4406_ROSCANS_2014

ever reen .0 Canton Office
g packaging 175 Main Street • Canton, NC 28716
JAG# 03-14
Certified Mail #7008 3230 0002 2595 2215
Return Receipt Requested
ested
February 5, 2014
Mr. Allen Gaither
NCDENR
2090 U.S. Highway 70
Swannanoa, NC 28778
Subject: Landfill No. 6
Area D-North Piezometer Abandonment
Blue Ridge Paper Products, Inc. - Canton Mill
Canton, North Carolina
Dear Mr. Gaither:
The following is presented to inform you of Blue Ridge Paper Products, Inc.'s successful
completion of piezometer abandonment at Landfill No. 6, in Canton, North Carolina, as
approved in an email from the North Carolina Department of Environment and Natural
Resources (NCDENR) Division of Waste Management (Christine Ritter), dated January 2,
2014.
A.E. Drilling Services, LLC, (AEDS), a licensed North Carolina well contractor (Well
Contractor Certification #3455-A), conducted the abandonment of 31 individual
piezometers during a four day period from January 6 through 9, 2014. All work was
performed in accordance with 15A NCAC 2C .0113(d)(land 2), entitled "Abandonment of
Wells". The locations of the 31 individual piezometers that were abandoned are shown in
Figure 1 and summarized in Table 1, below. Abandonment records (GW-30 form) for all
locations are also attached to this letter for your records. A licensed geologist registered in
North Carolina with AEDS transmitted the GW-30 forms to SME on January 27, 2014, as
requested by Christine Ritter on January 2, 2014. The GW-30 forms have been submitted
to the North Carolina Department of Environment and Natural Resources, Division of
Water Quality by AEDS, as required by 15A NCAC 2C .0114(b). _
RV E i V L
FEB - 7 2014
SOLID WASTE SECTION ff
ASH> VI LE R�GIQINAL OFFICE
Ire5 i )y QCSigCI ..
;cge Pockacina

TABLE 1
Piezometers Abandoned
(1/6-9/2014)
P13-101
P13-102
P13-103
P13-104R
P13-105
P13-106
P13-107A
P13-107B
P13-107C
P13-108
P13-109
P13-110A
P13-110B
P13-111
P13-112
P13-113
P13-114A
P13-114B
P-07-202A
P-07-202B
P-07-203A
P-07-203B
P-07-203C
P-07-204A
P-07-204B
P-07-204C
P-07-207
P-07-213
P-07-226A
P-07-226B
P-07-226C
The replacement domestic water supply well for the landfill attendant building is currently
scheduled for the week of February 10, 2014. Abandonment and installation permits have
been secured and completion records will be provided when the work is complete, as
required by the permits.
If you have any questions concerning this information please do not hesitate to contact me.
Sincerely,
ames A. Giauque
Waste Compliance & Landfill Supervisor
Canton / Waynesville
828-646-2028
Jim. giauquePeverpack.com
cc: Chet Chiles
Christine Ritter, SWS
Ed Mussler, SWS
Andrea Keller, SWS
Guy Cote, Sevee & Maher Engineers, Inc.
Attachments: Figure 1 - Piezometer Abandonment Locations
Well Abandonment Records
Fi1e:6DN Piez Abandon 020514 File:\\everpack\ctn\shared\eohs\Share\Groundwater\6DN Piez Abandon 020514

® A.E. DRILLING SERVICES, LLC
Two United Way a Greenville, SC 29607
Brian B. Johnson, P.E. 27 January 2014
Senior Geotechnical Engineer
Sevee & Maher Engineers, Inc.
RE: Evergreen Packaging — Canton, NC
Mr. Brian Johnson:
The attached GW-30 forms were submitted to North Carolina Department of
Environment and Natural Resources, Division of Water Quality by, as required by 15A
NCAC 2C .0114(b).
The logs were completed by NC Licensed Well Driller Gary D. Winbourn Lic# 3455
Sincerely,
W. Martin M. Johnson, LG
Vice President

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North Caroline Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR Ghewinn U t'
WELL CONTRACTOR CERT1 ATION H
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Well (3`stgn�o-t�mtu P-��-to\
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: (Z, ,'t , M . N County. }'tsv (W Moa
(Road Namv,.altd Number,
, Lot No.)
3. OWNER:_Gltti ?,,C e r Pr a t
1 i S i N 4ct/ Po %MX Llocb
4. ADDRESS:9-aw`tao t,a n
5. TOPOGRAPHY: draw, slope, hilltop, valley, flat
(circle one)
6. TOTAL DEPTH: s ) . S DIAMETER 3/y -
7. CASING REMOVED: ,5 4--, C--mQ�,.c,N arm
C'ti5re feet
ameter
(>:...r--ove� "fit. �C9k\r^a-;c:_�y
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement 1 bags of cement
gallons of water _7__ _ _ gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
tst �� etc
� a
11. DATE WELL ABANDONED l / G / I e4
Quadrangle No.
/ �GrgC'�eN Pac.K�,q�a/
WELL JJIAC9KAM: thaw a aetattea sKetcn or [ne
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
way � $ur�cvice
PvC-03
w ttY. a+.r5 r�,i eC
M-k co- ett
soma '
,r,-�l -T. -f
L1 7. S"
r�
K-9- o$�Sear+Gs
I do hereby certify that this well was abandoned in accordance with.15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well , ra, Date l i 1 7 / 114
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- 1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 0912004

L-
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR CztL.0 i nJ 6p v c a _
WELL CONTRACTOR CERTIF ATION #
1. WELL USE (Check Applicable Box): Residential 0 Municipal 0 Industrial 0 Agricultural 0 Monitoring it
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, 'List Use;
W,Lkt, 0 zSt3"*-,ttdns (a - t 3 - le L
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: C- County � Z-{,�vr.�rsocl
E�-Vr-c-e.fC.eN
(Road Nanx shd Number,
3.OWNER:
, Lot No.)
l Is, / Po Sit 41,0 o
4. ADDRESS; C
5. TOPOGRAPHY: draw, slope, hilltop, vailey, f Kat
(circle one)
6, TOTAL DEPTH: 314 DIAMETER 1/2!
7. CASING REMOVED: ,5��••.e_ cm„��\,�+ at
feet diameter
Sec ��•r-�ve� � tvX\rw.o`
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water_ gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
11. DATE WELL ABANDONED
Quadrangle No.
/ X.Jecq(teci
WELL VIAGKAM: craw a detattea sketcn of the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
Intervals of casing perforations, and depths and types
of fill materials used.
Sew\e.
Well. �
.Su�t�•
iDoce.�`•dlat-.
+� 11
-tap tss t'C�n
Need ��
anc5 �♦Se C
�.�
s,,,�
.5ae•eesv
'
r _•
34
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well ,ark„„"._ Date l / 1 . I +j
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

