDExperimental Tecbtlobgy DSUbskknCe Control 7g.Provide a brief description of the abandonment procedure:
OGeothennal(Closed Loop) OTracer
OGeot l(llesdlt$+'Co hngReturn) Ottter(explain under 7gI PULLED WELL OUT AND BEVTONZTED FROM BOTTOM TO 16' FROM
GROUND SURFACE AND BACKFILLED WITH CUTTINGS TO SURFACE AND
6.Datewe11(s)abandoned; 8-8-2024 CAPPED OFF WITH CONCRETE.
Sit.Well location:
Albemarle & Sharon Amity t 0 3 2O2
Fr..aima%SOrrr Name Facility WI(ifopplirable) 8.Certification:
3100 N. Sharon Amity Rd. Charlotte, NC 28205 G/`,P✓'ati. 4.. L'r '8I.9/2024
Sir :ifsedWeftContactor of Well°trier ..� Die
Physical Address.Cin.and Zip r><AMwe
MECKLENBURG 10301137 fay opting this farm 1 hereby certify that the welfla) was (were)abandoned in
(neat. PanYt idetdifa 'inn No-(Penh) accordance with 1,f t,VC:r1C 02r.',0100 or XC 0200 Well Construction Standards
and that a espy of this record has been provided to the well miner,
Sh.Latitude and kmgitude in degrees hninutestwcnnds or decimal degrees:
of NcII Irld,one ta:bug a sartrica4rat 9.Site diagram or additional well details:
You may me the back of this page to provide additional well site details or well
N W abardotunent details. You may also attach additional pages if necessary
CONSTRUCTION DETAILS OF WELI4S)BEING ABANDONED SUB iITIAL INSTRUCTIIONS
.tlkutt iu II constnrciia rt recordist r!uou+h.J+k. Iry muhtpk rrurcfrrm in rnrvmMr saami y
belts ONLY%nth the tome corrrrrwc Aeut aktindortment,ion awn sebmtt tineFi nn. Ina. For All Wel : Submit this form within 30 days of completion of via
6aWell lD*C'2 abandonment to the following-
. Disisloa of Water Rmmrces.Information Processing trait.
6b.Total well depth: 30 (ft.) 1617 Mail Service Center.Raleigh.NC 27699-1617
lob.For Infection WOW In addition to sending the form to the address in 10a
above,also submit one copy of ties form within 3()days of completion of sell
6c.Borehole diameter:1' (in.) abandonment to the following:
Divisive of Water Resources,Undergn,uad injecdonCoatis,Program.
td.H Ater level helm% ground surface: 21 (ft.) 1636 Mail Service Center.Raleigh.NC 27699-1636
Inc.For Water Sunny&Infection Web: In addition to sending the font'to
or.(hater casing length(if law%n): (ft.) the addresses) above, also submit one copy of this form within 30 days of
completion of%veil abandonment to the comity health department of the county
O.Inner casingr'tuhing length(if known): 20 (ft.)
where abandoned.
6g.Screen length(if known):10' (ft.)
Form ctw•%o Nortb Camtbn Dapoalmcwt of Em ironmettt and Nat teat Resomecs-Div is(on of Water Rcwnrces Revised August 2(0

WELL ABANDONMENT RECORD For lrlerinl Use ONIY
'fit s'forin can be used for single or mdtifie wells
1.Well Contractor tnform*tion: WELL ABANDONMENT DF.TAU$
Rich Lemire 7i.Number of wills being abandoned: 1
Welt Name for well osier personallyatualioning well on bola('propcny) ti w nethnpfe infection to, nonce Pair sliml sett ONLY whit :me Mime
t$aittm rtrwt abandonment,_von tun srib'i f one form
2593A
7b.Approximate volume of water remaining in w ell ts)NONE t gal.1
NC Well Conti.a.lor Catif>catioli Monk/
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Campos)Name 7e Type of disinfectant used:_
2 WdlCotistrtrction Penult#eWM0301368,
liar df.opptievni:nett pa•n m fit(:ovine.State;l rirtonce injection,MO ff ham,n 7d Antonin of disinfectant uactt:
3,Well use(cheek well use):
Water Supply Welt: It.Scaling inateriak uwil cheek uduthat apply):
OAgricuhutal ❑Municipal/Ptrblic 0 Nutt Cement Grout CI Bentonite Chips or Pellets
DGeothermat(lleating/Caoling Supply) °Residential Water Supply(single) t7 Sand Cement Groin 0 Dry Clay
❑hidusitriaL'Commercuti 0 Residential Water Supply(stw op 0 Concrete Grout 0 Drill Cuttings
Obligation 0 Spy Grout 0 Gravel
Non-Water Supply Well: CI Bectanite Shim 0 Other(explain under 7g)
[79Monitoring 0ktemery
Injection Well: 7f.For card)material selected aboves provide a boned of materiels used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Sittmnsa[etDrairuge Bentonite. :2501b ,Wtr:gal. BENTONITE PELLETS Amount:250
❑Experimental Technology ❑Subs rlen ee Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) UTracer
PULLED WELL OUT AND BENTONITED FROM BOTTOM TO 16' FROM
OGeothermai tiietrtit►gt`Cooting Return) °Ether(explain under 7g)
GROUND SURFACE AND BACKFILLED WITH CUTTINGS TO SURFACE AND
t.Date wenO)abandoned: 8-8-2024 CAPPED OFF WITH CONCRETE. . . • .
