MO-4023_11855_C_CI_20190705_Monitoring Well Abandonment Forms & MW-3 Pictures

WELL ABANDONMENT RECORD
This forte eau be usW for Maids or Multiple wells
1. Well Cnatraetor Information:
For Irw=1 Uw ONLY
L4 rIl. R. N 5
Robert Miller
Well I'nrarrtefnr Nana tat hell uhrir per+nttarl.j ehnnr4ral0g a011 an hntrlr•r pMgW"% r
NC We41 CoxoncWT CCnir"Itin Nrrn*cr
7a. Number of wells being abandoned: 1
i w rwidrrlrlr arl4irtrrx ,w nv n wcdrr iu�rh
� „xvrrn� rhw .thrurchyrruuru r.ru oven wrhn+r tart h+rvu
h"11. ONLI ..raft 00w law
Mr. Appnrximew volume of water rernalning to well(m)Fr (gaL)
SAEDACCO Inc IFOR WATTR SUPPLY WRIA i ONLY:
Cann> Name 7c Type to( dhatdectrne wed: calcium hypchlorite
2. Well Construction, Permit 0: ,
h.r .W 'ptaftahlr waillvri viev Ir_r [ "4M..', Maw- I orwmv 1#(^tturr, err if ba+vw 7d. Amertat of dliilafectant filed:1 o8
J. We" use (ch"k well use):
DAgmuhtrral
❑C;roQremutl IH�unA+(`oolinle Snpph r
❑ hrdustr>SrirQenurxtn+al
Suppl. Well:
❑Aquifer Recharge
❑Aquifer Sionige and Recut crn
❑Aquifer lest
❑Egxnmrrlhd Teckw1vp
C1Geoderuuil (Closed l..00pi
C)Geodwitral ftwingCooling Rerurnt
4. Date viell(s)abandoned: 6-28-2019
Sa, Wel1 location:
FX111w0n• 4ww
❑ vInsucilviLl'obinc
❑Resideniurl Water Suppn• Isingle)
❑Rzsidcnrial Water 4u Mlt- (Qwmdl
014"o % c 11
❑Gmundwater Retmedl:awn
❑Salluily Bumer
❑Stommater Drainage
❑Subudencc Cortml
ClTmcer
00dw4npiarn tiodcr "gl
F�cilap Indu rrF tgr(llkahGe•t
8416 W Franklin St, Mt Pleasant, NC 28124
RIn aio al Aa n
Cabarrus
Counh
Patrc11de1udhewnnNo iPIN i
Sh. i.athudc and Iongitudc in del(rres+minateslscmnds arderimal rigpres;
7c. Searing materials ured (elrcrk all that apply):
* Ncm Cc=m Grout
Q l3cwtintre ChI;K or Peliets
❑ Sand Cement Grout
❑ Dry Cbn
❑ ConcTew Grow
❑ DtiN Cunt'llps
❑ Spcctnlr%, [avid
❑ Gralel
❑ Bentowle Slum
❑ Otlict wciplrrn under 7g)
7f, For each mrterlal wfccW above provide amount of materials u"A:
Neat Cem.:9411b ,Wtr:5gal. Sand Cem.:lb ,Wtr:
7g. Pro,tide a brlrnidruripdnn of the abandonment pracaldute:
1" PVC pipe pump grout from bottom of well displacing water.
g. CCrtllleaNirn:
-' 7/5/2019
1frvignri,W than harm+ 1 hr►eb.1, certrft• thdi the w'1111r.v, wav tner+t, ahwmko d r1i
orrtrnlnar'r with 15A.1$'.ICO2C.WOO Lkr:e' 0:00If41 r'w,vtraeturn �7rmw4rrrlt
.91rl Mar o (volt ref dire ail nitillxs� hrcrr 1*nnrchml far lh+ trrlf teener
gtf.eclt fr`Irl uric Ltr+46etx n wrlfictcrir 9. Site diam am or additional well delaili:
You mat tee the bad: of this page to pm,ide additiotsil well sits dMils or well
35.398642 N 80.435343 W abaudonrrtetu deuriis. You wry also tatecch iddiuowd pages if nc"nxen
LOME N K DQN k Q SUBMITTAL f
trrmch "rfl ..tartan. uem rreiwdly O u,wluhlr h,e mrilriple iwv+ tlam ,lr rwm-w t r wpph
w 4A MV1.), "Ath The nenw r runr.wfi wr .ah(M&ffurnr, row tun avhrorr wn• Finn 10
6a. Wen [DO.-M-1
rib. Twat Ran depth 20
6c. Borebnte diatuder. 4" (in.)
htl. Water k+d lick" Zmand surface.. a
A. �++tr All _4clis. Sld)mu then form wlllun S0 offs of Completion of well
abrindonrrerd to the follow•mg
Division of Water Rewur m. lnforrma&n PruccWtig Unit.
