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Home My WebLink AboutNC0004979_Allen_Appendix D_20191231Corrective Action Plan Update December 2019 Duke Energy Carolinas, LLC - Allen Steam Station SynTerra APPENDIX D HB 630 - PROVISION OF WATER SUPPLY COMPLETION DOCUMENTATION ('DUKE ENERGY August 1, 2018 Ms. Shelia Holman Assistant Secretary for Environment North Carolina Department of Environmental Quality 1636 Mail Service Center Raleigh, North Carolina 27699-1636 Subject: Allen Steam Station HB 630 Completion Dear Ms. Holman: Paul Draovitch Senior Vice -President Environmental, Health & Safety 526 South Church Street Mail Code ECUP Charlotte, NC 28202 980-373-0408 Duke Energy has been diligently working to fulfill the requirements of North Carolina House Bill 630 (HB 630) since it was ratified July 1, 2016. As provided in G.S. § 130A-309.213(d)(1): The Department shall classify an impoundment as low -risk if the impoundment owner satisfies both of the following criteria: a. Has established permanent water supplies as required for the impoundment pursuant to G. S. 130A-309.211(c 1). b. Has rectified any deficiencies identified by, and otherwise complied with the requirements of, any dam safety order issued by the Environmental Management Commission for the impoundment pursuant to G.S. 143-215.32. Completion of Provision of Permanent Water On December 7, 2016, Duke Energy submitted the Permanent Water Supply Plan to NCDEQ for the Allen Steam Station, located in Gaston County. The initial plan identified 272 households as being eligible under the requirements of HB 630 and recommended offering all but one household a connection to the local public water supply line or the installation of a water filtration system; the remaining household was offered only the installation of a water filtration system. On January 17, 2017, NCDEQ conditionally approved the Permanent Water Supply Plan for Allen. Duke Energy contacted all of the eligible homeowners with the identified options for a permanent water solution. Enclosed is Allen's HB 630 Provision of Permanent Water Supply Completion Documentation. The spreadsheet lists all of the properties identified in the Proposed Plans submitted to the Department in December 2016 and approved by the Department in January 2017, with those properties identified as initially requiring a permanent water supply being noted by a "true" in the column labeled "Included in Original DEQ Submittal." If it was later determined that a property was not eligible under HB 630, it is noted by the word "false" in the "Eligible for HB 630" column. Properties were later determined not to be eligible because they were a business, a church, a school, already connected to the public water supplier, or an empty lot. Empty lots may contain buildings such as barns, sheds, or garages, but do not contain a household. - Eighteen households were added to the eligible list. For the most part, these were duplexes that required more than one connection to the public water supplier. - Six of the originally identified households were later deemed not to be eligible for a permanent water supply because it was determined that the property did not contain a household (i.e., empty lot), including the one location that was initially offered only a water treatment system. Tax information from the Gaston County GIS website for these locations is provided at Attachment E. - Three additional locations were also removed from the eligible list because they were not households, but rather a business, church, or school. - One hundred ninety-one households were connected directly to the City of Belmont water supply by Duke Energy. The three Aqua North Carolina wells, which serve 77 households, are being abandoned as these Aqua North Carolina distribution systems have been directly connected to the City of Belmont water supply. Confirmation of connection is provided at Attachment A. Also included at Attachment A is confirmation of the nine households that were connected to the City of Belmont prior to the passage of HB 630. - Ten households are receiving filtered water through a water treatment/filtration system. Confirmation that the systems were installed is provided at Attachment B. - One household opted out of a permanent alternative water supply. Its selection card is provided at Attachment C. - One household was non -responsive. A timeline of the efforts Duke Energy took to contact this homeowner is provided at Attachment D. - One household was demolished after the date of HB 630. Per the Department's May 8, 2018 letter to Duke Energy, this household will be connected at a future date, once the household is rebuilt. A copy of the letter sent to this homeowner is provided at Attachment F. Rectification of Deficiencies Identified by Dam Safety Order On August 22, 2016, the NCDEQ, Division of Energy, Mineral, and Land Resources (DEMLR) issued to Duke Energy, Dam Safety Order (DSO) 16-01. For the coal ash impoundments identified in the DSO, which included Allen, the specified repair plans have been completed, and completion reports submitted to DEMLR. DEMLR has conducted as -built inspections for each item and has issued Certificates of Final Approval indicating that the work had been completed as designed. In addition, subsection (d)(1)(b) of G.S. § 130A-309.213 requires DEMLR to conduct the annual inspection of each dam associated with a coal combustion residuals surface impoundment required for that year, no later than July 1, 2018. The annual inspections for Allen have been completed, and Duke Energy has received Notice of Inspection reports that document no deficiencies are present. KA Request for Confirmation In light of the foregoing, Duke Energy respectfully requests that NCDEQ confirm the requirements set out in G.S. § 130A-309.213(d)(1) have been satisfied and that the Department issue a low -risk ranking for the basins at Allen Steam Station. Sincere Pa 4Dravitch\:�Z Senior Vice President Environmental, Health & Safety Encl: Allen HB 630 Provision of Permanent Water Supply Completion Documentation K, Allen Steam Station HB630 Provision of Permanent Water Supply Completion Documentation August 1, 2018 Allen HB630 Summary of Households Facility Allen Orig # 1 Address # 2096 Street South Point Rd Option Public Water Supply Submittal TRUE HB630 TRUE Permanent Water Solution Appendix A Allen 1 2098 South Point Rd Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 2 2072 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 3 2092 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 4 2084 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 5 2076 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 6 Boat Club Rd FALSE FALSE Empty Lot N/A Allen 7 2080 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 8 South Point Rd FALSE FALSE Empty Lot N/A Allen 9 2333 South Point Rd FALSE False - BCS N/A - BCS N/A - BCS Allen 10 102 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 11 206 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 12 2700 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 13 103 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 14 165 River Run FALSE FALSE Empty Lot N/A Allen 15 South Point Rd FALSE FALSE Empty Lot N/A Allen 16 9015 Wing Point Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 17 411 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 18 110 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 19 211 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 20 101 Dana Michelle Ct Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 102 Dana Michelle Ct Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 103 Dana Michelle Ct Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 104 Dana Michelle Ct Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 105 Dana Michelle Ct Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 20 106 Dana Michelle Ct Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 20 107 Dana Michelle Ct Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 20 108 Dana Michelle Ct Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 20 203 Michael Dominick Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 204 Michael Dominick Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 205 Michael Dominick Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 206 Michael Dominick Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 209 Michael Dominick Dr Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 20 210 Michael Dominick Dr Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 20 212 Michael Dominick Dr Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 20 2719 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 20 2723 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 21 9104 Shorewood PI Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 22 1317 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 23 710 John Douglas Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 24 102 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen Allen Allen 25 26 27 200 2330 507 Heather Glen Ln South Point Rd Cadman Ct Public Water Supply Public Water Supply TRUE TRUE TRUE TRUE FALSE TRUE Aqua Customer Empty Lot Aqua Customer Appendix A Appendix E Appendix A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 1 of 11 Allen HB630 Summary of Households Facility Allen Orig # 28 Address # 128 Street Midwood Ln Option Water Treatment System Submittal TRUE HB630 TRUE Permanent Water Solution AL2003 Appendix B Allen 29 1351 Armstrong Rd Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 30 2352 South Point Rd FALSE FALSE Existing Municipal Connection Appendix A Allen 31 118 Idlewood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 32 135 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 33 2401 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 34 308 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 35 304 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 36 115 