►. . •
A.Well ineation: .. _
Ablemerle & Sharon Amity SEV 7p7
i,,c pits(hrrmr Name Facility 11)9(ifapplicable) B.Certification:
�. IT :-
3100 N. Sharon Amity Rd. Charlotte, NC 28205 ...P/t"s L`a :.. 8/9/2024
Pin sieat Address.City,sod Zip Sigamr of -:idled Well Coumwtei to Well Omer Dare
MECKLENBURG 10301137 RI'signing this form, I hereby�pctrhr that the wel1{si was(here,abandoned in
Count Parcel ldentitxcatiou N.. :I't i ,.,ronianee wail I S,1.Y(.:AC O ,010O or 2C 0206 Trott consinwtm Srtui rds
and that a raper of this record has been provided to the well owner.
$it.latitude and longitude in ik reesfminutesfsccnnds nr decimal decrees:
(it.sell richt OM:hi.koi n iintoV1ap 9.Site diagram or additionalwv.11 details:
You may me the dacha of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DFTAMIS OF WELI.451 BE1N G A1l A l)O 11'D SUBMITTAL INSTRUCTIONS
tooth.at'.fl MIA rctrnrotfji if awjlabk. 1-or multiple injection nu tx,n-)iatrr supply
»e114°N&Y rwltfi the"Ito C tear ciiew44"dF k-1"cyan Alt "1- 10a. For Ali Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well IDIt c'
Division of Water Rrsuunes.information Processing Unit.
1617 Mail Service Center.Raleigh.NC 27699-1617
6b.Total well depth: 30 (fI4
10b.per Infection Wes: In addition to sending the feint to the address to 10a
f►c.Borehole diameter,1' (in.) above,also submit one cop} of this form within 30 days of corupktion of well
abandonment to the follow wig
6d Water level below ground surface: 21' ( } Division of Water Resources.Undervosind Injection Control Program.
1636 Mail Service Center.Raleigh.NC 27699-1636
ba.tauter casing length i if I�inw n): M.) tic Fyn Water Synoty&infection We 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 depanatera of the camp
0 bac abandoned,
61.bluer caslkind!)ngitubinkind!)(if know n): 20 {fL)
6g.Screen length(if!.non n 1:10 (IL)
Ferro(IWli i North Carotaa Deprounci t of Et imemesi awl Naomi Resouxes-Div Won of Water Resources Revised Aupast 2013

DWELL ABANDONMENT RECORD ForImmo!Ike ONLY:
Tots form can be used for single or multiple wells
1.Welt Contractor Information: N F.1.1.ABANpONMFNT DF.TAUToS
Rich Lemire 7*.Number of wells being ahandoned; 1
Well Contractor Nance(or well Owwaer personally:rbarrdareing well on Molter property) For malnple tiij cnu•r .K sari%-vrotee supply wells ONLY with she srHr„-
emuMrrtron(tbandenete•nt,ftie earl svlweu one 1Fh>7n.
2593A
NC Wdfl Connector tknitcstlen Nuui6d 7b.Approximate anionic of nater remaining in well(r)0 t((AI.
SA>tDACCo FOR WATER SUPPLY AS ELLS ONLY:
Compton Name 7c,Type of disinfectant used:
2.Well Construction Permit t#:9010301368, ,
la.1 AN op illoihie+cell perm (,.r_(camas Sheer,f`irrianm iP a iieut ret.1 a1taxmen 7(1.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling material%used(check all that apply):
OAgrKuhund °Mu nicipal/Public 0 Neat Cement Gran ❑Bentonite Chips or Pellets
°Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) 13 Sand Cement Grout 0 On Cho
OlndusttiLeCommercial ❑Residential Water Supply(shared) 13 Concrete Grout ❑ Unit Cuttings
❑Irrigation ❑ Specialty Grout 0 Gra%el
Non-Water Supply Well: CI Bentonite Slurry Li Other(explain under 7g)
®Monitonng ❑Recovery
Injection Well: 7f.For each material selected ahorc provide amount of naterial%used:
❑Aquifer Recharge OGrinudwater Rem ediation
❑Aquifer Storage and Recovery °Salinity Barnet
❑Aqutcr7cst ❑Slommalcr Drat wage Bentonite. :2501b ,Wtr:clal_ BENTONITE PELLETS Amount:250
❑Experimental Technology 0SttbtadeaeeCoatiul 7g.Prosidc a brief description of the abandonment procedure:
°Geothermal(Closed Loop) ClTracer
PULLED WELL OUT AND BENTONITED FROM BOTTOM TO 16' FROM
t;)Geotherntal tHmongCoolingRetun1) DOther(explain under 7g)
GROUND SURFACE AND BACN:FILLED WITH CUTTINGS TO SURFACE AND
4.Dew views)abandoned: 8-8-2024 CAPPED OFF WITH CONCRETE.
sa.Weil location:
Ablemarle & Sharon Amity
FaciiitsiOerrr Name Facility ma(irappn e) S.Certification: 5 t j 21 a
C � ,
3100 N. Sharon Amity Rd. Charlotte, NC 28205 _ -�/1h ' ' ' �'879/44
Ph.sical Address.Cm,and Zip Sterna=of e, :ificd Wen Contractor or Weil Omer
MECKLENBURG 10301137 By signing this form. I hereby certifr that the weU(sJ was(werri abandoned in
riles% Parcel fdenufamma No.(P1H) occonianet with 1SA.111.7.1C O2C„O160 or 2C 0200 Well Construction SYrmdrrefs
and that a c op),of this record has been provided to the well turner.