1617 Man Scs'mjce Center, Raleigh, ,NC 27699-1617
IUh. Ear Injection H'clls: In mWillon to scraling the form to the address in I(la
above_ also submit one copy of this form wilhin tin days of comph:ito r of well
attamlonincif to the following
111,10 ton of Water Rttiotirres. Underground injection Control Ftmgraul.
1636 Mail Seabee C'crtter, RaleiRb, NC 27699-tfwib
tip. Outer casing lemgttt lif know is): (R) Imo- Far `aver_-Sla liz�r ]nlceti«ir 1►'r11►: In aMition to sending The fool to
Illy addlesstes) above, also subirm one copy of lids form within 1(I days of
conirklion of nell abmdowreat to the cou nh limilit deprnmetr of the county
hf. Inner citAoXhuhing length (if known): (f1.1 whore obandottcd
6g. Screen length (if {mown): 01.1
Fonn Gw-V NoahUirm ra [kWftCrO tIt) lrvironalCH1 urd Nanrll Rev"wts - Nt ifimi of Wwr ftL1ortMvs Rn teed Aupas 2011

WELL AHANDONMENTRECORD
'Mii Corns dan tv usod far Oigk- or nndtrpie "ells
1. Well Contractor Information.
Rif livicruel Uw C1NIN
RAN IN c
Robert Miller
Well Voa+ odm NArie fun cell ostoo lv:rwi211) Aluttbudvr'A'll ou hr hen Iff4w"i 1
NC Wdl Nemec
711, Number of wells bria(l abandoned: 1
i'ol MidTAI.7e aljrtiirul Wu• ride-araevr ue;lj 0A) tiLlr lln' arkl�r
," t'lrw iNom ,/i�ili Prli 4friAlfti, ltii� riar� 5'Yl>d116! lm'' rOrM
7b. ,4 giro%lnurts lrsiume of *alter remaining in nd1(1)5 ' 1 Rid.)
SAEDar'CO Inc FOR WATT .SUPPLY Wi LLS ONLY:
Corlgla") Nxlk' 7r. T)pr of disinfectant wren: calcium hypchlorite
2. Well Conalruction PavWt N:
;.lrt.afit)gratrl,/r ur17�u•r,rtlPa' 11-,' i'..urdl, ,51•_l,irlr,rcz_ l,tlanPlum, r!f rl�aruwrr 7f1, AmuianiUf dLalnfritan( Uacd:l oZ
J. Well use (check well use):
Water Supple Well:
ClAgmitiftorld
Meodicrrnul (llc:oioWCoaling 4lalrgs!► t
0 bilhntnsah'Comnwruial
Nan -Water Srppl Well:
❑Aquifer Rceiurrge
rJApotfer SiijamLv aml kc.m--cn
L7Aytnfcr "test
C7 E xywri nlcr as l l lnmlo�i
1:10imthernutl fClosed Ltsalsl
Cl(kollterntol (Hcahng•'Coolin
4. Mirwe"(%) aiaadoned: 6-28-2019
Sa. Well location.,
r,MURICIpnl'i IMIC-
❑krsidetitial Witter Svpph (r ngic)
0Residential WmIcTSuplrh-tshared)
olfmt's Cal
[1GmunduXtet l(cmedlaaton
Owiuit} Burner
0slom tvlitterDraioupc
❑substdcrKe Cbmrol
L [racer
7r, Seallnig materiab awill (cheek all that appl.N):
12 Nimt C•cmcm Cieoui
Q l3clatlnitc Chipis of Pcl M
Ci Sand ('4miery Grout
G Ny C %
Cl Cimcretx Groin
0 Drill Culimp
❑ Speciulh Gtuul
CJ Gras el
11 fkfNotnle Shim,
la C)thcl (e.fjlklrri nndot 7g)
7f For each material provide Amount Of materia b land:
Neat Cem.:9411b ,Wtr:Sgal. Sand Cem.:lb �Wtr:Zal.