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 37 123 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 38 2320 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 39 320 Reese Wilson Rd Water Treatment System TRUE TRUE Permanent Water Solution AL2006 Appendix B Allen 39 324 Reese Wilson Rd Water Treatment System TRUE TRUE Permanent Water Solution AL2007 Appendix B Allen 40 301 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 41 707 John Douglas Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 42 711 John Douglas Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 43 184 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 44 105 Reese Wilson Rd Ext Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 45 2329 South Point Rd FALSE FALSE Empty Lot N/A Allen 46 112 Reese Wilson Road Ext FALSE FALSE Empty Lot N/A Allen 47 109 Reese Wilson Rd Ext Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 48 131 Southpoint Dr Water Treatment System TRUE TRUE Permanent Water Solution AL2010 Appendix B Allen 49 110 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 50 107 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 51 Reese Wilson Rd Ext TRUE FALSE Empty Lot Appendix E Allen 52 9225 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 53 2726 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 54 9205 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 55 9111 Shorewood PI Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 56 9213 Egret Ridge Public Water Supply FALSE FALSE Empty Lot N/A Allen 57 2744 South Point Rd FALSE FALSE Existing Municipal Connection Appendix A Allen 58 9022 Wing Point Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 59 2708 South Point Rd (home) Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 59 2708 South Point Rd (office) Public Water Supply FALSE False - BCS N/A - BCS N/A - BCS Allen 60 9220 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 61 9201 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 62 111 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 63 131 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 64 125 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 65 1307 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 66 130 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 67 123 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen Allen 68 69 1303 111 Armstrong Rd Wildlife Rd Public Water Supply Public Water Supply TRUE TRUE TRUE TRUE Permanent Water Solution Permanent Water Solution Appendix A Appendix A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 2 of 11 Allen HB630 Summary of Households Facility Allen Orig # 70 Address # 108 Street Wildlife Rd Option Public Water Supply Submittal TRUE HB630 TRUE Permanent Water Solution Appendix A Allen 71 114 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 72 126 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 73 206 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 73 210 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 74 2650 South Point Rd Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 75 2513 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 76 106 Wildlife Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 77 122 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 78 214 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 79 203 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 80 Egret Ridge FALSE FALSE Empty Lot N/A Allen 81 9217 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 82 South Point Rd FALSE FALSE Empty Lot N/A Allen 83 125 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 84 607 Highland PI Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 85 134 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 86 108 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 87 112 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 88 126 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 89 120 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 90 103 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 91 131 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 92 2505 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 93 1319 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 94 706 John Douglas Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 95 109 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 96 207 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 97 Wing Point Dr FALSE FALSE Empty Lot N/A Allen 98 103 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 99 202 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 100 9239 Egret Ridge Water Treatment System TRUE TRUE Permanent Water Solution AL2000 Appendix B Allen 101 218 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 102 112 Reese Wilson Rd Ext Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 103 216 Reese Wilson Rd Water Treatment System TRUE TRUE Permanent Water Solution AL2005 Appendix B Allen 104 122 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 105 9221 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 106 109 Wildlife Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 107 9105 Shorewood PI Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 108 9210 Egret Ridge FALSE FALSE Empty Lot N/A Allen 109 9236 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen Allen Allen 110 111 112 9034 9235 Wing Point Dr Egret Ridge At the end of Lake Hill Cir Public Water Supply Public Water Supply Public Water Supply TRUE TRUE FALSE TRUE TRUE FALSE Permanent Water Solution Permanent Water Solution Aqua Well Appendix A Appendix A Appendix A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 3 of 11 Allen HB630 Summary of Households Facility Allen Orig # 113 Address # 2411 Street South Point Rd Option Public Water Supply Submittal TRUE HB630 TRUE Permanent Water Solution Appendix A Allen 114 2703 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 115 121 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 116 117 Idlewood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 117 Corner of Hwy 273 & Heather Glen Ln Public Water Supply FALSE FALSE Aqua Well Appendix A Allen 118 110 Wildlife Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 119 116 Idlewood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 120 2300 South Point Rd TRUE False - BCS N/A - BCS N/A - BCS Allen 121 303 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 122 1347 Armstrong Rd FALSE FALSE Empty Lot N/A Allen 123 133 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 124 217 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 125 113 Wildlife Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 126 107 Wildlife Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 127 114 Wildlife Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 128 115 Idlewood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 129 307 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 130 124 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 131 2417 South Point Rd Opt Out TRUE TRUE Opt Out Appendix C Allen 132 208 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 133 Midwood Ln FALSE FALSE Empty Lot N/A Allen 134 113 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 135 129 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 136 127 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 137 109 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 138 South Point Rd FALSE FALSE Empty Lot N/A Allen 139 318 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 140 2407 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 141 318 Mitchell St FALSE FALSE Empty Lot N/A Allen 142 2343 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 143 403 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 144 2306 South Point Rd Public Water Supply TRUE False - BCS N/A - BCS N/A - BCS Allen 145 South Point Rd FALSE FALSE Empty Lot N/A Allen 146 Reese Wilson Rd FALSE FALSE Empty Lot N/A Allen 147 Access Rd FALSE FALSE Empty Lot N/A Allen 148 402 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 149 400 Reese Wilson Rd Water Treatment System TRUE TRUE Permanent Water Solution AL2008 Appendix B Allen 150 Reese Wilson Rd FALSE FALSE Empty Lot N/A Allen 151 Reese Wilson Rd FALSE FALSE Empty Lot N/A Allen 152 130 Canal Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 153 2402 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen Allen Allen 154 155 156 408 2360 2656 Heather Glen Ln South Point Rd South Point Rd Public Water Supply Public Water Supply Public Water Supply TRUE TRUE TRUE TRUE TRUE TRUE Aqua Customer Permanent Water Solution Permanent Water Solution Appendix A Appendix A Appendix A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 4 of 11 Allen HB630 Summary of Households Facility Allen Orig # 156 Address # 2658 Street South Point Rd Option Public Water Supply Submittal FALSE HB630 TRUE Permanent Water Solution Appendix A Allen 157 107 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 158 119 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 159 127 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 160 Reese Wilson Rd FALSE FALSE Empty Lot N/A Allen 161 106 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 162 2359 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 163 9224 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 164 2640 South Point Rd FALSE FALSE Empty Lot N/A Allen 165 210 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 166 214 Lake Hill Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 167 9100 Shorewood PI Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 168 1313 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 169 2509 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 170 112 Wildlife Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 171 2519 South Point Rd FALSE FALSE Existing Municipal Connection Appendix A Allen 172 606 Highland PI Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 