5b.Latitude and longitude in degrces/minuto/second%or decimal degrees:
(if well r,;w,one laulong)s srdrscrrm) 9.Site diagram or additional era details:
You may me the back of this page to provide additional Kell she details or well
N W abanxiotuneri details. You may also attach additional pages if necessary.
CONSTRUCTION DI:'lAl1,ti OF SS Fl.l(St BEING ABANDONED $tIBMITTAL INSTRUCTION
;tooth wl.J+:c. 1-or mulrepie oyes r/ury ur.%ur La47 randy
'9414°.A" "ft the isauaa rorarrnrru>JJ'hlw ua1rl1)ua nb„ '1 it whr s»m loi. For All Wells: Submit this fomi within 30 days of completion of well
6a Well IDar:B-2 abandonment to the following'
Division of Water Resources.Information Processing Unit,
1617 Mail Service Center.Raleigh.NC 27699-1617
6b.Total well depth: 30 ills)
lob.For Iafection WetJii In addition to sending the form to the address In 10a
abmr.also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter:1' (in.) abandonment to the following:
Ditisloa of Water Resources,Code ill nw nd Injection Control Program.
lot.SS titer les el below ground%urfare: 21' (it) 1636 Mail Service Center.Raleigh.NC 27699-1 636
the.for SVatcr Sunnh'&lniectkrn Wcll,: In addition to sending the form to
6c.Outer casing length(if knots n): (ft.) the addressees) above, also submit one copy of this form within 3() days of
completion of well abandonment to the county health department of the county
where abandoned.
of.Inner casingitubing length(if knonnI: 20 (D.)
(.g.Screen length(if Lnowa):10 (ft.)
Porno(1W-330 North Cambria Uctunnk rot of Enttranmcrd and Naomi Resources-Dl.okrn of Water Resources Rts and August 20r3

WELL ABANDONMENT RECORD For funnel Use ONI.Y:
This form can be used for single or rnuhipk wells
I.Well Contractor Inforn'ation: WELL ABANDQNMENT DETAILS
Rich Lemire 7*.Number et wells belay abandoned: 1
w H r •Ift:IiD+I ti:lf L(Or Men Ott OCT aliandcnung nett Oft hillier propen%) For rx q'le tnlscvrun or ono-batter supply wells ONLY with the-;sane
o nnstrpetioivabav a'i rot,'tits can submit raiaforms
2 5 93A 7b.Approximate volume of water remaining he wells) ONS ( ,)
NC' en Contractor Certification Number
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Company Name It.Type of disinfectant used:
2.Wdl Construction Permit#:WM0301368,. t
hod(/l appikable well pavan ri.r.twain. ;f ortdmee,.injection.rte)(tknnown 7d.Amount of diddeetant used:
3.Well use(chcd:well use):
Water Supply Well: 7e:Sealing materiata used(cheek 1Uthat apply):
❑Agrignitutal DMunicipal/Public 0 Nc nt Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating+Cooling Supply) °Reside►tial Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑ttdustrisVConuuctcial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑lmga ion 0 Specie!»•Grout 0 Gravel
Non-Water Supply Well: CI Bentonite Slurry Cl Other(explain under 'g
Monitoring flReco'eiy
Injection Well: 7f.For each material selected moss,proside amount of material.used:
0 Aquifer Recharge °GroundwaterRemediation
❑Aquifer Storage and Recover ❑Salinity Barrier
[Aquifer Test flStomn'alctDtsinagc Bentonite. :2501b ,Wtr:gal. BENTONITE PELLETS Amount:250
❑al:erion:mai Technology ❑Subsidence Control 7g.Pro%idt•a brief dcacription of the abandonment procedure:
°Geothermal(Closed Loop) OTracer
PULLED WELL OUT AND BENTONITED FROM BOTTOM TO 16' FROM
OGeothermal(Heating/CoobngReturnt DOkher(explain under 7g)
—
GROUND SURFACE AND BACKFILLED WITH CUTTINGS TO SURFACE AND
4.Deg wcilla)abandoned: 8-8-2024 CAPPED OFF WITH CONCRETE.
Si.Well location:
Albemarle & Sharon Amity [P J rt cui4
FacilM/OnFri turn Facility RJA inapplicable) 8.Certification:
•
3100 N. Sharon Amity Rd. Charlotte, NC 28205 (//�yt..e�l^nv+*t.�};'c; • ; '8/9/2024
Ph.sical Arena.Cm.,and Zip Sigrarare of . :died Well Connector or Well Oweer Due
MECKLENBURG 10301137 By signing this firm, 1 hereby cerhjt that the wells)was(were)abandoned in
County kiztantatiOnINo.(PMN) (re[xnionewithllfNC,iCO2e,oI(N)or2C,(120OWeltcvngrrk:tionSitimdards
and that a clam.of-this record has been pros4ded to the well owner.
.13h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
t rt u cit f.k1,one lat.long 9.Site diagram or additional wen details:
You may test the back of this page to provide additional well site details or well
N Vi' abandotanent details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF V1'ELL(S)BEING ABANDONED SUBMITTAL INSTRUCTION
.trod,Val t.inrtruc told e srdiir Ii utvildtk. Far multiple uuetbuv tr..,s-worry nipph•
%elk,OM.)"with the.mime cvtt'Yrdctuur nduratru*ieOr.lU i trtn AMMO/turn minor. 10a. For An Wells: Submit this fort within 30 days of completion of Well
61 Well IDtt.Tp-1 abandonment to the following'
Division ofaater Roamrte.,Information Processing Unit.