7g. Provide a Irri eescrlptina of tie ahanduamrnt pruccdoliC:
1" PVC pipe puN grout from bottom of well displacing water.
rxtla.:fr+ract Nnnw rxild. IM Iir illirahici tl. CrHlfkalifin:
8416 14 Franklin St Mt Pleasant[ NC 28124 .. _A 7/5/2019
Plc}sicifl Ad sr s, CI%i, aid Zip __ 41j♦Iit16•, c �^..,>4r t7a,c
Cabarrus 131 ,v0sh(rlx tlsa}r-wiri, I h,mhi rcrlih-An 0W arrll.vt +srs.r Decor, idswit ied in
Ctlaia,ts I'aerst td.walk:ninu Aiu. tri:�) alcax,nbaara 1ri#/i l,1.1 d4`l-'at' f),',t.' Ol iNi i�r,:'f" O 3flt) if idl r'llraslnenxlna sYraaarl�mlla
:atullllcaf t1 tryrt of /lair etr:r/ralh<aa 1..f,,u1",n•ul tinny lhe�»�1! rmnt'r
ib laltlivdc anti Inazl'ii►tdc in ilf rrrtilrnirlpteal+citiindi or decimal degm-s:
s, it well rwkL, v,ic lau"infi�g h svllx*civ 1 9, Site diagram or additliond well drtal :
You Itik use lix bad: of this page to ptfn idc Wthtioculi Aril Biro r)Cn21iii or well
35.398642 1r 80.435343 W Autsfan+naxat detai6, You ttm alw attach liddiiianal jmges if net'cLstin
LOHIS'I'iill["i'ION -DETAI1G,,,5,OV MUI 1 NN.ING Al3ANRQb!E ! C1aB%ifTT-5L I a5T�3i:S'f101S_
f "If "tl) tvnsttaa Urm aruetfirar 11 uxvh*a k, NO wuluj* tghenula ah rNHwwdsH tjg7111
401.-N a nth r6e mAnit f fow w(wo abawka-rRaCml, w 1.441.11)1Mil rum'1trtri 10ii Nor All ►%ells' �SiItbmn this torn willlfn 11) d—% of 'elnl lelion of %%ell
tie -Well rn*:10-2
fib, Total>ttd] depth: 27' 1rt.)
(re. Borehole dials ter 2"
6d. W utvr in d brink Rnrund snrfaee, UQ
cnr Atindounito the fi llowsrig, � � P
Ph isioo of Water Rriauurerx. luiorminian Processing Unit.
1617 mil 5en(ce Center, Raleigh, N(' 276"-1b17
10b. Fui Inlcetlan ►tYrils: tit ,uld6on to kodit+d Ilse form to itnc Wdiem in loa
above, also sobmit eerie cagy of this forin aitltlo 0 cam s of completion of hell
albandeirawd to the fallowlr1g',
liiviiikin of Willer R"mirces.1'nlermna itid itnim(lnn Conlrul Prugrvm,
1636 Mail tirn ice Cruirr, Rakich. NC 27699-1636
6r Outer rastadd Irng1i 1H known): flt.) It►c. For Water �,i,1) #j llh�l',f jrl,(L}j'eilr: lit addition to sending files limit to
tlw addrim(es) above. wlso sublimi oat cop� of tills forth within Iti days of
COMPistinu 01' %idl afi7n lnnnlcul to the t:glylir 10011111 &WM"C1d Of the Lemon
(of iunert°aM1n:;''l:ibiall length (if knows); (A.)vilicm otmndor"
lr,Scrrrn kut:th fiflatoka): All
Funk GA'Ai tNnath ti`mAiru tXMititivra of Emviremn" and Nuturrl Ilcmvimra - l)n 14aan of Wawl nasoumxs Ae, Pied Amfara 3ra P

WELL ABANDONMENTRECORD
-11ut, Conn can ire i sed for shlgk ur unalfipla wills
I. 1i cll ('rrotracfnr Ilrtonnnttirtu:
fnrirsowil f w ON1.V
}Z,��, gA ivlHFl�f DICTAili
Robert Miller
Well Cananum Nanrr toa vivil tar, nLj Mmtarlh adwndanhlg cell un haAwf )nuperry r
NC Well C'ownclor Ccrl liatia wo Nnnirrn
7r. Number of wells being abandoned: 1
Fri rou lbrk I,Unt,r.t ix• rxm-ower .rail pA
I oMrv,I), WI ,Ilslrrkurr�u,nat arlu i Iva sal hunk r.wr h/rrn
7b. AlgrrMlmArc waleme of warms remaining In wellla.lF r (gam )
SAEDACCO Inc jFOR WAUR 51)PPI.Y WFUS ONLY
i t'o" i Ngr„ 4 7c Tlpe of dials wool used: calcium h chlorite
2.11 di COMMI rclium Per'rnit #:
11x1 uN uJydicaldr well ro-eIVIN II I' I"Warn. 'VAJAe. I 1ara,7Aca. !a(rPr.erlAn. YA_r f1 kinlwn
7d, Asu►rttt of dl►initY roar uk d:1 oz
J. Wdl aw (ebccic wev uw):
WaterSnppl► W.A.
