MO-9514_40951_CA_WSW_20191101_Abandonment Record & NRP Discussion Emails

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Charles Mullis
Well Contractor Name (or well owner personally abandoning well on his/her property)
4447-C
NC Well Contractor Certification Number
Gopher Utility Services, Inc
Company Name
2. Well Construction Permit #:
List all applicable Krell constriction permits (i.e. UIC, County. State, Variance, etc.) ifknoun
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Municipal/Public
❑Geothermal (Heating/Cooling Supply)
❑Residential Water Supply (single)
❑Industrial/Commercial
❑Residential Water Supply (shared)
e Irrigation
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
❑Geothermal (Heating/Cooling Return)
❑Other (explain under 7g)
4. Date well(s) abandoned:
11/1/2019
5a. Well location:
DCW Real Estate - Mint Hill, LLC
Facility Owner Name Facility ID# (if applicable)
1498 Oakwood Avenue, Kannapolis, NC 28081
Physical Address, City, and Zip
Cabarrus
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient)
35.469 N 80.6426 W
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 19 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: Sterllyne
7d. Amount of disinfectant used: 3oZ
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout a Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
5-501b bags of Bentonite Plug
7g. Provide a brief description of the abandonment procedure:
Pulled pipe and jet, chlorinated, pour in bentonite
chips and hydrate.
8. Certification:
✓' A�
11 /1 /2019
Signature of Certified Well ontractor or Well Owner
Date
By signing this form, / hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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 constriction record(s) ifavailable. For multiple injection or non-watersupply wells
ONLY pith the same constriction/abandonment, you can submit one form. f 1 f II
6a. Well ID#:
6b. Total well depth: 108
6c. Borehole diameter: 2 1 /2 (in.)
6d. Water level below ground surface: 32
10a. For All Wells: Submit tits torn wrthin 30 days o comp etion o we
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: 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
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): (ft.) 10c. For Water Suouly & 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.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Beverly, Trudy
From: Beverly, Trudy
Sent: Friday, November 1, 2019 2:40 PM
To: Bob Payne; Josiah Payne
Cc: Taraban, Ron
Subject: RE: [External] FW: Well Abandonment - 1498 Oakwood Ave Kannapolis, NC
Hey Bob,
I will need a draft copy of the NRP for my review and approval as soon as possible with the groundwater
language matching that in the template. It will be ready for Ron's review and signature once I have approved
the latest draft. Josiah will need to confirm with Ron prior to arriving on Monday morning that he is in the office
and available to sign the NRP. I will not be in the office on Monday. I can email you the conditional letter after
Ron informs me that the NRP has been signed and notarized by our office.
Thank you,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
D-1E North Carolina Department of Environmental Quality
rL�n[O menta� �r UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy.Beverlykncdenr. 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: https://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hitps://deg.nc.gov/about/divisions/waste-management/ust/ast-pro¢ram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httDs://deo.nc. eov/about/divisions/waste-manaeement/waste-manaeement-rules-data/waste-manaeement-eis-mans
File Review Procedures:
https://deo.nc. eov/about/divisions/waste-manaeement/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://edocs.deq.nc.gov WasteManagement/Search.aspxx
Document Submittal & UST File Names for Laserfiche Policies:
https:Hfiles.nc. gov/ncdeq/Waste%2OManagement/DWM/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%2OMemo%2OUpdate.pdf
hitps:Hfiles.nc. gov/ncdeq/Waste%20Management/DWM/UST/Corrective°/`2OActionfUST%20file%20names%20for%2OLaserfiche.docx
From: Bob Payne [mailto:[e-mail]]
Sent: Friday, November 1, 2019 2:14 PM
To: Beverly, Trudy <[e-mail]>
Cc: Taraban, Ron <[e-mail]>
Subject: [External] FW: Well Abandonment - 1498 Oakwood Ave Kannapolis, NC
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
t to [e-mail]

Hello Trudy. We now have a Low Risk property for this incident. I will have Josiah come by Monday to get a
signed NRP for filing. If possible, can we get the Conditional NFA letter at such time? Thank you,
Robert A. Payne, L. G.
(cell) 336-684-2734
Cedar ]crt
F.NV1 RON M ENTAU
Jeremiah 9:23-24
From: Jody Eller
Sent: Friday, November 1, 2019 2:00 PM
To: [e-mail]
Subject: Well Abandonment - 1498 Oakwood Ave Kannapolis, NC
Please see attached.
Thank You,
Jody Eller
Gopher Utility Services, Inc.
Office Manager
704-932-7662 Phone
704-933-1538 Fax