1812_DukeMarshall_PiezometerAbandRecords_FID1628536_20211220

(' DUKE
ENERGY-.
December 20, 2021
North Carolina Department of Environmental Quality
Division of Waste Management
Solid Waste Section
1646 Mail Service Center
Raleigh, North Carolina 28778
Attn: Ms. Sarah Moutos (submitted electronically)
Re: Piezometer Abandonment Records Submittal
Industrial Landfill No.1
Permit No. 1812-INDUS-2008
Marshall Steam Station
Terrell, North Carolina 28682
Dear Ms. Moutos:
526 South Church St.
Charlotte, NC 28202
Mailing Address
P.O. Box 1006
Mail Code EC 13K.
Charlotte, NC 28201-1006
717-982-0986
The Solid Waste Section approved Duke Energy's request for abandoning seven piezometers associated with
Industrial Landfill No.1 (1812-INDUS-2008) Phases 2, 3, and 4 in letter dated November 22, 2021. The seven
piezometers included CLF21-17, CLF21-18, CLF21-19, and CLF21-20 from Phase 2, and CLF-302, CLF-403, and
CLF-404 from future Phases 3 and 4.
Duke Energy is providing the well abandonment records for the seven piezometers in this submittal. The
piezometer abandonments were conducted by S&ME on December 6t" and 7th, 2021. Note there are seven ash
basin groundwater monitoring wells, that were approved for abandonment by Division of Water Resources,
abandoned during the same time as the seven piezometers and therefore included in this records submittal.
Abandonment records were submitted separately to the NCDEQ Information Processing Unit.
If you have any questions or concerns, please do not hesitate to contact me at Ashley. Healv(aDduke-energv.com or
[phone].
Respectfully submitted,
Ashley Healy, P.G.
Environmental Services
Attachments: Well Abandonment Records (GW-30 Forms) (S&ME, December 2021)
cc (via e-mail): Ben Jackson, NCDEQ
Sherri Stanley, NCDEQ
Ed Mussler, NCDEQ
Julie Roberston, S&ME
Jasmine Tayouga, S&ME
Kyle Baucom, Duke Energy
Chris Varner, Duke Energy
James Malloy, Duke Energy
Ryan Czop, Duke Energy
www.duke-energy.com Page 1 of 1

s
II�
December 20, 2021
North Carolina Department of Environmental Quality
Division of Water Resources — Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Attention: Information Processing Unit
Reference: Well Abandonment Records (GW-30 Forms)
Duke Energy — Marshall Steam Station
Ash Basin Closure Project
S&ME Project No. 21410007, Ph. 02
Information Processing Unit:
S&ME, Inc. (S&ME) is submitting the enclosed completed and signed Well Abandonment Records associated with
the Ash Basin Closure Project and Industrial Landfill Expansion located at Duke Energy's Marshall Steam Station in
Catawba County, North Carolina.
Wells were abandoned by a North Carolina registered well driller in accordance with 15A NCAC 02C Standards
and Duke Energy's Guidance for Well Abandonments in North Carolina (EHS Work Standard, Revision 1) All
fourteen (14) wells were abandoned between December 61" and 71", 2021.
S&ME thanks you for your receipt of these records. Should you have any questions or need additional
information, please do not hesitate to contact us at [phone].
Respectfully Submitted,
S&ME, Inc.
Jasmine Tayouga
Associate Project Manager
Enclosures: Fourteen (14) GW-30 Forms
f
Michael T. Romanello, PE
Project Manager
cc: Ashley Healy, P.G., EHS Waste and Groundwater Programs, Duke Energy
S&ME, Inc. 12016 Ayrsley Town Blvd., Suite 2-A I Charlotte, NC 282731 p 704.523.4726 1 www.smeinc.com

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
OMonitorine ❑Recovery
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
s Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1/3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) 8. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. Well ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft )
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Justin Marlowe
Well Contractor Name (or well owner personally abandoning well on his/her property)
4452-A
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #: Not Applicable
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
Duke Energy
12/6/2021
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Not Applicable
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 14 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
• Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Approx. 1 /3rd batch used
(see mix description below)
7g. Provide a brief description of the abandonment procedure:
Each batch of bentonite slurry mix consisted of 24
gallons of water and one 50 pound bag of Quik-Grout
(sodium bentonite-based grout). This mix was pumped
into the botton of the well using 1 inch tremie pipe.
Facility/Owner Name Facility ID# (if applicable) S. Certification:
8320 E NC 150 Hwy., Terrell, North Carolina 28682 12/8/2021
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 461803426350
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No. (PIN) accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field, one lat/long is sufficient) 9. Site diagram or additional well details:
35.60858630 N-080.97552940 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same constructionlabandonment, you can submit one form.
6a. wen ID#: AB-613RA
6b. Total well depth: 105 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 1 2.1
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 100 (ft.)
6g. Screen length (if known): 5 (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection 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
loc. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016