C)Ag n, tdtnud CI Munw IpAIiP16k
06mIlEcm4wl (HcvnnW('oolinp iatrpty) ❑t e0knrial WAler Slipph- (S"Icl
13Inimmn;IVC00tn crCial ❑Residrutial Waivt Supply t• used)
ifrEale;Iuur,
lino-" Ater %Opp IV Well:
3 Alvuatormu ❑Itau►rn
0 Aqu.lfer lt,cdurge
DAquifer Slranige Ural Rt'a Mot)
l7 AquIlet Tait
01::tpcntnMwl l tchaArlop
MCA-rthImml (Cklsod Loop)
1.10
a. Rate wtc111lri pbantkmcti: 6-28-2019
Sa. Wei! lneatkrs:
010mutsd>.nser1 cim::dIA1011
f.ltiakaih Hurtrct
L7Slomnr,Il er DnI tinge
175tiauclew4: Coal"
C.)7mccr
O(Aber4CNIA rrl 111KkT 7SI
71r, seating Irraiedws uani (chock an that spill} ):
0 Neap 47 m it OnKd
n llerttonilt VIIIP6 of pe0ch
Sauld Cenwid I'rotu
rj Utr CIm
11 t [ In' TeIr Groot
Cl Mill cutrlllp
d SIKCIMIh 6youl
0 Grad
13 Rettlonire shirt)
U Oilrcr ("pialn undo 1g)
7f. For each marrr ir1 wlected Alin%v, ilimide amount of nwc•riol. used:
Neat Cem.:9411b ,Ntr:5gal. Sand Cem.:lb ,Wtr:gal.
7g. Provide a frricl' rkaerilrtkln of rbe a4Anahurnws3j pnlccdore,
1" PVC pipe pump grout from bottom of well di!lacing water.
Fatless: faurr�s NAnIe Fx04,v ILNt tifa9,trikahlc) 8• CerINICaNun:
1
8416 N Franklin St Mt Pleasant NC 28124 7/5/2019
I'M Gi a] Adlhccs. Car, Ails Xi}a Srt�aAtr�ti •' ^:a;: u I •nocr lire
Caborrus
Comm)
!i1 .+h„marlJcr thaw jam' 1 helvh,l rerto Aup dw tvvd�"%f wav (wervt sthanxa Awd )n
f'.+h I lrLi#rlkxrYru Nn WOO 44XAanirartr'• trios Lid . 'f' kt' ilk' ,fJlfN1 aer yV'.J)It1l) if !1 [ auavtntt°fagsn ,�71tnaA»rh
rarul Jlra,d rt rta�4' t�Jhix Ta�a.arrvl lase hrx7r 1rn�,•rria:,'i Jn Jhe n•rl! trrrgrE'Y
Sh. 1.at1tu4le and innOtotde in dtg;rlfeafioirtntrtlsrcwlndo or dreimol degnvc
¢ ICwIa1t fielFt, u,rc I;tl'1i)ral; al,niticktM)
35.398642 N
80.435343
9, Site diagram or additional wtil derails:
You nmy trit ilia ba13: ofihial %tAc to pluv do immliollal uell site dreads of well
W Abaasloninew dewi6. You «my also alt,4ch asWiliottul paps' if occcuan
C 1 5 N 1 S' M1 hI t ti5
. rrrl+rrr Xri! a FJIUJFNI IIIkn aCa 1 U%t!A! 11 ,nrAlaA)r' Fir hwhii,le orrlR r,u" . V mej0 v.II['J' 1a,1,941
u,^8).t 02VU took I& marts' Irurrltrtkraa#r .atrwulllexae�ar, a+N ceaar,u,hnu) rrlrrJ'am 10 M ' All 11' •lt.. S ga laiai Irld ;b
6a. Well ID#:MN-4
6b, Total! A cU depth: 27 (fl.l
6e. Norebale dbutwer:2" (in.)