6b.Total well depth: 30' (�)
1617 Mail Service('enter.Raleigh.S('27699-1617
lob.For Election Wes: hi addition to sending the form to the address in 10a
abode.also submit one copy of this form Within 1(}days of completion of well
abandonment to the following
( ) Division of Water Resources.Undemrou nd In jet o s Coatis!Provost.
Water ater k'el helot, ground surface: 21' 1636 Mail Soria Center.Raleigh,NC 27699-1636
10c. For Water S%DOWv& Injection Weal: In addition to sending the form to
he.Outer casing length lit(Wino ni: Me) the addresses) above. also submit one copy of this fort within 30 days of
completion of well abu ndannaem to the county health dep itmCd of the comfy
when abundoncd..
6f.Inner rasingitubingnl tenh Limon):krnn): 20 (fL)
log.Screen length(if t.nonn):10 (R.)
Pam OW90 North Carolina Department of Environment and Natural Rcsauccs-Oh mon of Water kcsooyes Ranted Augast 1013

WELL ABANDONMENT RECORD For Intermit Use ONLY:
This form can he used for single or multiple bells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rich Lemire 7a.Number of wells being abandoned: 1
Welt Contractor Name(or well ow a¢r peesanalb abandoning well on hailer property For main pie infection or nr.o-w:err swiftly veto ONLY with (1a
cnnenwenoWabando n wn hoer man et.mN torte flaw,
2593A
NCWt1lCatgMr 7MrCielifirelo11KttnA6et "Il.Allllnlrilnatrso11111C f Water remaining inw di(�) 0 (RAI.)
FOR 1,VI FR St`PPLY WELLS ONLY:
SAEDACCO
Convoy Name ?c.'I y pr of disinfectant used:
2.Wdl Cotsstniction Permit t#:11M0301368, ,
List cartart/rabic well"'route at ee.wiry Vale.1'WI ant hyect,otsefxltf)aw- n \rnount of disinfectant used:
3.Wdl use(check well use):
Water Supply Well: 7e.Scaling materials used(check ail that apply):
°Agricultural Ohltmicipal/Public [.1 Neat Cement Grout 0 lientonite Chips or Pellets
❑Geothermal(Heatiug/Cooling Supply) °Residential Water Supply(tangle) 0 Sand Cement Grout 0 Dn Clay
❑indus(tiat'Commercial °Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0lnigation 0 Specialn Grout 0 Gravel
Non-Water Supply Well: I I Bentonite Slimy 0 Other(explain under 7g)
Monitoring 0Ro 0%er\
Injection Well: 7f.For each material tielCcted abnle.pro.ide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Rtcoi'en °Salinity Barrier
❑AquifrrTtst 0$lotrtubatttDrairaagc Bentonite. :2501b ,Wtr:gal. BENTONITE PELLETS Amount:250 F
❑Experimental Technology °SubsidenceConrol 714.Provide a brief description of the abandonment procedure:
0Geottnennal(Closed Loop) °Tracer
OOeottlennal(Herating/CoolingRetur)) DOther(e�cplain under 7g) PULLED WELL OUT AND BENTONITED FROM BOTTOM TO 16' FROM
GROUND SURFACE AND BACKFILLED WITH CUTTINGS TO SURFACE AND
4.Date well(s)abandoned: 8-8-2024 CAPPED OFF WITH CONCRETE.
Sa.Weft location:
Ablemarle & Sharon Amity ^ '•
Facilm,Chs rler Name Facilav Th(ifapplicabie) 8.Cettifitatlen: r
C �
3100 N. Sharon Amity Rd. Charlotte, NC 28205 ( �d/Vht.+4i. ,� 20— 8/9/2024
Physical Address.tIty,and Zip Signature of_ ..Vint Weft Contractor i PWeNfi mire •..: s -
1e&CKLENBURG 10301137 13) signing this form, I hereby certify that the well(at was(were)abandoned in
Count) Pared Ideatdkauon No.MN) conkmce with ISA NCAC 02C.((1(N)or 2C.0200 Well Conslrnrtron 5randards
and that a copy aphis riei. brace been provided to the well owner
Sb.latitude and longitude in deggrees/minutes/secondsordeximal degrees:
411..cal rR Id desk sat Minh.,h surfo.wfii 9.Site diagram oradditionalwell details:
You may me the back of this page to provide adchtional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELIASi BEING ABANDONED SIJBMITTAI.INSTRUCTIONS
.Vlach welt.r.nrlrarelear rccnrdiia If uluilobie. l se nn,lOpfr uyeeuur,ran rare-wutar uteri,
Seib,°.tit) with the sons comirmenctu altakki nWnOL_it*arm iatb W l slat}iMit, 10a. For AS Wells: Submit this fomt within 30 days of completion of aril
6a WellIDd:P_2 abandonment to the following
Division of Water Resources.Information Processing Bait.
6b.Total web depth: 30' (f t:)
1617 Mail Service Center.Raleigh.NC 27699-1617
lob.For Ialcetksa Wd: In addition to sending the form to the address in 10a
above.also submit one copv of this form within 30 days of contphtion of well
Or.Borehole diameter:1' (in.) abandonment to the following
bd.\y Ater Ircel below ground surface: 21 ( ) Dhisiom of Water Resources.Underground Injection Control Program.
1636 Mail Service Center.Raleigh.NC 27699-1636
lie.Outer casing length lit Imuw n): � � IOc.for Water Sanely&lnicctfon Welk: in addition to sending the form to
the address(es) above. also submit one copy of this Rum within 30 days of
completion of well abandonment to the county health departnient of the county
where abandoned
..
or.Innercasingitubing length(if{union): 20 et.)
or.Screen length(if 141011n):10 (ft.)