173 204 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 174 119 Idlewood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 175 2501 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 176 135 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 177 219 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 178 2347 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 178 2351 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 179 407 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 180 Mitchell St FALSE FALSE Empty Lot N/A Allen 181 111 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 182 401 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 183 2714 South Point Rd FALSE FALSE Empty Lot N/A Allen 184 2718 South Point Rd FALSE FALSE Existing Municipal Connection Appendix A Allen 185 2340 South Point Rd FALSE FALSE Existing Municipal Connection Appendix A Allen 186 2346 South Point Rd FALSE FALSE Empty Lot N/A Allen 187 506 Cadman Ct Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 188 128 Reese Wilson Rd Ext Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 188.1 128 1/2 Reese Wilson Rd Ext Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 189 South Point Rd FALSE FALSE Empty Lot N/A Allen 190 703 John Douglas Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 191 209 Heather Glen Ln Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 192 213 Heather Glen Ln FALSE FALSE Empty Lot N/A Allen 193 118 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen Allen Allen Allen 194 195 196 197 816 812 Boat Club Rd Plant Allen Rd Bell Post Rd Bell Post Rd Public Water Supply Public Water Supply FALSE TRUE TRUE TRUE FALSE FALSE TRUE TRUE Empty Lot Empty Lot Permanent Water Solution Permanent Water Solution N/A Appendix E Appendix A Appendix A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 5 of 11 Allen HB630 Summary of Households Facility Allen Orig # 198 Address # 1006 Street Nutall Oak Ln Option Public Water Supply Submittal TRUE HB630 TRUE Permanent Water Solution Appendix A Allen 199 629 Kenneth Wilson Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 630 Kenneth Wilson Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 248 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 252 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 254 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 313 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 317 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 319 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 321 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 199 323 Reese Wilson Rd Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 199 325 Reese Wilson Rd Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 199 329 Reese Wilson Rd Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 200 619 Kenneth Wilson Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 201 185 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 202 132 Midwood Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 203 519 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 204 Reese Wilson Rd FALSE FALSE Empty Lot N/A Allen 205 406 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 206 Reese Wilson Rd FALSE FALSE Empty Lot N/A Allen 207 601 Shady Creek Ct Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 208 1329 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 209 503 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 210 500 Lake Breeze Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 211 105 Lake Mist Dr FALSE FALSE Empty Lot N/A Allen 212 113 Lake Mist Dr Water Treatment System TRUE TRUE Permanent Water Solution AL2001 Appendix B Allen 213 1213 Armstrong Rd FALSE FALSE Existing Municipal Connection Appendix A Allen 214 Armstrong Rd FALSE FALSE Empty Lot N/A Allen 215 1219 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 216 504 Lake Breeze Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 217 327 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 218 109 Lake Mist Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 219 1209 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 220 Egret Ridge FALSE FALSE Empty Lot N/A Allen 221 Wing Point Dr FALSE FALSE Empty Lot N/A Allen 222 9200 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 223 3495 Boat Club Rd FALSE False - BCS N/A - BCS N/A - BCS Allen 224 Reflection Pointe Blvd FALSE FALSE Empty Lot N/A Allen 225 South Point Rd FALSE FALSE Empty Lot N/A Allen 226 106 Old Spring Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 227 1325 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen Allen Allen 228 229 230 956 1341 115 Armstrong Rd Armstrong Rd Southpoint Dr Public Water Supply Public Water Supply FALSE TRUE TRUE FALSE TRUE TRUE Existing Municipal Connection Aqua Customer Permanent Water Solution Appendix A Appendix A Appendix A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 6 of 11 Allen HB630 Summary of Households Facility Allen Orig # 231 Address # Street South Point Rd Option Submittal FALSE HB630 FALSE Empty Lot N/A Allen 232 106 Woodbend Dr Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 233 2311 South Point Rd N/A - BCS TRUE False - BCS N/A - BCS N/A - BCS Allen 234 2657 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 235 South Point Rd FALSE FALSE Empty Lot N/A Allen 236 2621 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 237 2649 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 238 2653 South Point Rd FALSE FALSE Empty Lot N/A Allen 239 2615 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 240 South Point Rd FALSE FALSE Empty Lot N/A Allen 241 Reese Wilson Rd FALSE FALSE Empty Lot N/A Allen 242 2945 South Point Rd FALSE FALSE Existing Municipal Connection Appendix A Allen 243 2323 A South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 244 2935 South Point Rd Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 245 South Point Rd FALSE FALSE Empty Lot N/A Allen 246 2309 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 247 2323 B South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 248 2625 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 249 103 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 250 114 Warren Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 250.1 114 1/2 Warren Drive Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 251 South Point Rd FALSE FALSE Empty Lot N/A Allen 252 305 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 253 201 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 254 2369 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 255 331 Sunderland Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 256 122 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 256 Southpoint Dr TRUE FALSE Empty Lot Appendix E Allen 257 116 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 258 310 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 259 314 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 260 1034 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 261 1113 Sawtooth Oak Ln Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 262 1028 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 263 1103 Sawtooth Oak Ln FALSE FALSE Empty Lot N/A Allen 264 1109 Sawtooth Oak Ln FALSE FALSE Empty Lot N/A Allen 265 1037 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 266 1112 Sawtooth Oak Ln FALSE FALSE Empty Lot N/A Allen 267 1025 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 268 815 Bell Post Rd Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 268 261 Reese Wilson Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 269 2095 South Point Rd FALSE FALSE Empty Lot N/A Allen Allen 270 271 1015 1108 Nutall Oak Ln Sawtooth Oak Ln Public Water Supply FALSE TRUE FALSE TRUE Empty Lot Permanent Water Solution N/A Appendix A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 7 of 11 Allen HB630 Summary of Households Facility Allen Orig # 272 Address # 1101 Street Sawtooth Oak Ln Option Submittal FALSE HB630 FALSE Empty Lot N/A Allen 273 South Point Rd FALSE FALSE Empty Lot N/A Allen 274 125 Lake Mist Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 275 1002 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 276 1010 Nutall Oak Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 277 7012 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 278 7008 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 279 1350 Armstrong Rd FALSE FALSE Empty Lot N/A Allen 280 1354 Armstrong Rd Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 281 2624 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 281 South Point Rd TRUE FALSE Empty Lot Appendix E Allen 282 253 Plant Allen Rd FALSE False - BCS N/A - BCS N/A - BCS Allen 283 1029 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 284 7009 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 285 816 Ardent Trail FALSE FALSE Empty Lot N/A Allen 286 9019 Wing Point Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 287 OFF Armstrong Rd FALSE FALSE Empty Lot N/A Allen 288 101 Daybreak Ln FALSE FALSE Empty Lot N/A Allen 289 503 American Bittersweet Ln FALSE FALSE Empty Lot N/A Allen 290 1100 Sawtooth Oak Ln FALSE FALSE Empty Lot N/A Allen 291 1111 Sawtooth Oak Ln FALSE FALSE Empty Lot N/A Allen 292 7021 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 293 7013 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 294 7016 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 295 1104 Sawtooth Oak Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 296 632 Ardent Trail FALSE FALSE Empty Lot N/A Allen 297 105 Daybreak Ln FALSE FALSE Empty Lot N/A Allen 298 505 American Bittersweet Ln FALSE FALSE Empty Lot N/A Allen 299 119 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 300 106 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 301 1024 Nutall Oak Ln Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 302 1033 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 303 123 