64L Water level Iaeluvo gnm"d wrfacr. ffl.)
>L ua a ,. , t nut t anti Nit n .. dA% trt Cnraftictwrn of Air.
:ihnnrlr-nIjICW to lbtf0lloWirg':
I►Ieisiala ofWarr Rmou rm, Informution PrumAng Unit,
1617 Mall tico-ke ['cater, li IaKb, NC 27G7r1-1617
lOb. }lir Iaicelttan Wrlt.s: In ,nldlglem lea ben&4 floe form to the MkIrest, in 10a
.tN,vt_ n6o sntrsnil one ::cip% of this farm widen a(t dam s of Iamtgrletion of well
:tband alEnwin In the fella wing
i1h'ItJtra of Welrr Rams rrt, URilergiimued 101rc- ion Control Prugram.
1636 Mail !unite Crider, linlcigh, NC 270,'17-1636
irk. I:or `a1RC 5eenit 6r Refection Wig; Ti, ;t[Ickuoll to �Ikbi)g lbw foml to
f)ttter casio><lnE�th Ili lunara e); _ [n•i llw addnsues) above. also %tsbunt utse cols} of this foml 4trllim 30 (hats t)f
complelina of nt41 aahnrtdonmeln to the tounty hcahh ricprinmcni at the Coulih
wircgc nh andnracd
frf. InnerCYatinga/iplrlolg ll'tlPt, ll lif tawrr a): [li.l
bg, S'r'vvu kegtb IVJam" n): At
Foan (TWOR Nonh taunhra 1]riauacne of Em iroanv A And Wour:ri Nesiouxin -- Do-p6mm of Waver Rcsunats Ro wed .Nauru ZM t

WELL ABANDONMENT RECORD
TI" form Can bit used for strtgk or nrulliple uvIls
1. Well Contractor hdnrmadoa
For Inserted Use ONl Y
WFI.I, ABANDONMENT OFTA1l S
Robert Miller
INCH Oluuiftim NAnK ire IA01 owwr pcmumrdl� uhsrr4rnW ~Mull an tusrl>rr smwerh I
NC ('loll Commcwr Ccnlriarnmrr Nanbcr
SAEDA'CO Inc
CrrMMM Name
2. Well Coamtortion Penult M: f�
11a414trikahk welflwrmeh II a Vwrat, ,VuAd. f oridj x hyf tjun eta_, fn&Ia.wn
J. Wdl use (Cheek 'Reg use):
Water Supply Well:
GAgrt;mhutnl
❑GNIficMMI (Hcaunyt'Cooling Srrpph !
Cl hdusmslr('onarxroal
�] Ir ntnrltun
Non-►4atcr !supply 14'cp:
❑f►timfer ItccWn ge
❑Aquifer Storage and Recos q%
0Aquifer Tom
❑Eyxtrmcrtlal Tmhmlo&%
UGeodlemmi (Closed L.00pl
DGeothetnral (HrxttingCooling
4.Date wcM%)abandoncd 6-28-2019
5a. Won kwalion:
ElMumcrp3MIncc
❑Resider ml Water Supph Ismpiel
❑Rcsidetrtlal Water Stggth' Islatredl
❑Gnnurd,aia kemedtnrtuar
❑SahnaL Hamer
❑tiloon►ealer Dtwnuge
❑5nbstdmx Control
ClTmcer
❑Qthertexplain under 71t)
7a. Number of wets being abandoned: 1
lair widtiple ime.wnn W twn-oarrr inivAh
(",.mi n my ,YPI vahmoo I.+Ir hirto
"-fli tl.4L) raft 11ti, r(Mna
710. Appr,klwadr volume of water remaining In we ll%)P ' SAIL)
FOR WATTR SUPPLY WEU S ONLY:
7e. T}pe of dlsiafeetant used: calcium hypchlorite
7d. Anura nt of dWafeeiam used:1 oz
7e, Sealing materials used (Check all that appl\ ):
* Neat Cement Graft
0 Hentanue Chrph or Pellets
❑ Sate Cement Grout
❑ Drr Cbn
❑ Concrete Grow
❑ Dull Ctrtfinp
❑ Spct:raln Crow
❑ Granel
O Be11110MIC Slum
❑ Oda wNplatn under 7tp
7f, For each material x1octed abase, pro%W amount of mauvials and:
Neat Cem.:941lb ,Wtr:Sgal. Sand Cem.:lb ,Wtr:gal.