w
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR C:1 t .) , n l �o u r nl
WELL CONTRACTOR CERTIFICATION # 3 4 5S A_
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural 13 Monitoring [B�
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Watt DCS15"gi'ttattu p. �3 - 1a3
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: County t,e5
(Road NarnaAd Number, Comm nity, ubdivision , Lot No.) Quadrangle No.
3. OWNER: Glue 9- cAge 1PAxhr-C-_ f1rclit'S_I / t�/ec faecJ An t� a
17 S. rM .fit / Pc Z x goad
4. ADDRESS: C.o,sa"�ot4 . N c a ,9 7 1 t'
WELL raw a detailed sketch of the
❑ ❑ well showing total depth, depth and diameter of
5. TOPOGRAPHY: draw, slope, hilltop, vaYey, at screens remaining in the well, gravel interval,
(circle one)
�. intervals of casing perforations, and depths and types
6. TOTAL DEPTH: G S DIAMETER '`i in+e of fill materials used.
7. CASINGREMOVED:
feet diameter
Z.�a
al c
baceL.eL`
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
C�.SeC
9. SEALING MATERIAL:
�, �`�
Neat CementN
Sand Cement
bags of cement 1 bags of cement
�z
gallons of water-_ gallons of water
Other
SS
"T o�
Type material
S�-.Vizo
Amount
"''
-•�
.rS
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
QskrteM- o F ,
t''
f,csa%a re- nomstea bit
seed ��.
�...
6S
11. DATE WELL ABANDONED t / e/ 1-1
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well ��r Date l / 17 / 1 -J
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-I617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ADAND®NMENT RECORD WELL CONTRACTOR &e t 13 t eJ bd U t Al
WELL CONTRACTOR CERTIFICATION # _ 3 Sf SS -• 1k
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial 0 Agricultural l7 Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other © If Other, List Use:
wckl ��st�n,q' tc,h, P.k—s Soy( Q
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nbarest Town:_ _ (Z "to M . fU C_ County -
(Road NamcAd Number,
•
, Lot No.)
1 i S rV,01'. .g e€t! Pe tic 4aoo
4. ADDRESS: p
5. TOPOGRAPHY: draw, slope, hilltop, valTay, flat
(circle one)
6. TOTAL DEPTH: G o DIAMETER :�/q ►.,c�
7. CASINGREMOVED: -5-4 -c-
feet diameter
-rNser mN. r_,l -knt, cnX�M.a �y
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement 1 bags of cement
gallons of water. 7 gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
cAS Ce Stc
11. DATE WELL ABANDONED 1. �V / J �i_
Quadrangle No.
/ �ecgc�en) PecK���`�
WELL DIAGRAM: Draw a aetailea slcemn or the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
Uaell
Vx
-,.-e p T
�i
ter•
.�
�t'C?
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the weii1_/_C3 Q.1% , Date t / 17 11,14
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn-. Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
OW-30 Revised 09/2004

L-
North Carolina Department of Envirorunent and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD wELL coNTRAcroR G,�
WELL CONTRACTOR CERTIF ATION # SS "
1, WELL USE (Check Applicable Sox): Residential ❑ Municipal CJ Industrial O Agricultural Cl Monitoring 2---
Recovery 17 Heat Pump Water Injection ❑ Other O If Other, List Use:
wf-k1 0-t3 - 10-5"
2. WELL LOCATION: (Show a sketch of the location on back of form.) ll
Nearest Town: C_,L"te, ry ri C. County v r �, ► ttsod
1 . 1C.11
(Road Nameand Number,
, Lot No.)
3. OWNER: s tts S 'J�, � L
7 5 f�er �e;c/ Pe DaX 400ca
4. ADDRESS: n
5. TOPOGRAPHY: draw; slope, hilltop, vaTiey, flat
(circle one)
6. TOTAL DEPTH: �L 8 . 8 DIAMETER. yy
7. CASING REMOVED: 5-4--
feet diameter
-t-. cOX\
' a flex
9. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement f bags of cement
gallons of water_ gallons of water
Other
Type toaterial
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
F Q-9S rd u`CC 1vti
IL DATE WELL ABANDONED
Quadrangle No.
� �esgCteN �me,�� a q
WELL DIAGFULI& Draw a detailed sketch of the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
N em"C C�.ae�
0-3
r.
�q.3
I do hereby certify that this well was abandoned in accordance with I SA NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well ..� �) Date 1 / 1 7 / 1 q
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- 1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

i-
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR Cyz U-) w 6av e n1 - -
WELL CONTRACTOR CERTIFIAA TION N
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring fBl�
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
wckt, 0eS13"4 tkescv p, %'S - tdS
71. WELL LOCATION: (Show a sketch of the location on back of form,) t
Nearest Town: o fVc �+ County }�(avrue,od
�ycta.0 C]i_ . ec gnl�lri 1-^.INFT 1 i
(Road Name-abd Number,
, Lot No.)
3. OWNER C:;t„e- P ..cr tc _' c
t -, S � / Po %--X 40c,
4. ADDRESS: Gas. tao , "9119 7162,1
5. TOPOGRAPHY: draw, slope, hilltop,
p, vaIl-ey, flat
(circle one)
6. TOTAL DEPTH: 40 , S DIAMETER .2
7. CASING REMOVED: S-4..ae_�Q`a-'Cicx� ot�c'J
feet diameter
<%Sec lcr-%P•Crvea� -t-0 cvk\ti.o-�-i�r
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement bags of cement
gallons of water__J� gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
P
♦ a
11. DATE WELL ABANDONED
Quadrangle No.
/ J�./er�cee0 10 %.., V-/
WILL INAUKAM: Draw a detailea sKeten or the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used,
LAB,
tic\� o.o+� SvC�se
bo<ey.et�.
f.��i� £+�- may-- t•-*c.�
`° Pv L Ser�ec�
ts+ttk mcr5 �♦SeC
V
2`S���yr
J fir.
•�
e�asv_
3c>
..
GA
;.
Sa.�d •" t
f .Z-
o-C Sc�eeJ
I do hereby certify that this well was abandoned in accordance with.15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well Date y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-16I7, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