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 304 101 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 305 7001 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 306 220 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 307 232 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 308 808 Ardent Trail FALSE FALSE Empty Lot N/A Allen 309 9209 Egret Ridge Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 310 2734 South Point Rd FALSE FALSE Empty Lot N/A Allen 311 236 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 312 Cromlish Crossing FALSE FALSE Empty Lot N/A Allen Allen 313 314 109 7004 Daybreak Ln Highland Way Public Water Supply FALSE TRUE FALSE TRUE Empty Lot Aqua Customer N/A Appendix A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 8 of 11 Allen HB630 Summary of Households Facility Allen Orig # 315 Address # 1358 Street Armstrong Rd Option Submittal FALSE HB630 FALSE Empty Lot N/A Allen 316 2618 South Point Rd Water Treatment System TRUE TRUE Permanent Water Solution AL2012 Appendix B Allen 316 2622 South Point Rd Water Treatment System TRUE TRUE Permanent Water Solution AL2013 Appendix B Allen 316 South Point Rd TRUE FALSE Empty Lot Appendix E Allen 317 224 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 318 812 Ardent Trail FALSE FALSE Empty Lot N/A Allen 319 824 Ardent Trail FALSE FALSE Empty Lot N/A Allen 320 828 Ardent Trail FALSE FALSE Empty Lot N/A Allen 321 2425 South Point Rd Public Water Supply FALSE TRUE Permanent Water Solution Appendix A Allen 321 2452 South Point Rd FALSE FALSE Empty Lot N/A Allen 322 102 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 323 2738 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 324 108 Acadian Way FALSE FALSE Empty Lot N/A Allen 325 91 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 326 100 Mitchell St FALSE FALSE Empty Lot N/A Allen 327 97 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 328 200 Mitchell St Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 329 127 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 330 Reese Wilson Rd FALSE FALSE Empty Lot N/A Allen 331 506 Reese Wilson Rd Public Water Supply TRUE TRUE Future Connection Appendix F Allen 332 1205 Armstrong Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 333 CANAL RD FALSE FALSE Empty Lot N/A Allen 334 616 Ardent Trail FALSE FALSE Empty Lot N/A Allen 335 Corner of Hwy 273 and Heather Glen Ln Public Water Supply FALSE FALSE Aqua Well Appendix A Allen 336 1344 Armstrong Rd Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 337 613 Ardent Trail FALSE FALSE Empty Lot N/A Allen 338 605 Shady Creek Ct Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 339 112 Acadian Way FALSE FALSE Empty Lot N/A Allen 340 501 American Bittersweet Ln FALSE FALSE Empty Lot N/A Allen 341 717 Ardent Trail FALSE FALSE Empty Lot N/A Allen 342 624 Ardent Trail FALSE FALSE Empty Lot N/A Allen 343 Armstrong Rd FALSE FALSE Empty Lot N/A Allen 344 100 Acadian Way FALSE FALSE Empty Lot N/A Allen 345 Daybreak Ln FALSE FALSE Empty Lot N/A Allen 346 713 Ardent Trail FALSE FALSE Empty Lot N/A Allen 347 721 Ardent Trail FALSE FALSE Empty Lot N/A Allen 348 Armstrong Rd FALSE FALSE Empty Lot N/A Allen 349 712 Ardent Trail FALSE FALSE Empty Lot N/A Allen 350 820 Ardent Trail FALSE FALSE Empty Lot N/A Allen 351 701 Ardent Trail FALSE FALSE Empty Lot N/A Allen 352 608 Ardent Trail FALSE FALSE Empty Lot N/A Allen 353 604 Ardent Trail FALSE FALSE Empty Lot N/A Allen Allen 354 355 7029 633 Highland Way Ardent Trail Public Water Supply TRUE FALSE TRUE FALSE Aqua Customer Empty Lot Appendix A N/A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 9 of 11 Allen HB630 Summary of Households Facility Allen Allen Allen Orig # 356 357 358 Address # 800 804 Street Ardent Trail Ardent Trail Ardent Trail Option Submittal FALSE FALSE FALSE HB630 FALSE FALSE FALSE Empty Lot Empty Lot Empty Lot N/A N/A N/A Allen 359 625 Ardent Trail FALSE FALSE Empty Lot N/A Allen 360 621 Ardent Trail FALSE FALSE Empty Lot N/A Allen 361 Lake Mist Dr FALSE FALSE Empty Lot N/A Allen 362 7000 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 363 7028 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 364 1338 Armstrong Rd FALSE FALSE Empty Lot N/A Allen 365 628 Ardent Trail FALSE FALSE Empty Lot N/A Allen 366 708 Ardent Trail FALSE FALSE Empty Lot N/A Allen 367 509 Littleton Ln FALSE FALSE Empty Lot N/A Allen 368 709 Ardent Trail FALSE FALSE Empty Lot N/A Allen 369 608 Shady Creek Ct Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 370 221 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 371 629 Ardent Trail FALSE FALSE Empty Lot N/A Allen 372 620 Ardent Trail FALSE FALSE Empty Lot N/A Allen 373 609 Ardent Trail FALSE FALSE Empty Lot N/A Allen 374 240 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 375 7025 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 376 607 Shady Creek Ct FALSE FALSE Existing Municipal Connection Appendix A Allen 377 700 Ardent Trail FALSE FALSE Empty Lot N/A Allen 378 Ardent Trail FALSE FALSE Empty Lot N/A Allen 379 705 Ardent Trail FALSE FALSE Empty Lot N/A Allen 380 617 Ardent Trail FALSE FALSE Empty Lot N/A Allen 381 Bell Post Dr FALSE FALSE Empty Lot N/A Allen 382 2639 South Point Rd Opt Out - NR TRUE TRUE Opt Out - No Response Appendix D Allen 383 110 Southpoint Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 384 111 Warren Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 385 Sunderland Rd FALSE FALSE Empty Lot N/A Allen 386 1001 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 387 1107 Sawtooth Oak Ln FALSE FALSE Empty Lot N/A Allen 388 131 Lake Mist Dr Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 389 1038 Nutall Oak Ln FALSE FALSE Empty Lot N/A Allen 390 2730 South Point Rd Public Water Supply TRUE TRUE Permanent Water Solution Appendix A Allen 391 7005 Highland Way Public Water Supply TRUE TRUE Aqua Customer Appendix A Allen 392 104 Acadian Way FALSE FALSE Empty Lot N/A Allen 393 98 Mitchell St FALSE FALSE Empty Lot N/A Allen 394 113 Daybreak Ln FALSE FALSE Empty Lot N/A Allen 395 704 Ardent Trail FALSE FALSE Empty Lot N/A Allen 396 505 Littleton Ln FALSE FALSE Empty Lot N/A Allen 397 612 Ardent Trail FALSE FALSE Empty Lot N/A Allen Allen 398 399 7020 Highland Way South Point Rd Public Water Supply TRUE FALSE TRUE FALSE Aqua Customer Empty Lot Appendix A N/A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 10 of 11 Allen HB630 Summary of Households Facility Allen Allen Allen Allen Allen Allen Allen Orig # 400 401 402 403 404 405 406 Address # 165 508 112 520 2608 Street Morgans Branch Rd Ardent Trail Serenade Ct Ardent Trail Serenade Ct South Point Rd Ardent Trail Option Submittal FALSE FALSE FALSE FALSE FALSE FALSE FALSE HB630 FALSE FALSE FALSE FALSE FALSE FALSE FALSE Empty Lot Empty Lot Empty Lot Empty Lot Empty Lot Empty Lot Empty Lot N/A N/A N/A N/A N/A N/A N/A Allen 407 525 Ardent Trail FALSE FALSE Empty Lot N/A Allen 408 Ardent Trail FALSE FALSE Empty Lot N/A Allen 409 164 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 410 213 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 411 169 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 412 516 Ardent Trail FALSE FALSE Empty Lot N/A Allen 413 512 Ardent Trail FALSE FALSE Empty Lot N/A Allen 414 517 Ardent Trail FALSE FALSE Empty Lot N/A Allen 415 505 Ardent Trail FALSE FALSE Empty Lot N/A Allen 416 168 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 417 104 Serenade Ct FALSE FALSE Empty Lot N/A Allen 418 108 Serenade Ct FALSE FALSE Empty Lot N/A Allen 419 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 420 200 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 421 217 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 422 212 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 423 208 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 424 209 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 425 201 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 426 173 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 427 521 Ardent Trail FALSE FALSE Empty Lot N/A Allen 428 509 Ardent Trail FALSE FALSE Empty Lot N/A Allen 429 100 Serenade Ct FALSE FALSE Empty Lot N/A Allen 430 105 Serenade Ct FALSE FALSE Empty Lot N/A Allen 431 109 Serenade Ct FALSE FALSE Empty Lot N/A Allen 432 Cromlish Crossing FALSE FALSE Empty Lot N/A Allen 433 216 Morgans Branch Rd FALSE FALSE Empty Lot N/A Allen 434 513 Ardent Trail FALSE FALSE Empty Lot N/A N/A - BCS: Not applicable, Buseiness, Church and/or School (outside H13630) WTS ID: Water Treatment System ID Page 11 of 11 Appendix A: Confirmation of Connection from Public Water Supplier (� DUKE ENERGY. July 18, 2018 Adrian Miller City of Belmont 37 North Main Street Belmont, NC 28012 Subject: North Carolina House Bill 630 Dear Mr. Miller: 526 South Church Street Charlotte, NC 28202 Mailing Address. Mail Code EC12J/ P.O. Box 1006 Charlotte, NC 28201.1006 704.382.8768 704,907.8628 Duke Energy appreciates the assistance you and your team have provided to us as we have been working to fulfill the obligations under North Carolina House Bill 630 amendments to the Coal Ash Management Act (CAMA), which requires Duke Energy to provide a permanent water solution to eligible households located within a half -mile of our coal ash impoundments. On July 3, 2018 the North Carolina Department of Environmental Quality informed Duke Energy that the agency will require a signed statement from the local public water suppliers that Duke Energy has connected households to the local public water supply system in 2017 and 2018. They also requested a signed statement that the households identified as connected to the water system prior to the CAMA amendments bill were, in fact, connected to your system. A copy of the letter has been attached. Therefore, Duke Energy respectfully requests a letter on City of Belmont stationery confirming that the following households are currently connected to your water system, or have had a connection in the past that has been