7a, Prsrvide s hritidesesiption of the abandaameat preerdum:
1" PVC pipe pump grout from bottom of well displacing water.
FocrlmijO%rw N®nc Fwila% IDH Irr.Ig{+Ir. l+lu! B. r=Mil�Cali1/M1:
9416 W Franklin St Mt Pleasant, NC 28124 7/5/2019
Plhmal Address, ern, and 2yI Si psi w, rcr DW
Cabarrus
Comoro.
Pa: d I&mal31.ra No 4PIN 1
5k Latitude and bngitade In rkgmv,ilminutordsemnds or deolml degrees:
of w011 frc4l one Lru1mlig o %asOkrcrs 1
35.398642 N 80.435343
/A signing das frrrnL I hembl cerllh fAut ih• rrvllf"o wow brans( abandoned rn
ar tankmstr with MA .►CAC02C 11100 or _C 0200 Well ll C'unrtrur7rrru Slav 6mb
mid drat a r ytfi of slim rkrafV lwu been fm nvrtird fro Mr a•r, ll rm- nrr
4. Site diagram or additional well detaiLt:
You nta} use the back of this page to provide addilional nrll site dmils or will
►� Amdommerademils. You um% also much Wdinotrul pages if rta'cen w
jVNSTBj)(MON. DEMI tiOF W13A,M BEING ARANDOMED SUBMITTAL INSTRLrc- ON
11hALh Ofll LUMI'YLAIM r{YUMl P if Waduhtr Fie IRmtwple n(tl'[wmr tw rain."'LA ' uIpph
Wrib (MU' "JITI OW ftAM l'APT-OWMM JhWWhVMO [. I'M Wn ulh Ml .#W fiJFM..
6a. Wed 1Dp•KX-�5
6b. Total ,,oil depth: 21 Ift,l
6c. Bamhole diameter, 2"
6d. Water Intl belm gnwnd surfaaY: (fL)
10a. Kos rt►11 �4elL►: Sabmu tiles soma uttiun 30 ems of ComplClran of Nell
aba donrrtcrr to the follow"
Division of Water Resources, Infanutrtbrn Processing Unit.
1617 Mail Sersier Center, Raleigh, K(' 27699-16s 7
10b. Flf taiecNon Wells: In addition Io sending the form io the sdthcss in lou
above. also submit one ooM of this form within 30 days of compkiion of well
abandonment to the fallo sag
Divislnn of Wa1rr Resource, 4nderVaund Injection Conlnrl Prrtgram,
1636 Mail `ier►ior Center, Raleigh. NC 27699-106
10c, For Water Sunni & fnk*cl& Shill: In addition to setdiug the fart to
I;e. Outer casing Itmgib 1 if Ina, a): IR, n
Me atWtesslCsl abwe, also stlbnru one cap► of this font within U) eats of
completion of ndl ahandamuent to the cotttuy herllh department of the court
6f. saner easinghablag krogth (if larnwal: Ifl.l
where abandoned
6g.Sawn length (if knowa): Iri,t
Form GW-To NonhCurah® Depanarar of Ern Irooalar and Nurmal Rest uses - Drrnlou or W'oecr R%soltm:* Rn, nod Auprur 29ll

WELL ABANDON MENT RECORD
Boys fond can be ukd fat sieyk of ontlliple, aril
1. Well Contractor Inturmation:
Robert Miller
MAI C onwnam Nakur wi uklt o A xi pttwtmlla arinei"mlvg as.11 uu hW3IWr pwga n� a
W- Will COHMour Ccr rk;xl inn Nnni+rs
SAFDACCO Inc
Como, ty P+amr
d. Well Cosstr atlion Permit M: l ..
13a# ,Wl.j;y.L, „hlf v41lnrmif, ii_r r',avr=s _ ,1'lwae 1.1,joace lnarr.vou, "I"� ri.Gniwu
J. Well use (cbcrk well nse):
Wattrsuppls Well.