Form CIW::1n Nonh Carolina Dcplsninent of Environment aril Natural Resources-Division of Water ResoureeS Rcv$cd August 2013

WELL ABANDONMENT RECORD I For lraurnsl Use ONLY
This fonn can be used for single or multiple hells
i.Well Contractor Information: I WELL ABANDONMENT DETAILS
Tyler Brown 7a.Number Owens being abandoned: 1
Well Contractor Name(or Steil owner personally abandoning well on hira'her property) Foe RlVlaple rn)r<rrru, e• rem-realer apply wills ONLY woke the
axnrrwcrua=u?h uriufinemt,N W t W Nolan' tom
4625A
NC Well Contractor Crnification Number 7b.Apprus m Isw hnate rolac of ater remaining in ell(s)9 g;al.l
SAfiDACCO FOR WATER SUPPLY N',Lis ONLY:
Conman.Name 7e.Type of disinfectant used:_
2.WellCaratruction Permit ti:, IIST#MO-3143/Incident#7079, J
Los ill,alplhuble well pertmax(,e.Canty.SAW.i liriaMCe!media*.ek..) Yana Ammon 7d.A of disinfectant used:.
3.Well use(check well use):
Water Supply Well: le.Sealing materials used(cheek all that apply):
OAgricuhural OMunicrpctliPublic 51 Neat Cement Grout 0 Bentonite Chips or Pellets
O(icothemsal(Heating/Cooling Supply) ORcstdcntial Water Supply(single) O Sand Cement Grout 0 Dry Clay
❑hdusmriallComnetcial ❑Rcsidenttal Water Supply(staved) D Concrete Grout ❑Drill Cuttings
CIkit/atlon C3 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Shiny 0 Other(explain under 7g1
Monitoring DRed:osrety
Injection Well: 7f.For each material selected/bone.jinnide amount of materials used:
❑Aquifer Recharge OGtonndwalerRettiediation Neat Cem.:971b ,Wtr:8gat1. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recovery' 0Salinity Barney
❑Aquifer Test OStermaater Drainage --
OE.epetimentaiTechnohgy OSabsidentceContiol 71z.Pnrtitie a brief descriptir m of the abandonment pnreedure:
DGeothertrral(Closed Loop) I'Tracer
tremie grout from the bottom up
OGeothermtal(Heating:Coolin2Return> 'Other(explain under 7g)
4.Date wel(%)abandoned: 8-9 2 4
ter,Well loeadon: 'E P j 5 2024
Rimtrax Corporation Site B.CertllkaR011: Il:v ^:'
.
FaCilc4 tier Name I.,, I:ts lDN(ifuppIr4bk? .
10701 Reamer Rd. Charlotte, NC 28269 8/9/2024
Physical Address.City,and Zip arc otCert red Wet Cotwactor or Well Owner Date
Mecklenburg 1Sr .agutng this from, I hereby cam'that 1he wants)war(were)abandoned in
('‘oars' I ateet Ilan if i anion No.tight txcondan a with 1 U AC.4('OX..0100 or 2C.0200 Well C'ullrtruetion Standards
and that a cv,wof this rrcard has been provided to the'Well owner.
5b.Latitude and longitude In degrees/minutes/woods or decimal degrees:
(if sett rick!.tux t rd brtg is sndl>4tcea> 9.Site diagram or additional it eh details:
You may use the bade of this page to provide additional well site details or well
N W abandonment details.. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL.(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
:dtfawi.veil ttemeale eat rrcYir<l(ar:1 ete:M.k. .h a Mulapk otjettoot M'rwn•wcOrr supply'
ith th tie&ONLY we some kworrxnon air rrdb armt.)uu oar*heti)ow form 10a. For AU Was: Submit this form within 30 days of completion of well
6 Well IDd:MtP-6R abandonment to the following:
Division of Water Rnmurecs,Information Pnrccsaing Unit,
bb.Total well depth: 18 (ft.) 1617 Mail Service Center.Raleigh.NC 27699-1 6 1 7
toll.feria(allots Wclb: let addition to sending the forms to the address in.10a
abope. also stdyuiit one cop!'of this foram within 30 dares of completion of well
6c.Borehole diameter:2 (in.) abandonment to the following'
6d Water khei hdlnw ground.surface: n�a (ft.) Division of Water Resources.Underground Injection Control Program.
1636 Mail*nice Center,Raleigh,NC 27699-1636
ilk.For Watct,Sunnis & inaction Wells: in addition to sending the form to
6e.Outer casing length(if lame el: 8 lft.) the addresses) above. also subunit one cop. of this form within 30 days of
completion of well abandonment to the cotmts health depannxnt of the county
where abandoned
of.Innercasintetulring length(if 141011n1: (IL)
og.Screen length(if knnon):10 (ft.)
Point 6W-t0 North Carotins Deponnnnl of Environment and Natural Reswaecs-Diaisiom of Water Rtsoatesas Rc+sed August 2011

. WELL ABANDONMENT RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor information: WELL ABANDONMENT DLL fAiI.S
Tyler Brown 7a.Number of wells being abandoned: 1
Wen Caetracwr Nellie tor well owner ptnsorotlf abandoning well onbira'herproperty) Fur roulupk onternon a,. ow-water *apply wells ONLY rah ii were
c%n true on-ohawh•.Hmenr.you con saba,it arEettNin:
4625A
7b.Approximate vulamc of water remaining In well(s)i t gal.)