disconnected for any reason (i.e., renovations, moving, delinquent payment). A separate request will be sent to you once Duke Energy has finished connecting the remaining eligible households to the public water system. If any of these households does not currently have an account with you, or has not had an account with you in the past, please let us know so that we can reach out to these homeowners and offer a connection. Duke Energy appreciates your anticipated cooperation. If there is anything Duke Energy can do to help expedite the review of the addresses below, please let us know as soon as possible. To keep this state -mandated project on schedule, it is important to have a response within two weeks (August 1, 2018). I can be reached at 704-382-8768 or via email at Jessica.Bednarcik@duke-eneroy.com if you have any questions or if you would like to discuss this issue in more detail. Sincerely, essi . Bednarcik Duke Energy cc: Martha Thompson, Duke Energy District Manager Andrew Shull, Duke Energy EHS Project Manager Jerry Hatton, City of Belmont Elizabeth Bell, City of Belmont Encl: July 3, 2018 letter from NCDEQ, Sheila Holman Addresses requesting confirmation of connection: 956 Armstrong Rd 1205 Armstrong Rd 1209 Armstrong Rd 1213 Armstrong Rd 1219 Armstrong Rd 1303 Armstrong Rd 1307 Armstrong Rd 1313 Armstrong Rd 1317 Armstrong Rd 1319 Armstrong Rd 1325 Armstrong Rd 1329 Armstrong Rd 812 Bell Post Rd 815 Bell Post Rd 816 Bell Post Rd 130 Canal Rd 101 Dana Michelle Ct 102 Dana Michelle Ct 103 Dana Michelle Ct 104 Dana Michelle Ct 105 Dana Michelle Ct 106 Dana Michelle Ct 107 Dana Michelle Ct 108 Dana Michelle Ct 9200 Egret Ridge 9201 Egret Ridge 9205 Egret Ridge 9209 Egret Ridge 9217 Egret Ridge 9220 Egret Ridge 9221 Egret Ridge 9224 Egret Ridge 9225 Egret Ridge 9235 Egret Ridge 9236 Egret Ridge 115 Idlewood Ln 116 Idlewood Ln 117 Idlewood Ln 118 Idlewood Ln 119 Idlewood Ln 619 Kenneth Wilson Ln 629 Kenneth Wilson Ln 630 Kenneth Wilson Ln 500 Lake Breeze Ln 504 Lake Breeze Ln 109 Lake Mist Dr 125 Lake Mist Dr 131 ^^ Lake Mist Dr 203 Michael Dominick Dr 204 Michael Dominick Dr 205 Michael Dominick Dr 206 Michael Dominick Dr 209 Michael Dominick Dr 210 Michael Dominick Dr 212 Michael Dominick Dr 120 Midwood Ln 121 Midwood Ln 122 Midwood Ln 123 Midwood Ln 124 125 Midwood Ln Midwood Ln 126 Midwood Ln 127 Midwood Ln 129 Midwood Ln 130 Midwood Ln 131 Midwood Ln 132 Midwood Ln 133 Midwood Ln 134 Midwood Ln 135 Midwood Ln 91 Mitchell St 97 Mitchell St 101 Mitchell St 102 Mitchell St 103 Mitchell St 106 Mitchell St 109 Mitchell St 200 Mitchell St 201 Mitchell St 301 Mitchell St 305 Mitchell St 310 Mitchell St 314 Mitchell St 318 Mitchell St 1006 Nutall Oak Ln 1010 Nutall Oak Ln 1024 Nutall Oak Ln 106 Old Spring Rd 184 Reese Wilson Rd 185 Reese Wilson Rd 206 Reese Wilson Rd 210 Reese Wilson Rd 248 Reese Wilson Rd 252 Reese Wilson Rd 254 Reese Wilson Rd 261 Reese Wilson Rd 313 Reese Wilson Rd 317 Reese Wilson Rd 319 Reese Wilson Rd 321 Reese Wilson Rd 323 Reese Wilson Rd 325 Reese Wilson Rd 327 Reese Wilson Rd 329 Reese Wilson Rd 402 Reese Wilson Rd 406 Reese Wilson Rd 503 Reese Wilson Rd 519 Reese Wilson Rd 105 Reese Wilson Rd Ext 109 Reese Wilson Rd Ext 112 Reese Wilson Rd Ext 128 Reese Wilson Rd Ext 1281/2 Reese Wilson Rd Ext 1104 Sawtooth Oak Ln 1108 Sawtooth Oak Ln 1113 Sawtooth Oak Ln 601 Shady Creek Ct 605 Shady Creek Ct 607 Shady Creek Ct 608 Shady Creek Ct 9100 Shorewood PI 9104 Shorewood PI 9105 Shorewood PI 9111 Shorewood PI 2072 South Point Rd 2076 South Point Rd 2080 South Point Rd 2084 South Point Rd 2092 South Point Rd 2096 South Point Rd 2098 South Point Rd 2309 South Point Rd 2320 South Point Rd 2340 South Point Rd 2343 South Point Rd 2347 South Point Rd 2351 South Point Rd 2352 South Point Rd 2359 South Point Rd 2360 South Point Rd 2369 South Point Rd 2401 South Point Rd 2402 South Point Rd 2407 South Point Rd 2411 South Point Rd 2425 South Point Rd 2501 South Point Rd 2505 South Point Rd 2509 South Point Rd 2513 South Point Rd 2519 South Point Rd 2615 South Point Rd 2621 South Point Rd 2624 South Point Rd 2625 South Point Rd 2649 South Point Rd 2657 South Point Rd 2703 South Point Rd 2714 South Point Rd 2719 South Point Rd 2723 South Point Rd 2726 South Point Rd 2730 South Point Rd 2738 South Point Rd 2744 South Point Rd 2935 South Point Rd 2945 South Point Rd 2323 A South Point Rd 2323 B South Point Rd 2708 South Point Rd (home) 2708 South Point Rd (office) 110 Southpoint Dr 111 Southpoint Dr 115 Southpoint Dr 116 Southpoint Dr 119 Southpoint Dr 122 Southpoint Dr 123 Southpoint Dr 125 Southpoint Dr 127 Southpoint Dr 135 Southpoint Dr 331 Sunderland Rd 111 Warren Dr 114 Warren Dr 114 1/2 Warren Drive 106 Wildlife Rd 107 Wildlife Rd 108 Wildlife Rd 109 Wildlife Rd 110 Wildlife Rd 111 Wildlife Rd 112 Wildlife Rd 113 Wildlife Rd 114 Wildlife Rd 9015 Wing Point Dr 9019 Wing Point Dr 9022 Wing Point Dr 9034 Wing Point Dr Aqua Heather Glen Corner of South Point Rd and Armstrong Rd Aqua South Point Landing Corner of South Point Rd and Woodbend Environmental Quality July 3, 2018 Paul Draovitch Senior Vice President Environmental, Health & Safety Duke Energy 526 South Church Street Mail Code EC3XP Charlotte, North Carolina 28202 ROY COOPER Loverr" MICHAEL S. REGAN Secretory Subject: Completion of Permanent Alternate Water Supply Requirements Under General Statute 130A-309.211(c1) Dear Mr. Draovitch: On May 31 and June 8, 2018, the North Carolina Department of Environmental Quality (DEQ) received letters for Cape Fear Steam Electric Plant and H. F. Lee Energy Complex, respectively. In both letters, Duke Energy requested that DEQ confirm that the provisions for permanent alternate water supply has been met for the subject facilities. For DEQ to provide confirmation of completion of G.S. 130A-309.21 I (cl), the following information must be provided for each facility: • A complete list of all eligible households as defined in 130A-309.211 (cl). • For each eligible household, provide the requested information below: 1. Households that selected public water suppi : A signed statement from the public water supplier that the households have been connected and are receiving public water. 2. Households that selected whole -house filtration systems: A signed statement from the filtration system vendor that the filtration system was installed and the household is receiving filtered water. 3. Households that opted out: A copy of the returned selection card from the household. 4. Non-res onsive households: A statement of the timeline of events and submittals that were received/not received (reference DEQ's May 8, 2018 letter to Duke Energy). • For each household within the one-half mile radius from the established compliance boundary of a coal combustion residuals impoundment, but that was already connected to public water; please provide a signed statement from the public water supplier that the household is connected and receiving public water. -::�-"Nothing Compares--%-, State ol'North Carolina i Environmental Quality 217 West Jones Street 11601 Mail Service Center I Raleigh. North Carolina 27699•i6O1 919 707 8600 Please provide the requested documentation in one complete package to DEQ for each facility. Additionally, please note that since many of the Duke Energy facilities are still in the process of submitting or finalizing Comprehensive Site Assessments and Corrective Action Plans and the results of groundwater modeling have not yet been received, DEQ reserves the right to request additional households be provided permanent alternate water solutions per G.S. 130A-309.211(cl ) based on any new information provided. If you have any questions, please feel free to contact me or Debra Watts at (919) 807-6338. Sincerely, 77 Sheila Holman Assistant Secretary for Environment cc: Jessica Bednarcik, Duke Energy, 526 South Church Street, Mail Code EC12J, Charlotte, NC 28202 -_'/'Nothing Compares_,.... State of North Carolina Environmental Quality 217 Wcst Joncs Street 11601 Mall Smfce Center l Raleigh North Carolina 27699-lb01 919 707 8600 From: Elizabeth Bell To: Bednarcik. Jessica L Subject: RE: Request from DEQ Date: Tuesday, July 31, 2018 8:38:21 AM Attachments: imaoe010.ana image011.o_na ima eg 012.pno imaae013.ona Yes they have been connected. Elizabeth Bell Finance Assistant, City of Belmont A 115 N Main Street, Belmont, NC 28012 M PO Box 431, Belmont, NC 28012 D 704-901-2060 O 704-825-5586 F 704-825-0514 E ebelIO)cityofbelmont.orci W +www.cityofbelmont.arq f 1 0 1 ® t• From: Bednarcik, Jessica L <Jessica.Bednarcik@duke-energy.com> Sent: Tuesday, July 31, 2018 8:01 AM To: Elizabeth Bell <ebell@cityofbelmont.org> Subject: RE: Request from DEQ Elizabeth, As mentioned a few weeks ago, I am now following up for confirmation that the last three connection have, in fact, been connected per your records. I was told by our contractor that we finished these homes last week. 2656 South Point Road 2700 South Point Road 2658 South Point Road Thank you for your help, Jessica From: Elizabeth Bell [mailto:ebell(a cityofbelmont.org] Sent: Thursday, July 19, 2018 8:27 AM To: Bednarcik, Jessica L Subject: RE: Request from DEQ Yes 2718 is connected. Elizabeth Bell Finance Assistant, City of Belmont A 115 N Main Street, Belmont, NC 28012 M PO Box 431, Belmont, INC 28012 D 704-901-2060 O 704-825-5586 F 704-825-0514 E ebell(&cityofbelmont.org W www.cityotbelmont.ora UUMS From: Bednarcik, Jessica L <Jessica. Bednarcik(@duke-energy.com> Sent: Thursday, July 19, 2018 7:17 AM To: Elizabeth Bell <ebelll@cityofbelmont.org> Subject: RE: Request from DEQ Elizabeth, 2714 South Point Road should have been 2718 South Point Road. I went through my notes and saw that the owner owns both parcel, but 2714 is an empty lot. Do you have an account for 2718 South Point Road? Thanks, Jessica From: Elizabeth Bell[maiIto: ebell(cbcityofbelmont.org] Sent: Wednesday, July 18, 2018 4:43 PM To: Bednarcik, Jessica L Subject: RE: Request from DEQ *** Exercise caution. This is an EXTERNAL email. DO