ClApnc:niiural
i7Cics)tlrcrnull Sllcxrtng+{'otolirtP SrtNph 1
I� hr#sairipi� f'onnncn;isi
svlgot►
M
OAqul,fc[ Ile`)etrgc
CAquifn Stomge and Mo ,cm
CAtluiler Test
L1Cxprnm%:oW1 Ttdtrtniokot
LIGecst w"lal {Cloned toot)
Rotim)
4. Irate wcil(r) abandoned. 6-28-2019
So, well kratloo;
CI isitutn. ilorOhiblu.
ORviikca tial Wafer Stipfi y fxingki
Cllicskkiiiial Woks yupph. tsltarcd)
❑Gmurduntes ArmiWit+ttm
Osahnin llarriet
C]Slormwater Dninagc
OSubtmknLx C"utrrol
U Tmccr
r'1[3tllr r lerplain uncler7g)
For lulexn y1 VW ON I N
yJQNMEATREIA11ti
7a. Number of wells being abandoned: 1
hoi nntkopte frhrr uav it ,w+P- alai arypfA
r rn,vty rrruf .dwIt, A-viminr, r,,w . ear v,vhmn -*,,- f ors,+
WOls OND .nb ray. xmw
7h. Approximmir %toluene of Haler remaining in weIROS r
FOR WATER SUPPLY WF.I.I N ONLY:
7c. Tf pc of disltt(ivism used: calcium hypchlorite �..
7d. Amovul of tlbdafMAW u#ietL 1 Os:
7t. Sealing materials vied (,perk tell that apph ):
61 Naar! C•cmenl Grrxo
n acfMa3rtdr C114* of POICK
0 Strad C'enwiv Gnxn
Q Don, Clot
tl C'atxrt:tr brow
a Drill C'uttillp
C3 SprcYaih' Gruel
0 Gam ri
CI 8ertfe1ulc Shirty
D CAlser to plool tioder 7g)
7f, for each vtatnial x*rted abet, protide amount of tetatertalr nwd:
Neat Cem.:9411b ,Wtr:5gal. Sand Cem.:lb ,Wtr:gal.
7g. Pro -Ode a brkf dewriptinn 4 the almndominetat pmccdsrr:
1" PVC pipe pump grout from bottom of well displacing stater.
rxtl41/QoW1Nnnw rwl)d, InNriftrppliGablct 8•Certllka[kat:
8416 W Franklin St Mt Pleasant. NC 28124 7/5/2019
Ph+cttAI Addts4, Cut, aid Tip ••' I : r•=::.—: -, .:;5.:�!`""""h't7a r 1]au
Cabarrus
C'n�tt
flm%a .1 tslnot1k:1 on Na ;PIN
Sh, Latitude and hrngltlsde In deVve+vmisutriiAtenndr or dtvimal 41
r if %c If ft la a Poc lat k ny, n auffisixoy t
35.398642 N, 80.435343
11 v svgmng Mai /an•tra, ( hereAf e.r)-trlt• All the sto+llfsr) woo ooenrr itharxdartrd in
racxirshrrur With li;l .i'C ;11.' I)�t",l)%i.Nl r.w A, 9,1H0 if f'11 t:juarinirpoli Monihards
4n1l11tv1 it aYgr.v qJ Mix rc-rurv] l w,+ by as }M+nwMi to the n•rt1 a ner
9. Site diagram for additional "vil *tafls:
You ntay use the bal: of lht% p.W its porn isle amfloetrl tte11 sift ddaih of %V01
W Axis imuticnt dcwils Yvu mm, abo attach addiriowd la go if tteogptary
(RDiSTRI1d"TION—UTAtl S Of VVFWS� RUNG AIIANDOIVlED sramn-t'AL iN5771U(MQNs
Pl4rzir rart7 e�rnslrarcfra,t ziarr�h�r 4i�+t,ePlrahla 1-ar arznfaaj+P� fJlkaNuu nr evda.�.dcd' xn¢gdr
o ltr ts;�t,l• rruia afro' mrbrrnt PrenHm stars r�r�r:knrnarrr€. arm ex)r, urt+mN zYn� jrinn In }P 1,11 y't�l: Sal %— f 'i lei 21) d It 11
fro. %,ED lD#:MW-6
bb.Total food depib: 24,
6a gambols diffm ier.2" 011 )
Gal, Wort" Ind belost ground surface: (ft.)
a. _9S_ n trtrt l tents tt 1 a _ m% n s.an+ws 1. etc
:tburdart)nenl ltl the f(Alowttag
Ditisioa of Water Rmarm, Inf6rmatkin Arormosing daft.