NC Well Common Cenifrca tits Number
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used:
2.WeilCou*tr/Ktion Penult 1t a IIST#BQ-31.43/Inc i den t(k7079,
Luc di applicable well peuwitx e.Conroy,Strom.l:rriwwe.kie,thatt rare of Moen
7d.Amount of disinfectant used:
3.Will use(cheek well trite):
Water Supph'Well: 7e.Sealing materials used(cheek ail that apply):
°Agricultural ❑Municipal:Prtblic Nth Cement Grout C)Bentonite Chips Of Pellets
C)Gcothemul(Heating/CoolingSupply! DResidential Water Supph tsrnglcl 0 Said Cement Grout O Dty Clay
❑halustrktlUCommeo.ial ❑Residenlral Water Supph (shared) O Concrete Grout 0 Drill Cuttings
Dhngation Cl Specialty Grout 0 Gravel
Non-Water Supply Well: Bentonite Shim 0 Other(evlain under 7g)
DMranitotittg ORdacos+ezy
injection Well: 7f.For each material sleeted at:use.provide amount of materials used:
°AtitriferRecharge OGniundwaterRetnelhation Neat Cem. :941b ,Wtr:8ga1. Sand Cem.:lb ,Wtr:gal.
°Aquifer Storage and Recovery OSalinity Barnet
❑Aquifer Test °Stor meter Drainage --
°E.gserinrental Technology ❑Sutbsdt not Cattrol
7g.Provide a brief description o'::'the abandonncnt procedure:
OGeothermal tCtosed Loop) OTracer
OGeothermal(Hauingr/CoolingReturn) OOtber(explain under 7g) tremie grout from the bottom up
4.Date well(*)abandoned: 8-9-24 •
Sa.wee location: S F P
1 c_ 2e24
Rimtrax Corporation Site
S.Certification: I I,'�;;
FaitIn%Chan-Nsm Pacilit IDNtifoppikabk! t
1...
I✓Il(J l ,1
10701 Reames Rd. Charlotte, NC 28269 t 8/9t2024
Physical Address.City.and Zip St.,vt ire of(MOW Well Contactor yr Well Oweer Date
Mecklenburg tip strung liar from, 1 hereby cern&that the witty' wax fwelw abandoned In
C<,,,,,r, Parcel ldenuri�cation No.(FiN) accordance wit*ISA ACAC U t- 0/00 or 2C,0200 Well C onttntrtion Standards
and than c'cr w e f this record I t )cede provided to the well owner.
!lb.Latitude and longitude in degrres/minufestaeconds or decimal degrees:
cif eell field.one belong is wfficoetr) 9,Site diagram or additional well details:
You mac use the bads of this page to provide additional writ site details or well
N 3� abandonntent details. You may also attach additional pages if necessary.
CONSTRLICTJON DETAILS OF WEL,I4S1 BEING:ABANDONED SUBMITTAL INSTRUCTIONS
:ittac*Kell eurvarrctitat news((e)-if ay.-phobic. blew•.mw1&pk agectrure PP nr n•xala vippIr
Welts ONLY rich the some ctnaVrr[tlOx,e"venk aateei.)+,Y eon iwbroeil<wr Ji rrrt. 10a. For All Wens: Submit this form within 30 days of completion of well
6a Well IDg: -SR abandonment to the following:
Division of Water Resources,information Processing Unit.
6b."lout»ell depth: 15 ((t j 1617 MaLiSereice Center,Raleigh,NC 27699-1617
rob.for Irleelloir Wig: In addition to seeding the form io the address in lied
tic.Borehole diameter:2 ()n) above.also submit one copy of this form within 30 days of completion of well
abandonment to the following.
Division of Water Resources,Underground Injection Control Program.
6d.Water level below ground surface: 9 (ft.) 1636 Mail Service Center.Raleigh.NC 27699-1636
hoe.for Water Snuck di Inkcthon Wells: In addition to sending the form to
6c.Outer ca.ingIc•nrth iif{aloe nt: 5 (ft.) the addresses) above. also submit one cots of this foes within 10 days of
completion of well abandonment to the counts health depaltmeta of the county
where atnandnncd.
fit.Inner c.s.in tu humg ltti gilt it tat smut: eft)
Screen length Itf knot% 10 (ft,)
Penn GW.96 Nonh Cando De atuient of Environment and Natural Rcsoinees-Dieisoon of Was.r Resources Revised August 2011

• WELL ABANDONMENT RECORD For banal Use ONLY'
This form can be used for single or multiple netts
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Tyler Brown 7a.Number of wells being abandoned: 1
Welt Cotetractca Name(or well ow ncr personally abandoning well on loather property) F,.. multiple Mica-vim: ,w .moi-wetter www# was ONLY with the sae
opreiflicuon.'uhipwhMime ut'Pm.ut submit wile Relit
4625A
NC Weft Contractor Certification Numberlb.Apprusimate stibnite of stater remaining in ileitis)?•5 I gat.)