NOT open attachments or click links from unknown senders or unexpected email. *** Hey Jessica, all of the addresses on the list have been connected except one. 2714 South Point rd. I don't see it anywhere that it was getting tapped on? Elizabeth Bell Finance Assistant, City of Belmont A 115 N Main Street, Belmont, NC 28012 M PO Box 431, Belmont, INC 28012 D 704-901-2060 O 704-825-5586 F 704-825-0514 E ebell@cityofbelmont.orq W ram. cityotbelmont.ora UUMNmor From: Bednarcik, Jessica L <Jessica. Bed narciU@duke-energy.com> Sent: Wednesday, July 18, 2018 1:55 PM To: Thompson, Martha W <Martha ThompsonCci)duke-energy com>; Adrian Miller <AMillerC@cityofbelmont.org>; Jerry Hatton <JHatton (@cityofbelmont.org> Cc: Elizabeth Bell <ebell(@cityofbelmont.org>; Shull, Andrew Wayne <Andrew.ShullPduke- energy.com> Subject: RE: Request from DEQ Adrian, Please see the attached request for confirmation that certain households are connected to the City of Belmont. This request is due to a new requirement received from the NCDEQ. I will send a similar request in the future for the remaining three households (2656, 2658, and 2700 South Point Road) requiring connection. Thank you for your assistance with this matter and please let me know if you have any questions. Also, if an excel spreadsheet with the addresses would be helpful (so you can sort as need to facilitate review), please let me know. Jessica Jessica L Bednarcik, PE, PMP I Duke Energy I EHS 526 South Church St Mail Code EC12J j Charlotte, NC 28202 Office: 704.382.8768 Mobile: 704.907.8628 1 Jessica Bed narcikPduke-energy com From: Thompson, Martha W Sent: Friday, July 13, 2018 11:04 AM To: Adrian Miller; Jerry Hatton (JHatton(d)cityofbelmont.orq) Cc: Bednarcik, Jessica L Subject: Request from DEQ Hello Adrian and Jerry. As we are finalizing our work surrounding Plant Allen, and across the state, DEQ has asked for confirmation of residents within the half -mile radius being supplied municipal water (or filtration system which we have confirmation). Additionally, those residents that already were connected to the municipal water system need to be confirmed. We have those identified (we believe there are a total of 12 that already had connected). Thank you for your assistance as we take these requested steps to confirm compliance with HB630. Jessica will be communicating the specifics to you. Please let us know if there is any additional information you need. As always, that you for your help. Martha Martha W. Thompson District Manager, Charlotte I Duke Energy 704-395-4355 office 1 704-718-5232 mobile � ENERGY. etc) DUKE � ENERGY® July 18, 2018 Shannon Becker Aqua North Carolina, Inc. 202 MacKenan Court Cary, NC 27511 Subject: North Carolina House Bill 630 Dear Mr. Becker: 526 South Church Street Charlotte, NC 28202 Mailing Address Mail Code EC12J1 P.O. Box 1006 Charlotte. NC 28201-1006 704.382.8768 704.907.8628 Duke Energy appreciates the assistance you and your team have provided to us as we have been working to fulfill the obligations under North Carolina House Bill 630 amendments to the Coal Ash Management Act (LAMA), which requires Duke Energy to provide a permanent water solution to eligible households located within a half -mile of our coal ash impoundments. On July 3, 2018 the North Carolina Department of Environmental Quality informed Duke Energy that the agency will require a signed statement from the local public water suppliers that Duke Energy has connected households to the local public water supply system in 2017 and 2018. A copy of the letter has been attached. While Duke Energy is requesting confirmation from the City of Belmont that the HB630 eligible communities served by Aqua North Carolina have been connected to their system, we would also like confirmation that the following households are currently connected to your distribution system, or have had a connection in the past that has been disconnected for any reason (i.e., renovations, moving, delinquent payment). If any of these households does not currently have an account with you, or has not had an account with you in the past, please let us know. Duke Energy appreciates your anticipated cooperation. If there is anything Duke Energy can do to help expedite the review of the addresses below, please let us know as soon as possible. To keep this state -mandated project on schedule, it is important to have a response within two weeks (August 1, 2018). I can be reached at 704-382-8768 or via email at Jessica.Bednarcik@duke-eneray.com if you have any questions or if you would like to discuss this issue in more detail. Sincerely, Jessica L. Bednarcik Duke Energy cc: Martha Thompson, Duke Energy District Manager Andrew Shull, Duke Energy EHS Project Manager Michael Melton, Aqua North Carolina, Inc. Laurie Ison, Aqua North Carolina, Inc. Encl: July 3, 2018 letter from NCDEQ, Sheila Holman Addresses requesting confirmation of connection: 1341 Armstrong Rd 1344 Armstrong Rd 1351 Armstrong Rd 1354 Armstrong Rd 506 Cadman Ct 507 Cadman Ct 102 Heather Glen Ln 103 Heather Glen Ln 108 Heather Glen Ln 109 Heather Glen Ln 112 Heather Glen Ln 113 _ Heather Glen Ln 200 Heather Glen Ln 203 Heather Glen Ln 204 Heather Glen Ln 208 Heather Glen Ln 209 Heather Glen Ln 214 Heather Glen Ln 217 Heather Glen Ln 219 Heather Glen Ln 303 Heather Glen Ln 304 Heather Glen Ln 307 Heather Glen Ln 308 Heather Glen Ln 401 Heather Glen Ln 403 Heather Glen Ln 407 Heather Glen Ln 408 Heather Glen Ln 411 Heather Glen Ln 606 Highland PI 607 Highland PI 7000 Highland Way 7001 Highland Way 7004 Highland Way 7005 Highland Way 7008 Highland Way 7009 Highland Way 7012 Highland Way 7013 Highland Way 7016 Highland Way 7020 Highland Way 7021 Highland Way 7025 Highland Way 7028 Highland Way 7029 Highland Way 703 John Douglas Ln 706 John Douglas Ln 707 John Douglas Ln 710 John Douglas Ln 711 John Douglas Ln 102 Lake Hill Ct 103 Lake Hill Ct 106 Lake Hill Ct 107 Lake Hill Ct 110 Lake Hill Ct 202 Lake Hill Ct 206 Lake Hill Ct 207 Lake Hill Ct 210 Lake Hill Ct 211 Lake Hill Ct 214 Lake Hill Ct 218 Lake Hill Ct 2650 South Point Rd 103 Woodbend Dr 106 Woodbend Dr 107 Woodbend Dr 110 Woodbend Dr 111 Woodbend Dr 114 Woodbend Dr 115 Woodbend Dr 118 Woodbend Dr 119 Woodbend Dr 122 Woodbend Dr 123 Woodbend Dr 126 Woodbend Dr 127 Woodbend Dr 131 Woodbend Dr 1C;,;. Environmental Quality July 3, 2018 Paul Draovitch Senior Vice President Environmental, Health & Safety Duke Energy 526 South Church Street Mail Code ECAP Charlotte, North Carolina 28202 ROY COOPER Governor MICHAEL S. REGAN Secretary Subject: Completion of Permanent Alternate Water Supply Requirements Under General Statute 130A-309.21 l(cl) Dear Mr. Draovitch: On May 31 and June 8, 2018, the North Carolina Department of Environmental Quality (DEQ) received letters for Cape Fear Steam Electric Plant and H. F. Lee Energy Complex, respectively. In both letters, Duke Energy requested that DEQ confirm that the provisions for permanent alternate water supply has been met for the subject facilities. For DEQ to provide confirmation of completion of G.S. 130A-309.21 l(cl), the following information must be provided for each facility: A complete list of all eligible households as defined in 130A-309.211 (cl ). For each eligible household, provide the requested information below: 1. Households that selected public water supply: A signed statement from the public water supplier that the households have been connected and are receiving public water. 2. Households that selected whole -house filtration systems: A signed statement from the filtration system vendor that the filtration system was installed and the household is receiving filtered water. 3. Households that opted out: A copy household. of the returned selection card from the 4. Non -responsive households: A statement of the timeline of events and submittals that were received/not received (reference DEQ's May 8, 2018 letter to Duke Energy). • For each household within the one-half mile radius from the established compliance boundary of a coal combustion residuals impoundment, but that was already connected to public water; please provide a signed statement from the public water supplier that the household is connected and receiving public water. -5-'�' Nothing Compares, State of North Carolina I Environmental Quality 217 West Jones Street t 1601 Mail Service Center € Raleigh North Carolina 27699.14b01 9t9 707 8600 Please provide the requested documentation in one complete package to DEQ for each facility. Additionally, please note that since many of the Duke Energy facilities are still in the process of submitting or finalizing Comprehensive Site Assessments and Corrective Action Plans and the results of groundwater modeling have not yet been received, DEQ reserves the right to request additional households be provided permanent alternate water solutions per G.S. 130A-309.211(cl) based on any new information provided. If you have any questions, please feel free to contact me or Debra Watts at (919) 807-6338. Sincerely, Sheila Holman Assistant Secretary for Environment cc: Jessica Bednarcik, Duke Energy, 526 South Church Street, Mail Code EC 12J, Charlotte, NC 28202 Nothing Compares--, State or North Carolina Environmental Quality 217 West Jones Street 1 1601 Mail Service Center J Rakfgh. North Carolina 27699-1601 919 707 8600 From: Ison, Laurie T. To: Bednarcik, Jessica L Cc: Becker, Shannon V.; martha.thompsonCalsuke-eneroy.com; Shull. Andrew Wayne; Melton. Michael A. Subject: FW: Duke Energy Belmont Connections - Request from NCDEQ Date: Thursday, July 19, 2018 2:43:50 PM Attachments: image001.Dna image002.Dna image003.pna image004.pna *** Exercise caution. This is an EXTERNAL email. DO NOT open attachments or click links from unknown senders or unexpected email. *** Jessica, There were three addresses missing from the list. These include: 1338 Armstrong Rd 1350 Armstrong Rd 1358 Armstrong Rd These properties were just recently connected which is most likely why they were not captured on