1617 fibil Srrsicac Cooler, Raklgh. NC'. 27IM-1617
10b. For Jgkcdon Wdts: lit addition its kodingt ttse Conn to the )tdtlfess In lino
above. also submh oat carp► of this form %idtin ,V dirt s of compldion of well
ubandonmetd In the Cr4lowing
ilidt3un of Water Rcrnorees. Underground In)" -don Conlrul Ptrlgram.
1636 MailSenirr Center, Raleigh, NC 27is5►9-1636
6e. Outer coodag Irngth iifl,nttwn;: Ibc. £Ilt WBlgr %tams; & Isledlon Wells: litaddittotl W sandhog the fame to
tit•1 Ilse addrmstas) *env. also submd wire cop of 11L6 foram within in th a of
toolpktiau of +sd1 abuodsmntent to file counh heuith deputtntcto of ilre COMM
ttG Inner raringhubhg Irn$th lif latnwnt: if1.l
tvlxvc c tandnracd
rigs Scare len1:01 Of knotty): ih.1
Forts GA'•111 Ait,rth ('aoeslitas Dcparlaksv niEnstmuntem Paid wrnurrl9c>asnr.ts - Dn rsnon omiten It sounvt AoNed Aupoe 201 r

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Beverly, Trudy
From: Beverly, Trudy
Sent: Tuesday, October 8, 2019 7:48 AM
To: David Stoner
Cc: [e-mail]; Kevin Howell ([e-mail]); Eleanor
Salchak
Subject: RE: [External] Eagle Oil Company Incident No. 11855 Monitoring Well
Abandonment Records
Good Morning Dave,
Thank you for submitting the abandonment records.
Have a great day,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
L I rw 44 North Carolina Department of Environmental Quality
r rH r C I"� UST Section,
,Mooresville Regional Office
704.235.2182 (Office)
Trudy. B ev erly(d nc denr. gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: httos://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: httos://deq.nc.gov/about/divisions/waste-mana2ement/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httos://dea.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-ais-mans
File Review Procedures:
httos://deo.nc. eov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
httns://edocs.deq.nc. gov/WasteManagement/Search.aspx
Document Submittal & UST File Names for Laserfiche Policies:
htips:Hfiles.nc. eov/ncdeq/Waste%20Management/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubnuttal%2OMemo%2OUpdate.pdf
https:Hfiles.nc. gov/ncdeg/Waste%20Management/DWM/UST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx
From: David Stoner [mailto:[e-mail]]
Sent: Monday, October 7, 2019 5:17 PM
To: Beverly, Trudy <[e-mail]>
Cc: [e-mail]; Kevin Howell ([e-mail]) <[e-mail]>; Eleanor
Salchak <[e-mail]>
Subject: [External] Eagle Oil Company Incident No. 11855 Monitoring Well Abandonment Records
WExternal email. Do not click links or open attachments unless you verify. Send all suspicious email as an
nt to [e-mail]
Hi Trudy,

Attached please find the Monitoring Well Abandonment Records for the former Eagle Oil site in Mt. Pleasant,
NC, Incident #11855. All of the monitoring wells were abandoned except MW-3. Two attempts were made by
SAEDACCO, the North Carolina licensed well driller to abandon MW-3. The first was on June 28, 2019. In the
attached photos you will see that the location of MW-3 was under hundreds of used tires on June 28, 2019. A
second attempt was made on August 9, 2019 by SAEDACCO to abandon the well after the tires were moved, but
the well still could not be found. The Well Abandonment Forms have been submitted by SAEDACCO to the
NCDEQ Division of Water Resources.
We will now be working on a Trust Fund Claim to completely close out this project.
Best regards,
David
David A. Stoner, P.G., P.E.
Sr. Principal/Vice President
Shield Engineering, Inc.'s Risk Management Group
4301Taggart Creek Rd.
Charlotte, NC 28208
ph. [phone]
fax [phone]
e-mail DStonerkShieldEngineerinp_ com
Shield Engineering's Action Environmental Group is now Shield Engineering's Risk Management
Group with additional expertise and service lines!
40�j CLIHEERM&, INC. www.ShieldEngineering.com
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