L.
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOI,3 c L .Q a 6 u r d
WELL CONTRACTOR CERT]WICATION # 31 SS � A
1fiY R�iCS. i'
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring !1r.—*
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
L O,Lkl 0es,3"4~t%o" e' t 3— I o7 N
2. WELL LOCATION: (Show a sketch of the location on back of fornt.) Nearest Town ��-- o County. e5eA
;—yere.ceery - C:4;Z h 1A . l i -
(Road Nam6 and Number,
3.OWNER:
, Lot No.)
1 i s ry O'JV4 **Ct/ Po tic tioaa
4. ADDRESS 51—gj kt, , "c- I to
5. TOPOGRAPHY: draw, slope, hilltop, valley, rtLt
(circle one)
6. TOTAL DEPTH:_ 7C. q DIAMETER�� `
7. CASING REMOVED:feet
Ve- -over dice} e..o'�c
8. DISINFECTION:
(Amount of 70% hypochiorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement i bags of cement
gallons of water. T gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD }EMPLACEMENT
i`O.�F.�MATERIAL.
a
11. DATE WELL ABANDONED k / 6
Quadrangle No.
% �/er'gCtetJ Poc.�Cpq�.a,�
WELL ll1AUKAM: llraw a aetauea sKetcn or ene
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
rv�t ee � 6'^d r•see
;oe e.4
5.4
7;ej �a�
o
p�krto..g_ � , :
,-�:
ice
_-
�
Sarr�aO �.
4�''•
�`�
76
�3.9
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well, Date
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identiftcabon numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 0912004

Le
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR � r IJ Lny (- iJ
WELL CONTRACTOR CERTI ATION
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural Cl Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use.
we-kj l '*-S13 vo tko" P-\3 - 107 6
2, WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: C.�,a`to ri . N c_ County - �-C�v t �► ood
1�.i�re_tA_pr.] _-ie -._,-. 1 __.fit=:ll
(Road Na.me.and Number,
, Lot No.)
]-is
- fti%41-N Jli*'aEt/ Po sox LIo00
4. ADDRESS:
S. TOPOGRAPHY: draw,* slope, hilltop,
valley, tat
(circle one)
6. TOTAL DEPTH: "In DIAMETER 3/
7. CASING REMOVED:
K'�5ec feet
tdiameter �
DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement ( bags of cement
gallons of waters_ gallons of water
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
x ce- cm� tid e►
t`L7bF�,L!)sNr] kYSt YJ\AJ�
11. DATE WELL ABANDONED 1 / G / )q
Quadrangle No.
whLL inAC9KAm: craw a ae[anea SKeICn 01 [ne
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
LaN,
be•<e�+e�a-.
V� ��! I I I
o e a-4
Zse A
— ;
til j.
r.•.
Leo
3d
4 �
i
Y�
I do hereby certify that this well was abandoned in accordance with.15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well -Z-ZO . ��� Date l / l 7 / 1.Y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. (919) 733-70I5, and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

L.
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR L) t J LeU CA
WELL CONTRACTOR CEitn ,ATION #
1. WELL USE (Check Applicable Box): Residential O Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring M
Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use:
1. t.kL 0-es%g"d-ZZtko" P-t3 - lo7 e
2. WELL LOCATION: (Show a sketch of the location on back of form.) Nearest Town: 1 V C County s MOA
(Road Named Number,
• ./i,1_
, Lot No.)
1 i 5• tV%4.AN •gt'r+ee-t/ Po eat-40clea
4. ADDRESS: ❑❑ E,
5. TOPOGRAPHY: draw, slope, hilltop, vaTCey, at
(circle one)
6. TOTAL DEPTH: p DIAMETER 3
7. CASING REMOVED:.Sy-
feet diameter
C �5e.c ccj r-. P—, ''ti'a 0. tro}c �e..o`kCa ter
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water__ _ gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
Rco-ssv rc 8,n-`tca AFMty,
11. DATE WELL ABANDONED (/ G / 1q
Quadrangle No.
WbLL i)tAUKAM: Uraw a tietatteo sKetcn or the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
Nat
9oecx5�.al�
�rroci
a e.-Ot
NOT a�
�
Yr ti
.Se.Pti�
56.3
S O
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, weIl construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well. Date i / I ! l y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
OW-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR �' bj w e„ r d
WELL CONTRACTOR CERTIFI ATION 9 3 4 5S " E�
1. WELL USE (Check Applicable Box): Residential 0 Municipal 0 Industrial ❑ Agricultural ❑ Monitoring 0-1-
Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use:
Ci.3e.l(, D�St9nro'CIoN P- l3 - lOg
Z. WELL LOCATION; (Show a sketch of the location on back of form.)
Nearest Town: C®,`:tel lu County o
(Road Nanv-and Number, Community,�ubdivision , Lot No.)
Quadrangle No.
3. OWNER:_(A1„e_ q11asr_ P,... t Per Ut-1c- mac_
box y�
/ F.le.�'a
'�teN
lac �aq
./
4. ADDRESS: C c 6
-DIAGRAM:
[]
S, TOPOGRAPHY; draw,
WELL Draw a etas sketch o the
well showing total depth, depth and diameter of
slon-pe, hilIOtbp, valley, at
(circle one)
screens remaining in
the well, gravel interval,
6. TOTAL DEPTH: 'f 'L , DIAMETERA
intervals of casing perforations, and depths and types
of fill materials used.
7. CASING REMOVED;
feet diameter
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
N` ce.01C
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water gallons of water
Other
Type material
30, G
Amount
3 1. G
10. EXPLAIN METHOD EMPLACEMENT
Gskt.a— moo !
;'�;' (3ma's'`'`
�O�FMATERIAL.
,`:
IL DATE WELL ABANDONED / Q / 141
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well , . Date k / 1 i / �y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- 1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