yours. Please let us know if you need anything else. T 11.2 Mi. Laurie Ison Area Manager Aqua NC 0: 704.489.9404 Avaya Ext: 57234 M:704.507.5381 coo From: Bednarcik, Jessica L [mailto:Jessica.Bednarcik(@duke-energy.com] Sent: Wednesday, July 18, 2018 2:02 PM To: Becker, Shannon V. <SVBecker(@aquaamerica.com> Cc: Thompson, Martha W <Martha.Thomason(@duke-energy.com>; Shull, Andrew Wayne <Andrew.Shullt@duke-energy.com>; Melton, Michael A. <MAMeltonl@aquaamerica.com>; Ison, Laurie T. <LTIson(@aquaamerica.com> Subject: Duke Energy Belmont Connections - Request from NCDEQ Shannon, Two weeks ago, NCDEQ provided a new requirement to Duke Energy for the connections being made under the Coal Ash Management Act. Please see the attached request for confirmation of the homes being served by Aqua North Carolina by the Southpoint Landing distribution system and the Heather Glen distribution system in Belmont, NC. Thank you for your assistance with this matter and please let me know if you have any questions. Jessica Jessica L Bednarcik, PE, PMP I Duke Energy I EHS 526 South Church St Mail Code EC12J I Charlotte, NC 28202 Office: 704.382.8768 Mobile: 704.907.8628 1 Jessica.Bednarcik(@duke-energy.com Appendix B: Confirmation of Installation of Water Treatment System �•� DUKE ENERGY, July 17, 2018 Drew Kiser P.O. Box 570 Blountville, TN 37617 Subject: North Carolina House Bill 630 Dear Mr, Kiser: 526 South Church Street Charlotte, NC 28202 Mailing Address: Mail Code EC 12J/ P O Box 1006 Charlotte, NC 28201-1006 704.382 8768 704 907 8628 Duke Energy appreciates the assistance you and your team have provided to us as we have been working to fulfill the obligations under North Carolina House Bill 630 amendments to the Coal Ash Management Act (CAMA), which requires Duke Energy to provide a permanent water solution to eligible households located within a half -mile of our coal ash impoundments. On July 3, 2018 the North Carolina Department of Environmental Quality informed Duke Energy that for households receiving water filtration systems in 2017 and 2018, the agency will require a signed statement from the filtration system vendor that the filtration system was installed and the household is receiving filtered water. A copy of the letter has been attached. Therefore, Duke Energy respectfully requests a letter on Water Professionals stationery confirming that the following households are receiving filtered water from an installed water filtration system near Duke Energy's Allen Steam Station in Belmont NC. If any of these households are not currently receiving filtered water from an installed filtration system, please let us know so that we can reach out to these homeowners and offer a treatment solution. Duke Energy appreciates your anticipated cooperation. If there is anything Duke Energy can do to help expedite the review of the addresses below, please let us know as soon as possible. To keep this state -mandated project on schedule, it is important to have a response within two weeks (July 31, 2018). can be reached at 704-382-8768 or via email at Jessica.Bednarcik@duke-energy.com If you have any questions or if you would like to discuss this issue in more detail. Sincere! Ussica L. Bednarcik Duke Energy cc: Martha Thompson, Duke Energy District Manager Tim Hunsucker, Duke Energy EHS Project Manager Encl: July 3, 2018 letter from NCDEQ, Sheila Holman Label Number Duke Well ID Loc Address 100 AL2000 9239 Egret Ridge Belmont, NC 28012 212 AL2001 113 Lake Mist Dr Belmont, NC 28012 28 AL2003 128 Midwood Ln Belmont, NC 28012 103 AL2005 216 Reese Wilson Rd Belmont, NC 28012 39 AL2006 320 Reese Wilson Rd Belmont, NC 28012 39 AL2007 324 Reese Wilson Rd Belmont, NC 28012 149 AL2008 400 Reese Wilson Rd Belmont, NC 28012 48 AL2010 131 Southpoint Dr Belmont, NC 28012 316 AL2012 2618 South Point Rd Belmont, NC 28012 316 AL2013 2622 South Point Rd Belmont, NC 28012 Environmental Quality July 3, 2018 Paul Draovitch Senior Vice President Environmental, Health & Safety Duke Energy 526 South Church Street Mail Code EC3XP Charlotte, North Carolina 28202 ROY COOPER Covemof MICHAEL S. REGAN Secretary Subject: Completion of Permanent Alternate Water Supply Requirements Under General Statute 130A-309.211(el) Dear Mr. Draovitch: On May 31 and June 8, 2018, the North Carolina Department of Environmental Quality (DEQ) received letters for Cape Fear Steam Electric Plant and H. F. Lee Energy Complex, respectively. In both letters, Duke Energy requested that DEQ confirm that the provisions for permanent alternate water supply has been met for the subject facilities. For DEQ to provide confirmation of completion of G.S. 130A-309.211(cl), the following information must be provided for each facility: • A complete list of all eligible households as defined in 130A-309.211 (cl). • For each eligible household, provide the requested information below: l . Households that selected public water supply: A signed statement from the public water supplier that the households have been connected and are receiving public water. 2. Households that selected whole -house filtrations stems; A signed statement from the filtration system vendor that the filtration system was installed and the household is receiving filtered water. 3. Households that opted out: A copy of the returned selection card from the household. 4. Non -responsive households: A statement of the timeline of events and submittals that were received/not received (reference DEQ's May 8, 2018 letter to Duke Energy). For each household within the one-half mile radius from the established compliance boundary of a coal combustion residuals impoundment, but that was already connected to public water; please provide a signed statement from the public water supplier that the household is connected and receiving public water. Nothing Compares,.... State of North Carolina I E.nvironmentalQuAty 217 West Jones Street 11601 Mail Service Center I Raleigh North Carolina 27699-1601 919 707 8600 Please provide the requested documentation in one complete package to DEQ for each facility. Additionally, please note that since many of the Duke Energy facilities are still in the process of submitting or finalizing Comprehensive Site Assessments and Corrective Action Plans and the results of groundwater modeling have not yet been received, DEQ reserves the right to request additional households be provided permanent alternate water solutions per G.S. 130A-309.211(c 1) based on any new information provided. If you have any questions, please feel free to contact me or Debra Watts at (919) 807-6338. Sincerely, Sheila Holman Assistant Secretary for Environment cc: Jessica Bednarcik, Duke Energy, 526 South Church Street, Mail Code EC12J, Charlotte, NC 28202 �"-'Nothing Compares—,-, State of North Carolina EnWronmental Quality 217 West Jones Street 11601 Mall Service Center I Raleigh, North Carolina 27699-1601 914 707 8600 0,0 U101GIPr GS310001L Culligan of Tri-Cities PO Box 570 Blountville, TN 37617 423-323-4195 800-999-4195 Ms. Bednarcik, In response to your letter dated July 17, 2018 concerning North Carolina House Bill 630, WaterProfessionals is pleased to confirm that the following locations have a filtration installed and the household is receiving filtered water. Label Number Duke Well ID Loc Address 100 AL2000 9239 Egret Ridge Belmont, NC 28012 212 AL2001 113 Lake Mist Dr Belmont, NC 28012 28 AL2003 128 Midwood Ln Belmont, NC 28012 103 AL2005 216 Reese Wilson Rd Belmont, NC 28012 39 AL2006 320 Reese Wilson Rd Belmont, NC 28012 39 AL2007 324 Reese Wilson Rd Belmont, NC 28012 149 AL2008 400 Reese Wilson Rd Belmont, NC 28012 48 AL2010 131 Southpoint Dr Belmont, NC 28012 316 AL2012 2618 South Point Rd Belmont, NC 28012 316 AL2013 2622 South Point Rd Belmont, NC 28012 If you need any additional information, please let me know. Drew Kiser Area Manger Dm�, K-,.-- Appendix C: Opt Out Selection Cards Ol [G O c i I I I fQ =_ C33 ti //• ai T-J CG O o 3 c� I *- o a> N o o I O �i I oW t� cj V' ❑ y a co o �_ �1 1 O CD O ,- T- to Appendix D: Timeline of Events for Non -Responsive Households ID# 131 2639 South Point Rd, Belmont, NC 28012 December 2016: Letter sent to homeowner informing them of Duke Energy's submittal of plans to NCDEQ. January 2017: Letter sent with selection card and invitation to community information meeting. March 2017: Selection card resent via certified mail, due to no response. • Returned to Duke Energy. April 2017: Owner name and contact address updated based upon new info in the county GIS database. • Resent information from January 2017 via certified mail. • Returned marked "Unclaimed/Being Returned to Sender." July 2017: Letter sent via certified mail with selection card and requesting response. • Returned marked "Moved, Left no Address." • Resent via UPS, requiring signature. • Received confirmation of delivery. September 2017: Duke Energy hired a vendor to go door to door due to no response from homeowner. No one answered the door. A door hanger with information was left on the door, with a picture taken to show that information was left. November 2017: Letter was sent via certified mail with selection card and requesting response. • Returned to Duke Energy. • Resent via UPS, requiring signature. • Returned to Duke Energy marked "Not in on 3`d Attempt." February 2018: Letter with deadline sent via certified mail. • Returned to Duke Energy marked "Returned — Left no Address." • Resent via UPS. • Received confirmation of delivery. February 2018: Sent letter to the tenant of this address letting them know that multiple attempts had been made to obtain a solution selection from the property owner and if a response was not received by May 1, 2018, bottled water delivery would be terminated. Appendix E: Properties / Connections HB630 Eligible Originally But Later Determined Not to be Eligible (Does not include Businesses, Churches, Schools) M H H 0cq M H H O M O N N OD Oo"H 11 O 111 Nrr W r a w 144 H M Ln In 04 w 0 x CAO O O N 01 r-I r-I O OM 00 NN N 0000d HH 00 H colnNrr N r lD <M -W rn 0H M1nui F H Q O U] 00 p O o Hr 0 zH a H OD m O�O ra u,0� mA �>4 X G)0M a Q U) Q N off a LOQ1nrr)Ln HaOp: W OZ CqM �LMPP4 a 0 r r-I G. 