SAEBACCO FOR WATER SUPPLY WE I.t S ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Cottrstrnetlon Permit 0:t nfST#MO-3243J Inc i.dent#7079i
lair all ry.plkvbte well to P$eis tn.d_C.WYV,Jiak.t arhveer ek.)If known
it Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural OMunkipaL'Public 01 Neat Cement Grout 0 Bentonite Chips or Pellets
OCtroihcmwl(Hcatingi'Cooling Supply) ❑Rcsidentiai Water Supply.(single) O Sand Cement Canal ❑ On Chat'
01 utnat.`Comnicrciat ❑Rcsideutual Water Supply(shared) O Colonic Grout 0 Drill Cuttings
OIWRSIion O Specialty Grout Ci Gravel
Non-Water Supply Well: 0 Bettonite Slurry Cl Other(explain under ig)
®Monitoring ORecovety
Injection WdU: 7f.For each material selected All MC.prrnide amount of materials used:
❑Aquila Recharge °Groundttaterkentediaation Neat Cem. :941b ,Wtr:8gal. Sand Cem. :lb ,Wtr:gal.
OAquifcr Storage and Rceosc y ❑Salinity Barrier
❑Aquifer Test OStormwatcr Drainage --
OExpetinicntal Technology ❑SubsirknceCottml 7g.Preside a brief description a'the abrnduntnent proccdun:
oGeotttemral(Closed Loop) C)Tracer
°Geothermal(HeatinWcoohi Return) Dpther(explain under 7g) tremie grout from the bottom up , .
4.Date well(a)abandoned: 8-9-24 SEP = 2024
Sa.Well location:
Rimtrax Corporation Site
Faci*?iD+tier Name 1:n:et.t.u,.e,f,err
i,:•chi. 8.Certification:
10701 Reamee Rd. Charlotte, NC 28269
8/9/2024
PMsieal Address.Con,and Zip S awe:of Certified.Well Comm:tor or Well°water Date
Mecklenburg 8v.mming Omfloat, I hereby certify that the weih t was/were)abandoned in
Parcel Idemtt'icaimn No.(PiN) accordariiee with SA \'t'iC 42C.0100 or 2C 0200 It ell Construction.Standards
and that a copy oifthi..r.,urd!hav been prrnmkrl to the well miner
Sb.Latitude and longitude in degreestminuteatscconds or decimal degrees:
Of nett field.one kilong is sufficient 9.Site diagram or additional well details:
You may use the bad of this page to provide additional well site details or weli
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELi4S)BEING ABANDONED `UBMiTTAL INSTRUCTIONS
Ainrx#yell cvwartrnemut neenr,ftae it available. Foe multiple emerhati 'rem.waiir Apply
Metd. ONLY with the sswstecwouweactwoitwbooteloituteut.l+m ern saAntlt rote form IOa. For AU Wells: Submit this form within 30 days of completion of well
6L Well IDt1•ittt-2R abandonment to the following:
Division of Water Rcsourcos.Information Processing Unit.
18•5 (ft.)
1617 Mail Service Center,Raleigh.NC 27699-1617
oh.Total well depth: .
lOb.For Infection Wes: In addition to sending the form to the address in 10a
above. also submit one copy of this form within 30 days of completion of well
tic.Borehole diameter:2 (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program.
6r.Water level below ground surface: 4 (ft.) 1636 Mail Service Center,Raleigh.)W 27699-1636
10e.For Water Sunnis.& Infection Well: In addition to sending the form to
be.Outer casing length f:(if Wore): 8.5 (ft.) the addfess(es) above, also submit one copy of this form within 10 days of
completion of well abandonment to the county health department of the count)
af.Inner easing/tabftsk length(if lnnown): (h,) where abandoned
6g.Screen length lif 1u14)wnI:10 (ft.)
r>r(:as-,t o North Catohu Department of P.nviroaatent and Naomi Ratlines-Divuion of Water Resources Raised Atiraa 2013

WELL ABANDONMENT !(t CORU Internal For Intral Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
M,G �e_.,I1^avt Gt S 7a.For Geoprobe/DPT or Closed-Loop Geothermal W
Well Contractor Nance(or well owner personally abandoning well ou his/her mells having the Santo
property) well construction/depth,only i 9W-30 is needed. Indicate TOTAL NUMBER of
Zt{3 3-A wells abandoned: (NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): I 5 al.
Frai-t C cS We,1/1 J-- 4J0le FOR WATER SUPPLY WELLS ONLY: )
Company Name / / L
2.Well Construction Permit#: I I 'tate� 7c.Type of disinfectant used: ri TH.
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc)(Amur
7d.Amount of disinfectant used: c��
3.Well use(check well use):
Water Supply Well:
7e.Sealing materials used(check ail that apply):
°Agricultural °Municipal/Public Q Neat Cement Grout
• ❑Geothermal(Heating/CoolingSupply) Clay Chips or Pellets
upp y) ti�esidential Water Supply(single) ❑ Sand Cement Grout
pindusUiaUCcxnrrtercial 0 Dry Clay
°Residential Water Supply(shared) Q Concrete Grout
❑Irrigation 0 Drill Cuttings
Non-Water Supply Weil; 0 Specialty Grout ❑Gravel
°Monitoring °Recovery ElBentonite Slurry 0 Other(explain under 7g)
Injection Well:
°Aquifer Recharge If.For each material selected above,provide amount of materials used:
°Groundwater Remediation (50` 6 S
°Aquifer Storage and Recovery °Salinity Barrier
°Aquifer Test °Stormwater Drainage
°Experimental Technology °Subsidence Control
°Geothetmal(Closed Loop) °Tracer 7g.Provide a brief description of the a ndonment procedure:
°Geothermal(Heating/Cooling Return) °Other(explain under 7g) .5 l O Ca.)( k,y `t
4.Date wetl(s)abandoned: b C,2•� J 3'-2 CI
5a.Well location: f
Ctkotd?S V i 9 ClrCi-
FappcilitytOwae(r�Name //'� ( Facility IDS(if applicable) tt.Certillaa$ion•
Son oow Act l,flur e 3 o
PhysicalAddress.City,and Zip ` Nr�l �O Z 6� � (f'' �L f
S. of Certified Well Contrac+;or or Well Owner Date /1
Aec,k Q,VI,b0 v-9 037--2_32_-Q3
County By signing this form, I hereby cent&that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record hits been provided to the well owner.