L-
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR r L 3J 11-i 6o u r nl
WELL, CONTRACTOR CERTIFY ATION ai 29 -TS K
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Wv-kt 0eS%3"q:" t%CbN P-}3 - loq
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: C-dN-�a a , (V C_ Countyvr.� o�
. x tstts�en� Rnk�< «h La�, l 1 T.
(Road Name-ilid Number, Comm`dility; 'subdivision , Lot No.) Quadrangle No.
3. OWNER:- Ql.» e• �Roe-( eCs� z'C i—"L
1 •T 5 r -.a - s'C;gct/ Po %-x - oC,cd
% F-�/era4�CeeN toocI--
J
4. ADDRESS: C.o..' to . ti C_ 3,19 1�-,�
5. TOPOGRAPHY: ©,slope,
well ,L D : Draw a detailed sketch of e
showing total depth, depth and diameter of
d hilltop, valley, flat
screens remaining in the well, gravel interval,
(circle one)
6. TOTAL DEPTH: ,'o DIAMETER ��
intervals of casing perforations, and depths and types
of fill materials used.
7. CASING REMOVED: -5 -+1KC-9- Cxbm �mw atC)
feet diameter
jpecs-1,.o1`
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
?yC- stfee ca
9. SEALING MATERIAL:
`'��` oa•� ��.set
ft
Neat Cement Sand Cement
bags of cement i bags of cement
gcouC
gallons of water__ gallons of water
Other
6�
T
So.,s of
Type material
Amount
;;' ••; 7d
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
(Mt044— CA
Sctae..nf
S C� dou`�i�
11. DATE WELL ABANDONED Lf G l c{
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided two the well owner.
Signature of person abandoning the well >m= �1 • Date 1 / 17 / 1 q
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR G )-I rs llA u al
WELL CONTRACTOR CERTIFICATION # 3 cf 55 ik
1. WELL USE (Check Applicable Box): Residential El Municipal O Industrial ❑ Agricultural ❑ Monitoring Ilr-�
Recovery 17 Heat Pump Water Injection El Other 0 If Other, List Use:
Wc�l �cst9No;CtdN Q_ t 3 - ��e A
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: ty
N C- Coun �
(Road NamaAd Number, Comm`'unity;'$ubdivision , Lot No.)
Quadrangle No.
3. OWNER: 1 11ir- ee_ 181ter Pr11L3zt' < r—c-
l *7 5 N Ct/ PO a MX 4joC7b
/ lecgCeee3 to i �^''
4. ADDRESS:
WELL D
raw a detailed s cetc i o e
[❑j
5. TOPOGRAPHY: draw; slope, hilltop, valley, at
well showing total depth, depth and diameter of
screens remaining in the
well, gravel interval,
(circle one)
6. TOTAL DEPTH:—� DIAMETER
intervals casing perforations, and depths and types
of fill materials used.
7. CASING REMOVED:
feet diameter
� -�� �oc.\mow lm�..� ..5'�t'�r,.c�
tas�t� a.•a
S�rC-nec�.
8. DISINFECTION:
(Amount of 70% hypochlorite used:)l'yC
Sua=a
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water___ gallons of water
Other
;°e 6
S��
" f;
Type material
Amount
"`'
.'' -15'
10. EXPLAIN METHOD E LACEMENT OF MATERIAL.
G'E4*•- 4b4
11. DATE WELL ABANDONED 1 / rt Z 1 Y
I do hereby certify that this well was abandoned in accordance with. l 5A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well , Date i I U / Ly
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams, Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- I617 Mail Service Center - Raleigh, NC
27699-1617, phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
OW-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABA"QN.MENT RECORD WELL coNTRACToR Gwy L.QwpucrJ
WELL CONTRACTOR CERTIFI ATION # 4 5S a A
1. WELL USE (Check Applicable Box): Residential 0 Municipal El Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection 0 Other ❑ If Other, List Use:
WeA �cst�rvo`t�an► .P.13 - )to e
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: CZte, m r'VG County, yr o
%.mow �`w_!'l►►h\ _.iC.— _— % _ _ _= 1 1
(Road Natn-and Number,
, Lot No.)
3.OWNER: G11,r 1� eP C F'r�1Ittc Z�
t 7 S tN .**.--t/ Pa
4. ADDRESS: - _,�,C- a ,
5. TOPOGRAPHY: draw, slope, hilltop, vaRy, At
(circle one)
6. TOTAL DEPTH:_ DIAMETERy,`A
7. CASING REMOVED: .5-X-VAe-c-
feet diameter
-�Cert �O�e.�rs w
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water-1— gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL,
P .SS V re- i+s�`t�t 'F
11. DATE WELL ABANDONED / $ / / I
Quadrangle No.
/ F J rgC ACJ
W2rJ J, 01AUKAM: draw a ocumea sKetcn or the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
�Dote_L.el�
6-,r,t C- sexa"i
roe• ��
l�iC�Or.e� CDT
67.5
see .5co�eeN
5-7
r .��
O•C SGf�Ge.h�
6 7
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well � e„ Date 1 / t 7 / 1_.y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers,
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center- Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
QW-30 Revised 09/2004

L.-
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT "CORD WELL CONTRACTOR ( ot n7 ibe =0
WELL CONTRACTOR CERTIFl ATION k
1. WELL USE (Check Applicable Box): Residential 1J Municipal ❑ industrial © Agricultural E3 Monitoring [13�
Recovery ❑ Heat Pump Water Injection © Other O If Other, List Use:
(-t,3e,tL O�st9n�q'ttnnj (? t3.- m
2. WELL LOCATION: (Show a sketch of the Iocation on back of form,)
Nearest Town: . fU _ County
(Road Narrehd Number,
3.OWNER:
, Lot No.)
1 "I S. r%-�--q*A&-"/ Pa 4ax 40exa
4. ADDRESS: Ca.,,a`t®,s pp
S. TOPOGRAPHY: draw, slope, hilltop, vaTCey, flat
(circle one)
6. TOTAL DEPTH:— Q_y DIAMETER 3/�!g 1�
7. CASINGREMOVED:
feet diameter
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water. gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
%gA--%Mr0—
A ate
.a e
�L
11. DATE WELL ABANDONED 1 / Ot J yy
Quadrangle No.
w,bLL DIAU",M: Draw a aeiallea sKmon oI ure
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
beceSn��
nti�ts-e�1 I I I� t'�.SeC
Nat? g-;
, t 'me
L7iCrt.o�e••� �rC
,r` �
e'w'
o�-C Sex+ee.eJ
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well Date 1 / 17 ! 1 y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

a. -
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR
WELL CONTRACTOR CERTIFICATION N 2 ri SS " fk
1. WELL USE (Check Applicable Sox): Residential ❑ Municipal 0 Industrial ❑ Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
la,)�.11 O�st�rva'�te�ty P-13— 1�'�
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: �—!a.N`te, NC County }�cayr,�� od
(Road Nam"hd Number,
, Lot No.)
4. ADDRESS: �. c
5. TOPOGRAPHY: draw, slope, hilltop, valley, flat
(circle one)
6. TOTAL DEPTH: 3 f5. 3 DIAMETER 3�\
7, CASING REMOVED:
feet diameter
"47-6;;t (—,5 C� SUt&CE
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cemen#
bags of cement r bags of cement
gallons of water_ °� gallons of water
Other
Type material
Amount
I0. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
t.SS � Gau�Ct]
rA
.�a e�A
11. DATE WELL ABANDONED
Quadrangle No.
WELL 01AUKAM: Draw a aetauw sxetcn or the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
�--C--t�c•s 5��..1e,
•-t� ts.ntt� ®.o�c� Cti.SeC
aJ��t
dSmca�
°t
3q
3%.3
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well Date 1 / l % / I
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- 1617 Mall Service Center - Raleigh, NC
37699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
OW-30 Revised 09/2004

Le
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT UCOPJD WELL CONTRACTOR C t r n1 ba v r ri
WELL CONTRACTOR CER�T ION # ES d K
1. WELL USE (Check Applicable Box): Residential Cl Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring a
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
W,Lk( DeSta Nq leytV ? 13 - i I ;L
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: C-dha fty 81 C _ County, Xo,% (*A QcbA
(Road NarnaAd Number,
t • Iu1c t
, Lot No.)
17 S tvo+1M a. ct/ Pe arc L►000
4. ADDRESS: n❑
5. TOPOGRAPHY: draw, slope, hilltop, valley, at
(cirole one)
6, TOTAL DEPTH: 17), ci DIAMETER -1/ c\
7. CASINGREMOVED:feet at•�J
��5eC �a.r—wed ameter
—ta a�di"X\�^v--
1 -fort \ZVA w laZ sut°&e_e_.
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement ( bags of cement
gallons of water—'r� gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
11. DATE WELL A13ANDONED
Quadrangle No.
WELL DIAUKAM: Draw a QetatlW sketch or the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
Se-tt-
U.9V-1�.
�poce�nat�..,
•E'.l e�
'vmmr csa,--ft
-So7 a4
-r
Ste,
J --f
10
•••
r: ti
Sc rem )
_
t
o•� SeaewtJ
Seed
•?•'
f,-;,
17.$
17--1
I do hereby certify that this well was abandoned in accordance with. 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well r-,o Date 1 / 1 % l t y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

Lr
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL rABANDON1i NT RICO" WELL CONTRACTOR Gmu
WELL CONTRACTOR CERT ATION # -
39 57S A
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural O Monitoring +tS
Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use:
we-kt I?„ �3 _ �\&. &
2. WELL LOCATI.OJJN: (Show a sketch of the location on back of form.)
Nearest Town: C,...-te, to , r1l _ County Na MnA
(Road Narrcand Number, Community,-8ubdivision , Lot No.)
Quadrangle No.
3. OWNER:_ Q1ve \ao or-�cp.�F'rnr�0Zto.S-.iZ
P6
J �Ie-r
�• N QCt/ NX HOC)&
4, ADDRESS: C 6
❑ . ❑ ❑
WELL DIAGRA
well showing total depth,
raw a detailed sketc o e
depth and diameter of
5. TOPOGRAPHY: draw, slope, hilltop, vaYey, at
screens remaining in the well, gravel interval,
(circle one) 3
6. TOTAL DEPTH: !Sb . 3 DIAMETER INC�Ar.,
intervals of casing perforations, and depths and types
of fill materials used.
7. CASINGREMOVED:
St'Ae-
feet \ diameter
surtu—
'1t)e.cekn��
8, DISINFECTION;
(Amount of 70% hypochlorite used:)
9, SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement ( bags of cement
gallons of water_ gallons of water
Other
Type material
Amount
�;
.•; �o.
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
Gd, +tb,-- m 6
csx re—
.5-e d
11. DATE WELL ABANDONED 1.) 9 / %4
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well , „d, ,,,,�se� _ Date 1 / LIZ 1 q
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- 1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR Gb-) J r l b0U j nJ
WELL CONTRACTOR CERTIFI TION # 3 9 SS - A.
I. WELL USE (Check Applicable Box): Residential ❑ Municipal O Industrial ❑ Agricultural ❑ Monitoring 21-,
Recovery 13 Heat Pump Water Injection O Other ❑ If Other, List Use:
Wv-kl p.13 - IN 8
2. WELL LOCATION: (Show a sketch of the location on back of form.) `
Nearest Town: C- County vr.� oel
(Road Natnc-aitd Number, Comni nity,--Subdivision , Lot No.)
3. OWNER:__ L31„r 9,,oe P�„e-c Pc��►L S .'�ac
17 S ems/ Po %-X 4
4. ADDRESS: G
5. TOPOGRAPHY: draw, slope, hilltop, vaaey, at
(circle one)
6. TOTAL DEPTH: S 7 DIAMETER "``l i N cr,
7. CASINGREMOVED: 5+-4—f--
feet diameter
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement 1 bags of cement
gallons of waters_ gallons of water
Other
Type material.
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
rt� a
11, DATE WELL ABANDONED y
Quadrangle No.
WELL 01AUXAM: Vraw a eetauec sKetcn or ute
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
(yoell � .Sur{gc�.
bote�.ale.
—e a�
7; a�
s.;ti
,Scre�aa
sit
S 7
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well, Date l /) / I y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phooe No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

Ll-
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELLCONTRACTOR&oz Ww6aur'nl
WELL CONTRACTOR CERTIFI TION It 2 � 5'S " K
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial 0 Agricultural Cl Monitoring tFl
Recovery ❑ Heat Pump Water Injection 0 Other 0 If Other, List Use;
ww'kt
2. WELL LOCATION: (Show a sketch of the location on back of form.) `
Nearest Town:`©N _ (y County
(Road Nameand Number,
3.OWNER: (,lu
, Lot No.)
17 5 fw0',t4- ,$*ezt--/ Po c c y
4. ADDRESS:
5. TOPOGRAPHY: draw, slope, hilltop, vaaey,f at
(circle one)
6. TOTAL DEPTH: "lo DIAMETER 3/SI
7. CASING REMOVED: 5 ►4.e- com��.- as�1
feet diameter
8. DISINFECTION:
(Amount of 70% hypochlorite used;)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water__ gallons of water
Other
Type material
Amount
I0. EXPLAIN METHOD EMPLACEMENT OF MATERIAL
I I . DATE WELL ABANDONED
Quadrangle No.
� Lcreca'Ce.eN Pa```�j`�J
WbLL IRAUXAM: L)raw a aetarieo stcetcn or the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
ZaeN�
bece�.elt„
�g
`
Yr;ti
Sw1`Gl4�
�f•
•�
6a
GoStO►r� !►rC
.
I�w•
-
ea•C Sate e,�
-5--.g t 6
; ,
r .,
?I
�o
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well,
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW30 Revised 09/2004

w
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR W t a Le u c lJ WELL CONTRACTOR CERTTF ATTON 11 3'
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial 0 Agricultural ❑ Monitoring
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Wckt DCS'5"v`tkoN P- a% - 2a1 C3
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: C_..N-to C- County .
Sct o0
>- �po�. _sue--•- 1 _ _' l
(Road Na v and Number,
, Lot No.)
3. OWNER: Glue, ParC Qs• u-tc , L
ct / Po %ax %0&
4. ADDRESS: ag
j�
5. TOPOGRAPHY: draw; slope, hillot6p, valley, I K
(circle one)
6. TOTAL DEPTH: 1 _ DIAMETER N �[ 02 a�n.
7. CASING REMOVED: S—f1C--x- Com ml. cxtlt)
feet \ diameter
��-
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water T gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
a e
11. DATE WELL ABANDONED 1 J
Quadrangle No.
/ 9�-/e ro-eci f taa�
WELL 01AUXAM: Draw a oetatleo sKetcn Or me
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
�,.-t
LAB,
bac�di�,.
°
f v c- $cr."i
ts..*CSC�
�.cS �tief
3
, •,
.;c
SeretrrJ
cam..-
t
Set�eet�
Saws
t, ,.
o�
l G.
1 6
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well Date 1 / 0 / I y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- 1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