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W
abandonment details. You may also attach additional pages if necessary
ion
' Attach wS el constreO N DETAILS OFabls.1 orrWELLISImulttiip eectEING AI3A�NDONEDupplywells SUBMITTAL t or non-water
ONLY with the same construction/abandonment,Jou can submit are form.
N 10a. For it W te: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
6b.Total well depth: 72
Division of Water Resources,Information Processing Unit,
(ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
Z 10b.For infection Well: In addition to sending the form to the address in 10a
6c.Borehole diameter: (In.) above, also submit one py of this form within 30 days
abandonment to the following: of completion of well
6d.Water level below ground surface: 15 (R,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(If known): !v / A, (D) 10c.For Water Suno v 4 Inleci jon 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(It known): (.4 ) abandoned.
6g.Screen length(if known): Ai/A- (ft.)

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Con ctorInformation: WELL ABANDONMENT DETAILS
f `V v t Y �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
3 0 V 2 wells abandoned:
NC Well Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
C -$ FOR WATER SUPPLY WELLS ONLY:
s
Company Name //
�� / I 7c.Type of disinfectant used: f't
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.)rf known
I v-
7d.Amount of disinfectant used:
3.Well use(check well use):.
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural •
❑MunicipalPublic 0 Neat Cement Grout ❑ Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial OResidential Water Supply(shared) Ci-Concrete Grout ❑ Drill Cuttings
❑Irrigation - 0 Specialty Grout 0 Gravel •
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
0Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the aband cement procedure:
°Geothermal(Closed Loop) ❑Tracer / 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) / . l l c•Grl , ? i/fl 0,i�"-tit
•
4.Date well(s)abandoned: //6 /-2 t7 _ 1
5a�}Well location:• t 'J _ 102
l /o 14 e, !'/�1 eI S C
Facility/Owen Name Facility ID#(if applicable) 8.Certification: /....,!...,,
92 .1. - C . AcL (r , ..1012_42:y_
Physical Address,Cam,and Signature of Cemfi Well Contractor or Well Owner Date
By signing this form, I hereby certify 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.
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 LNSTRLCf10NS
Attach well construction record(s)(available.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
6a.Well ID#: Ai 4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: /f (g) 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: (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: /n i/4 (It) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Al 4 (ft) 10c.For Water Suooly&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): / ►'4'< ( (ft.) abandoned.
6g.Screen length(if known): /\)0 ¢ (g,)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Co Informations• WELL ABANDONMENT DETAILS
0.k' e ' `o."1 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
3 O (1 n wells abandoned:
NC Well Connector C fication Number 7b.Approximate volume of water remaining in well(s): (gal.)
r
FOR WATER SUPPLY WELLS ONLY:
Company Name //,
(,/ p/ 7c.Type of disinfectant used: y K
%
2.Well Construction Permit#: /0° / / y 11
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.)(([,brown
7d.Amount of disinfectant used: "/O t-
3.Well use(check well use):.
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑ cipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ElfResidential Water Supply(single) 0 Sd,Cement Grout 0 Dry Clay
❑IndustrialCommercial ❑Residential Water Supply(shared) Concrete Grout 0 Drill Cuttings
❑Irrigation • 0 Specialty Grout 0 Gravel '
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a b ' f description of the ab udonment procedure:
m❑Geotheral(Closed Loop) ❑Tracer //
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) c��v' h J. e'e sl C f e
4.Date well(s)abandoned: S / /I:, l•/ '
5a.W/11 location: E r •j ‘� Z U Z-1
/- <4Lir1c 4 4.../1-.„4,...4.- . .
Facility/Owner)Name / Facility ID##(if applicable) 8.Certifcation:
Physical //� /1
lrysCity,and Zip
� Signature of Certified Well Contractor or Well Owner Date
C(
By signing this form, I hereby certify that the well(s) was (were)abandoned in
Cotmty 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 construction records)([available.For multiple injection or non-water supply wells
ONLY with the same construction/aba clonment,you can submit one form.
//-''r///r7j 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: A1 A (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: v (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: /1/4 (g,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): /1/4 (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
6£Inner casing/tubing length(if known): /✓ (ft) abandoned.
6g.Screen length(if known): 0 (n)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20 t 6

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Howard L Rushing, 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
3342-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Carolina Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name 70% HTH
2.Well Construction Permit#:
10014665 7c.Type of disinfectant used:_
list all applicable well construction permits(i.e.UJC,County,State,Variance,etc.)if known 20oz
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
ID Agricultural ❑Municipal/Public 0 Neat Cement Grout HI Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) inesidential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ( 102 ) 50Ib Bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Chlorinated Well
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Completely Filled Borehole With Bentonite
4.Date well(s)abandoned: 6/20/2024
5a.Well location: • •
Havmoeller StV .j 2024
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
I '15�q Grasshopper Lane Charlotte, NC 28278 *ward L Rustiio,�r�. U f 6/22/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mecklenburg 217-191-13
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:
35.40.220 N 81.30.140 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)if available.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
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 400 (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: 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 39 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
6e.Outer casing length(if known): unknown (R-) 10c.For Water Suooly&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): (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