Lr
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WEILL ABANDONMENT RECORD WELL CONTRACTOR r­,L �_ t 6n U r' d
WELL CONTRACTOR CERTIFI ATION # 4 5S
1. WELL USE (Check Applicable Box): Residential ❑ Municipal 0 Industrial El Agricultural ❑ Monitoring li�
Recovery 0 Heat Pump Water Injection El Other ❑ If Other, List Use:
W,LkI Destgrvo'tko" p_e7 - 1as A.
2. WELL LOCATION: (Show a sketch of the location on back of form.) l
Nearest Town: Sa o Nye County nmd
i,:.,.. 1,.,0 _ . _. I _ S,C" r r
(Road NarndAhd Number, Comm`Gnity,"Subdivision , Lot No.) Quadrangle No.
3. OWNER:_GI%,e 1?,,.e_c Qr�szZ, I c-
e4rC/ ea WMA Ldooa
/ �ergl�e�
J
4. ADDRESS:
❑ . ❑ ❑ ❑
5. TOPOGRAPHY: Kat
WELL DIAGRAM: raw a detailed sketch of the
well showing total depth, depth and diameter of
draw, slope, hilltop, valley, f
screens remaining in the well, gravel interval,
(circle one)
6. TOTAL DEPTH: $ y ; DIAMETER
intervals of casing perforations, and depths and types
.
of fill materials used,
7. CASINGREMOVED: 5,44--c- cabmet 0*4 O3V-XJ\
feet diameter
8. DISINFECTION:
�e.��eeir+• 3J
(Amount of 70% hypochlorite used:)
ir,oCtoa.``�o ('CA
�C S�ae�a
9. SEALING MATERIAL:
�C
Neat Cement Sand Cement
bags ofcement i bags of cement
gallons of water �� gallons of water
Other
Type material
s.;: ScceesJ
-7'�
Amount
„'. -•� 74'1J�
10. EXPLAIN METHOD EMPLACEMENT OF
(3sEta, oar :N'
�MATERIAL.
P a ssM r� cvo't�cRorr•.
Sa�a�
_ �- Iz- '4. . .
11. DATE WELL ABANDONED 9 / t
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well ._ Date ti ! 17 / ► y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, "intersection and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- 1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

L-
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RIPCORD WELL CONTRACTOR Lk), b8urrj
WELL CONTRACTOR CER�TION M
1. WELL USE (Check Applicable Box): Residential 0 Municipal O industrial D Agricultural O Monitoring [t3-
Recovery 0 Heat Pump Water Injection ❑ Other O If Other, List Use:
WeA 0ZS13r-Ctk0N P—•o7 , 2o3 la
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: ,..; o n1 . N C. County, o0
1-•..�r._�P�e.� __SC_I
(Road Name-and Number, CommViiity,�•$ubdivision , Lot No.) Quadrangle No.
3. OWNER: G11ir-
1 IS* N ct/ Po Z-x 46c b
.�
4. ADDRESS:C.a,,,a-0,"C_ 1% 716
-
13.0 ❑ p
5. TOPOGRAPHY: draw,
WELL DIAGRAM: Draw a detailed sketch of the
well showing total depth, depth and diameter of
slope, hilltop, valley, t
screens remaining in the well, gravel interval,
(circle one)
ti. TOTAL DEPTH: ��•{ , 5 DIAMETER:S �,,, c.�``
intervals of casing perforations, and depths and types
of fill materials used.
7. CASING REMOVED: 5,�A4e_ C05Mfeet
•��Sec �.i�-rsye� -ta~+ dtcamoXern,.�i�
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
jDe`t�c«r.� t° PvL ScP�atJ
9. SEALING MATERIAL:
�**� a.►rS C'�SeC
Neat Cement Sand Cement
bags of cement f bags of cement
gallons of waters_ gallons of water
Other
a-�
S� T�a
Type material,
Amount
r • ..,
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL,
�ja+�t ow... e F ' '
P css rA& ca-tc r„.,
zbb o z
ys tint.;
11. DATE WELL ABANDONED / 9 / I �t
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well ,� e,,. • - Date i / 17 / I y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Mtn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD wm coNTRACTOR
WELL CONTRACTOR CERTIFIAA TION li 3 4 55 - a _
1. WELL USE (Check Applicable Box): Residential ❑ Municipal 0 Industrial ❑ Agricultural ❑ Monitoring 0-1-*
Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use:
Well D�P-s,yoo-tte" (a_o7 -203 c
2. WELL LOCATION: (Show a sketch of the location on back of form.) ll
Nearest Town: County • �a o u od
(Road N d Number, Comm pity, ubdivision , Lot No.) Quadrangle No.
3.OWNER:_(A►„s (Z,aoe „ec Pellnit tc lmi-s- % /er�t'eeN f.c, ti,��o
1 ? S �N��. EC/ Po t-x ;Joc)e>
4. ADDRESS: `31:%6WELL IA raw a detailed sketch of the
❑ ❑ ❑ well showing total depth, depth and diameter of
5. TOPOGRAPHY: draw, slope, hilltop, vaey, flat screens remaining in the well, gravel interval,
(circle one) intervals of casing perforations, and depths and types
6. TOTAL DEPTH: IS"' DIAMETER .y rr"eIn of fill materials used.
7. CASINGREMOVED:
feet diameter
<\5ec
i Xee
�er<er`net.�
8. DISINFECTION:
(Amount of 70%hypochlorite used:)
�, o,,� o
FvL screma
9. SEALING MATERIAL:
Neon
Neat Cement $and Cement
bags of cement f bags of cement
gallons of water—_ gallons of water
Other
{
�e e
Type material
Amount
�' •
-+
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
nkzaa a
T>"fW .c5 _ MAMA %2. x ,a,
1G 1
t�
11. DATE WELL ABANDONED I /
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well !�� Date 1 / 17 / 1_y
tS
WELL LOCATION: Draw a location sketch on the reverse of this shee# showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management- I617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. (919) 733-70I5, and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

t.-
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR � t >3 r a 6o u r rJ
WELL CONTRACTOR CERTIFI ATION N 29 55
1. WELL USE (Check Applicable Box): Residential ❑ Munioipal ❑ Industrial ❑ Agricultural ❑ Monitoring W"—'
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, list Use:
W,LkL 0e.St3"'t , ON • 0&•
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: aN tU County
1-y..�+0-e_d•sSC..—._._. 1 __ _A= t t ^�
(Road Nmrwhd Number, Comnitki ,subdivision , Lot No.)
3. OWNER: (Jj,e (�,��o� e,,.ne_C f x�j
4. ADDRESS:11
7 t 6
S. TOPOGRAPHY: draw, slope, hiIllttop, vaII-ey, flat
(circle one)
6. TOTAL DEPTH:.A '2. o DIAMETERS `&
7. CASING R EMOVED: 5-0e-9- 4L�C, otiv at �1
feet diameter
•C'�5�c ��r—®ve� —tom cvX�H.o`rc�t�r
8. DISINFECTION:
(Amount of 70% hypochlorite used;)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement 1 bags of cement
gallons of water_7 gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
CSC C� ut+G
Y
11. DATE WELL ABANDONED
Quadrangle No.
WbLL DIAGRAM: J)raw a detailed SKeten of the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
�,.-rr .--ta•,
Sc�.l�
�oce�.eLeer
io toN.
lqg
17 ktftr..— 04
Sm.,�td
t'7.0 'r
�.;< Scre�fil
e'er: � Ses+es.tJ
\Zo
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well d Date 1 / t 7 ! i y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

ry
North Carolina Department of Environment and Natural Resources . Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR &:$,y L011 bd U t 111
WELL CONTRACTOR CERTIR ATION # 39 5S — K
1. WELL USE (Check Applicable Box): Residential O Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 0--'
Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use:
WCll IJ�St�rvo'Ctssry F—sni — -,,6`! (3
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town:�-a,� o sal N ' County
v0-re.eeeM 9-..44f--,_,... I -_.1c; I I
(Road Name,.a`td Number, CommVnity,-�ubdivision , Lot No.)
Quadrangle No.
3. OWNER: ,I �aQc C,,aeC PT uC c �-'
17 S ect/ Pa Z x �¢000
F-�ecc�f�@n) c' q
J arc gt"aJ
.
4. ADDRESS: C.
F [J
5. TOPOGRAPHY: draw, hilltop, flat
WELL DIAGRAM: raw a etat s etc oft e
well showing total depth, depth and diameter of
slope, valley,
(circle one)
screens remaining in the well, gravel interval,
3
6. TOTAL DEPTH:_ -71 DIAMETER /Y ,
intervals of casing perforations, and depths and types
of fell materials used.
7. CASING REMOVED: 5�+4� �roae`ox+ ot•+�
�,.� --t�r�
Stc�\e.
feet diameter
'� � 1�C\ rs t..►-] �p.�_ .SCf f�t►.L' L' _
(!� �.11 C�
.Sv ('�q��
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
� `o
?VC- 5esccCJ
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement I bags of cement
gallons of water 7 gallons of water
Other
Type material
G S"`�
;cr;ti ,Scre�N
Amount
; r.
.., 7
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
(:tee air
Ice—
cg
7 Z
11. DATE WELL ABANDONED
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well Date 1 17 l i y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

J-
North Carolina Department of Environment and Natural Resources • Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR C:7I' -) t rJ b o u c AJ
WELL CONTRACTOR CERTIFI ATION ff 2 41,T S `" K
1, WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring
Recovery 0 Heat Pump Water Injection O Other ❑ If Other, List Use:
we.t� DeS15".ZM0 v p-a) - Zoo{ C.
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: ,-te, rni - fV c- County —
(Road Nan>tAd Number, CommVnity,-subdivision , Lot No.)
Quadrangle No.
3.0WNER: 1�It, R.�aoe P..�[ P�e���
15- Z-x
X/e re-eci
i - oo ,
4. ADDRESS: C
❑ ❑ ❑
5. TOPOGRAPHY:
WELL DIAGRAM: Draw a etas e s etc o t e
well showing total depth, depth and diameter of
draw, slope, hilltop, vaYey, flat
(circle one)
screens remaining in the
well, gravel interval,
6. TOTAL DEPTH: `'� 5r DIAMETER Y tw.cSA
intervals of casing perforations, and depths and types
of fill materials used.
7. CASINGREMOVED: S�►�-� ��e`ca�+ ate
{�s."t�
s�``��''
<%Sec -t7a wee*A�e� diameter
t
\ kart �e\Aw Su
9Doce.�.oL�
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Viand Cement
bags of cement f bags of cement
gallons of water_ gallons of water
gee e-F
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
mkt®,... . �4 , ; i
IIF DATE WELL ABANDONED l / iS / 1 '44
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well Date 1 / 1 7 / 1 y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1611 ]Bail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

L-
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR Ggl LOIJ,Q(-A)
WELL CONTRACTOR CERTIFICATION # 3"I5S a 1k
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring 1011-,
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
Z. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town:d I G County •�,,00
(Road NarncAhd Number,
, Lot No.)
3. OWNER:G1ig,_E,Na4,- P Oe_e QraAll�!g��s
17 S r aj- / pe Dot iioaa
4. ADDRESS: g
O
5. TOPOGRAPHY: draw, slope, hilltop, valley, f Kat
(circle one)
6. TOTAL DEPTH; g 4i DIAMETER
7. CASING REMOVED:—5—�----
feet diameter
�C'�sec CC-"-'8,rae1 "tt' C'+oyL fitw- �r
8. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement 1 bags of cement
gallons of water_gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL
Rc ssy rl- a"-tv. U 'Fcb,�rti �a cti,v.
11. DATE WELL ABANDONED
Quadrangle No.
wbLL U!A(iKAM: Liraw a actauea sKetcn or Me
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
bo<cL.n��
igeCtow.'�.� � V L $csxe cs
8"9.3
Y.-IJ Sef�esfJ
I do hereby certify that this well was abandoned in accordance with.15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well Date 1 / 1 y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - (Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
OW-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL, ABANDONMENT RECORD WELLCONTRACTORGr' 1JI' booed
WELL CONTRACTOR CiERTIFI ATION # 4 5•.�
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural 0 Monitoring Il
Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use:
tale.11 �dstgtvc,'�te�n� 9-67 -2%3
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: C�,,,"'� M I1e County ,, 10A�
(Road NanaAd Number,
ion, Lot No.)
1 O WNER:_(�11se' 9,,a a? _PA..e( f rc S T D
17 5-q4 *Ct/ Pe Sax .owe)
4, ADDRESS: G
El
5. TOPOGRAPHY: draaw; slope, hitlt6p, vayey, at
(circle one)
6. TOTAL DEPTH: 7 -Or DIAMETERw
7. CASING REMOVED: 05 —•
Le —et diameter
DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement f bags of cement
gallons of water_ gallons of water.
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
ss c&-
`-Co mi
11. DATE WELL ABANDONED
Quadrangle No.
WELL DIAGRAM: Draw a detailed sketch of the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
awl C Iry C,, ser c'i
iP Lt-b 0k� "
:w'C tr,+Ae wC
NOT �sr
S�
7 of
7S'
17S
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well �j-„ Date 1 17j r y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams, Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 0912004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECO wuL CONTRACTOR C:11( >J 1 ,ot 6 e u ram_
WELL CONTRACTOR CERTIFICATION H
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ industrial 0 Agricultural ❑ Monitoring 93 ,
Recovery 0 Heat Pump Water Injection ❑ Other Cl If Other, List Use:
Wv-1L Q— e7 —2.2-C N
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nbarest Town: ` e, County
(Road NarrmAd Number, ComniVni", ubdivision , Lot No.) Quadrangle No.
3.OWNER:__�_It.e ��� e F9a„! rc .s
175 f N / F5 epmx
,/es CeeN
4. ADDRESS: C e7 16
(�
S. TOPOGRAPHY: draw, Kat
WELL DIAGRAM: Draw a detailed sketch of the
well showing total depth, depth and diameter of
slope, hilltop, valrey, f
(circle one)
screens remaining in the well, gravel interval,
6. TOTAL DEPTH:_.gs . ! DIAMETER2''t�1
intervals of casing perforations, and depths and types
of fill materials used,
7. CASING REMOVED: S—r-Q--r-
feet diameter
�C'�5er q�.w-egre� --moo o� �ex,�re.o�.Ly
Lm..n
-eaKC %0V—\es L.--. ie.j�.S� cc
la�e.�� eel Sue�-�eee.
jpac¢�,eL�,
8• DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
w�`S rtsec
Neat Cement Sand Cement
(MV 0-.e0t
bags of cement I bags of cement
gallons of water^ gallons of water
Other
�o 0-4
e� 7--
Type material
Amount
n r • .. , �S-
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
,4
11. DATE WELL ABANDONED 1 / 8 / 14
I do hereby certify that this well was abandoned in accordance with 1 SA NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well. Date 1 / 17 / l_<1
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
G W-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR C-Ji Q r rJ 0 U (AJ
WELL CONTRACTOR CERT1 ATION # :3 9 SS - K
1. WELL USE (Check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ffrl�
Recovery ❑ Heat Pump Water Injection O Other ❑ If Other, List Use:
Well ®�stsn+e-tttln.s e - 07 -2 r, 8
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town: ri tm County -
(Road Nanw Ad Number,
, Lot No.)
3.OWNER. _.G11W �.���r �� c� '5—I,,, C-
1 15•/ Po t-ac y000
4. ADDRESS: G
S. TOPOGRAPHY: draw, sloe, hiIlltt6p, vaITey, at
(circle one)
6. TOTAL DEPTH: _S3 DIAMETERS l,,,cN
7. CASING REMOVED:
feet diameter
DISINFECTION:
(Amount of 70 % hypochlorite used)
9. SEALING MATERIAL:
Neat Cement
bags of cement 1
gallons of water—_
Other
Type material
Amount
Sand Cement
bags of cement
gallons of water
10. EXPLAIN METHOD EMPLACEMENT
\O�FMATERIAL
11. DATE WELL ABANDONED
Quadrangle No.
� �a/GCgCe�N P�4K.aa� o•9J
WELL DIAGRAM: Draw a detailed sketch of the
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
gr
`i q
�.•� see
17ia��.aN.. 4�T
`�
1 w• bJo��'r`
•'
S�•�
J
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well �-/-,n Date 1 / 1 % l 1 y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-1617 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
GW-30 Revised 09/2004

North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL ABANDONMENT RECORD WELL CONTRACTOR C i +' 1Jw6ou errj
WELL CONTRACTOR CERTIF ATION # XJ—TS — ill
1. WELL USE (Check Applicable Box): Residential 0 Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring l±*
Recovery ❑ Heat Pump Water Injection O Other ❑ If Other, List Use:
Wta,kt ��st��,®-�testy p _cy.7 — Z�ja C
2. WELL LOCATION: (Show a sketch of the location on back of form.)
Nearest Town:e,
f\it^ County
(Road NamaAd Number,
, Lot No.)
3. OWNER: Gt,, 9�qe �R..�[ Pr t-c
17 S f-0- / Pa Z-X z1ooa
4. ADDRESS: C..°,,Z3t_ir
5. TOPOGRAPHY: draw,, slope, hillltt6p, valley, at
(circle one)
6. TOTAL DEPTH: o DIAMETER - .I
7. CASING REMOVED: S-14-ut- cj*.m at-,)
feet diameter
S. DISINFECTION:
(Amount of 70% hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement 1 bags of cement
gallons of water____` gallons of water
Qther
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL
P6.,ss s v Cc,e- JFMr.,
N
11. DATE WELL ABANDONED l�g�•{
Quadrangle No.
WhL.L VIA.UKAM: Draw a aetatlea slCetcn 01 Me
well showing total depth, depth and diameter of
screens remaining in the well, gravel interval,
intervals of casing perforations, and depths and types
of fill materials used.
Sew e-
1
1A921i �
.�ud'�CBAK-@
'ipotc�.e�a;.
�SoLtoa*� °
[ V L $vee
cJ
tv 'ie.�'C' Gee a C
,t,.;r 5 ieeo
7 cl
I do hereby certify that this well was abandoned in accordance with 15A NCAC 2C, well construction
standards, and that a copy of the record has been provided to the well owner.
Signature of person abandoning the well /-1-3 ,. _ Date 1 17 ! I y
WELL LOCATION: Draw a location sketch on the reverse of this sheet, showing the direction and distance
of the well to at least two (2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit original to the Division of Water Quality, Attn: Information Management-16I7 Mail Service Center - Raleigh, NC
27699-1617, Phone No. [phone], and one copy to the owner within 30 days from completion of abandonment.
OW-30 Revised 09/2004