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O M Ho UI q zr w o 1n O a W Nx wwwpx a^Y In �,�� \0 E1 U) I q I�� 0 Ln >W+ u Ln ci) W Gq1 xrn°OmZmAF°W 04 � 0 m[QLf wm HaOR: W I a !ZIMNMIIXMPN a I U 0 Nv 0 r-Ir-i G 04 Q 0 w I O RCc,4 EH O EA oz0H ~r)M F� O\irH a �C ]C O N I w A w u Pq Ea w4Z IWgaWp CAP 0 P4 Ho 114,100 Ix I \-M000 aHU) F I wa `n UN �arHi�m OOIDQU 1 W4E.E,0441W 31- 1Zi00£r,: EFQ W u)i ar-I amaWU)xrl H a4W W MNU) H PQ 10 I r-4 WNM0FCC pDQZ n I In' 0o4in F �-I Ln In 4-% ri q mmpq • 9 I I H H x N >+ 1n o POA H W14a-) W > w U) \ W 4-1 Cl) I � N-1 OOlwIZrN U41 H W A; H 0 O IQ [x4 I 1xr�Om •N t aN a)) � I uxE-,u (a r0OFINoQo b4 r-I 0 a) Z W 040 N F o rZ, om az toM U I N H w zr-4Hm a I arum q I >+WNPg0 HF I va)wa\ m Ea ••WWI q� S•I C7 C7 a' \ I U a) FC W I m F 0o a W m o a C4 W i O o .. �� 0 0 U 0 N rtl z q -rt v F I z O ii Si z I >� u] \ U U)'d O I W a owz°Q N o a) a H 1-) M '!y -r1 U I p, Ln rroi- NH O �a 0 z FF H E rx W a F a x W F z uw a 0 u O0000 Uoo00 \oH H r-IEl ri Ca qhq x O FC W F M OD OOm x aaDcc) u) H aN H o a x ow N H q W U awwW0 ow u 0 a H U a \� a a F a qq OD rW� r� o rx H 000o q 0000 FLnLOUnLl a UODOODL- a hq 14 PS X 1Y4 Faaaw oC nxzzx 4F pg000In >. 1n u) u) r a: Wmmmm w H H H H aq 0000 000o a U)d�4 v'00 F 00 OD OD OD cn H M M M N W O f� Lr)� a N M a+ •• F xCVNsN U]OI m m N W � xxx uz U N N N a HHHH gUIU)N FW 055E on ��N PO wwww \ rr�� \000 \\ qz 04 W UWC C aE cn0lartro WNUINW Q�naaa W W 0v�1`rlr- O U O M M m N O O O O 0 gmoriN ariNNN z=m cn a a z H O a 0 O U] 00 r-i IO N 0 fn Ln O N Appendix F: Future Connection Letters to Homeowners DUKE ENERGY, John & Beverly Goins PO Box 427 Belmont, NC 28012 Dear Mr. & Mrs. Goins, June 25, 2018 Duke Energy would like to provide you an update on the connection of your property located at 506 Reese Wilson Road (Parcel 217833) in Belmont, NC to the municipal water supply provided by the City of Belmont. In a May 8, 2018 letter to Duke Energy, the North Carolina Department of Environmental Quality provided guidance regarding your well eligible property, where a connection cannot currently be completed due to the demolition of the eligible household after the date of the state law. As there currently is no household existing on your well eligible property, the State has advised Duke Energy that it does not need to complete the connection to your property within the deadline mandated by state law. Should you reconstruct your home in the future on this well eligible property and still desire a connection, you must contact us promptly to make arrangements for the connection. We can be reached at 800.653.5304 or WaterDelivery@duke-energy.com. Thank you, Duke Energy Permanent Water Supply Project Team ROY COOPER Governor MICHAEL S. REGAN Secretary Paul Draovitch Senior Vice President Environmental, Health & Safety Duke Energy 526 South Church Street Mail Code EC3XP Charlotte, North Carolina 28202 NORTH CAROLINA Environmental Quality October 12, 2018 Subject: Completion of Permanent Alternate Water Supply Requirements Under General Statute 13 OA-309.211(c 1) Allen Steam Station Dear Mr. Draovitch: On August 1, 2018, the North Carolina Department of Environmental Quality (DEQ) received a request from Duke Energy for Allen Steam Station for confirmation of completion of the permanent alternate water provision under the Coal Ash Management Act (CAMA) General Statute (G.S.) 130A-309.211(cl). Based on our review of the submitted documentation, DEQ hereby confirms that Duke Energy has satisfactorily completed the alternate water provision under CAMA, G.S. 130A-309.211(c1) at the Allen Steam Station. Please note that, since Duke Energy is currently in the process of preparing the updated Corrective Action Plan for the Allen Steam Station and the results of groundwater modeling have not yet been received, DEQ reserves the right to determine that additional households are eligible and shall be provided permanent alternate water solutions per G.S. 130A-309.211(cl) based on any new information provided. Any future determination of additional eligible households by DEQ will not affect this confirmation of Duke's compliance with the October 15, 2018 deadline in G.S. 130A- 309.211(cl). Further, this confirmation letter does not constitute a final classification for any impoundment under G.S. 130A-309.213(d). North Carolina Department of Environmental Quality 217 West Jones Street 1 1601 Mail Service Center I Raleigh. North Carolina 27699-1601 919.707.8600 If you have any questions regarding alternate water, please feel free to contact Debra Watts at (919) 707-3670. Sincerely, Sheila Holman Assistant Secretary for Environment cc: Jessica Bednarcik, Duke Energy, 526 South Church Street, Mail Code EC12J, Charlotte, NC 28202 WQROS MRO Supervisor WQROS Central Office NOfiTH GnnaID�n�y `� OepaMrntal Fmdramrnml Ouslly� North Carolina Department of Environmental Quality 217 West Jones Street 1 1601 Mail Service Center I Raleigh. North Carolina 27699-1601 919.707.8600 WELL ABANDONMENT RECORD This farm can be used for siggie or mullipte wells 1, WCH C'U"tramr lnrn—gtion_ 170T IrMemul Use ONLY: W E LL A BAN DQN M ENT DETAU Michael Wilson 7:L Numlrer rrt'wdla beio%abanJounl: 1 Wcli{'oaracim Kom (or vLdl onirT persmL%U.% A%uw nhig, A an hK lrr propcny) F,-y Irrirfriple INNiVicur V WN xwter etrppA- caasrrlrcr M rxar.vb mt cwe j;jrwi. 3351 A NC Wall CbnlWor Carl ifrrlliari Plaunber arlh AI'LY Lreg Oke saws lip. Appmximatc airlurric ref %atcr remaining in wdl(s): (Rai.) SAEDACCO Inc FOR WATER SIIPPI.Y WEL[S O I.Y; C°71v tn' Kama 7n T, pe ur dianfectant used: Hypochlorite 2. Weli Caastraction Pei ndt #. G_aston County Permit Application � , 1.,xr<Ni qr p� ka le w ?Iprrm,rr r,.e- i•rw,r 7d, rirhirant uFdisinfLCtaat uaatil: 1 oz & Wd t use (check well uae): Winer Supply Well; ❑Agrir.altkLTTkI ❑Gm1hcmw1 ftalin000liug 5uppLy I ❑indu51rial(ComrrL vial ❑Irripliois Non -Water SaI" Well - ❑Aquifer RecharDV [:]Aquifer Slonkge and 1kC0 M ❑Aquifer Teal ❑ExprAincn191 Trdicirpbe-v DGwihenikal (ClasixdLoopk LIC,eo(hemal (Hea0ngr1C'oo1i1kg 4. DMW-gIL(I~) abAniluncd: 6/11/2018 Via. T�'rIi hrL-atiirn. James & Linda Mauldin 11h1LLnir-iFM11Ftiblic MRcsidrnrial Water 4upph- f-,ingle) ❑RcsidlenriaL warn ��upply tsharedl ❑Gnnurdualer RenLedimiour ❑Salinii; Hamer ❑Stornm,dicr Dminage ❑Subridnrxe C'orrml l7Tracer LICrtlki:ftnplair under 7g) F ilily.CFlerLerNnmr FacilpsiDN(if LippltaNel 310 Mitchell Street Belmont, NC Pin -sisal Ad&cs. CM}, and Zip Gaston {`OMM.s NfUl lderuil 641L Na. (PIN) 5h.1�w i1udr and lonotsdc in du1vrvcsAMnutmiwmnd&ar dccimal dcuccN {ifwv.11 E441, iriL4 LitlwLg i. viff4r4i1} 38.182045 N 81.020372 7c, Staling msktcrials used (Cheek ir111hat mpply)- rid NCat Ccmcnt [craw ❑ 13cntonitc Chips or PCllcts ❑ Sard Cenrerd Gmut ❑ Dn C"las ❑ ConcrelrGroul ❑ Drill Cutliogs ❑ Specialty Gruui ❑ G0,;e1 n Henrouile SlkkM- ❑ C)ther lexplain under 7g) 7f, For t glch nkatpri;kl w1pe(C4 Ahnrc, protide 3mnlmt of m;kMriplx nwr(l' Neat Cem.:141lb ,Wtr:10gal. Sand Cem.:lb ,Wtr:gal. %, Cr did a Irrlef dcscrilitiva of the alranikknmrot pnoLmlum: Grouted well from bottom to top. S. ' 6/11/2018 By .TjA7urjg thes)brm, f fremby certify rlhar the wLJ1fsJ was (here abandoned in Trux,rykF&e wilh 2(4 ,V': iC 02C.k9ioo , x-. w wtv conarvaikn %mArdz imdfJ'mtacopyofAriNr-xordhubeenpro dedfaOrewef!owner. 9. Site diagram or ad4itEoitalvvell details: You may use the back of this page to prrn•ide additional well site details or %V11 W abai dommiLI detail,. You rba}• a1w Al2CIL additional pages if IreCrasa(V- C,ONSTRII-CTF ]N DETA11.5 OF W£LLtS) BEING ABANDONED SU11MITTAL rNSTRUCT[JQ .lrGuir vrf1 cr,mvJrucJre,re rrcnrxt�u �7 �Vrul�d,k. Iru m�lrr,tr x�rr,rm r,r rse,a-wx.rdrr xup� mxl'rx ONLY w id The= &Wet nrfmtfr Lvre)efi 10s For All W011#E Subnril 117i5; form within 30 date of comrpletFon of well 6a. Weil IN: 1 6h. T61s1 tk+e1J depth: 100' (F0 Coe. Borehrrledlarmew:2" flu.) 611. %ViAttr kr¢l hclnw pukind -mlrfi4cc- RI) abpndanm¢ry tg ft fgllmsing- Divisiro of W irr Rcmiuren, Jurormaruro Procnsing U61, 1617 Kail Smicr Center, RalriRh, Iti C37frrJ'9-1617 14b. Four ILilettinn VrLclls: rik addilion [a selsding rlke forikL io the address in 10,k above- atsu skrbodi oir cops of This Form nvidiio NP days ref uomptNion of welJ obardanrrLeW to the t'blioasmg: Diyislon of Water R(aou reps, Undlergrou ad Injection Ciral rol Program. I.G36 MIA-Sm-igC Ccut[r, Itair'igh, NC~ 27649-163d I Ac. For Water Su msl v & In lertion Wells: In addition to selyding the faro to 6c. Outrr casing Icngtb {if loim a): I l the address;es) above- also sub -mil owe cop- of this form wilhin YU daYs of comptetioo of nrll abunlomnent to 1lo coumy Imi-th depmrlmeiv of the C'Uunly rr]aCnC �ibtirrd4rR"il (rl. lnncrL:asinghikl&1p kmjoh lif knrrwnl: 6�,Semm l4ngoHh;tf hno%a):. ffi.I Fomk GW-10 Nonh Carol= Depannion ofEm ironincni "NaLulaL Rcsuurccs - Diti isuan of WiLerR550urCtii Rnkscd Aupsi 20B WELL ABANDON M ENTRECORD 'Plis fcttm Call, be iisicil formokll: tit nittlipIte %tvllt 1. Well Contractor Information-, John Miller Well Co'nImow"I Arliettillill- EtCll fill tits pem I 4337-B 14C V%F,11 Conlraout SAEDACCO Inc Vo'Fv,hlno N:iqu,, 2. Welt Coutitructlon Permit 4- Gaston County Permit Application, Le 1,011011C�% "Ifil"'JuJI4 .-h J. Well UW (cbc&- well wwl: ClAgnc.itltomt Cl% I itilic I ri;:1 Lpt I b I tz 06cadwrtmal (ficatinI;j'ooling Siyppb,) Nfic-ddcritial Niiatcr ltuppt% I=Jiii g1c) ORLsidctitint %tici-Sapple" islarcdb 0 Aqutf�r Recimrg-c- 0Aijorfer Switiage intill kt,,ovciA O.Ailun& ElExpennictont I't.-clinallop 4, Date, writts) alointioned: 3/25/19 54. Welt location: Ocimonill,t-wet Rizinethatiou 0s,alinit38-amer CSItyrnmitter L'Taintive DStjbIiiEk:tcc Control ri'll-nicer IFq, 'minlili I I c ON I V WYLL ARANDONME-L41- DFTAR w100,04, 0.1e, i!,, rk ,oe)"wh, �cl", ONLJ �Wi[ di,wi`, kwiwoi, wo,,m, ;4hwlu,,wil I irml 71h. Approxiiii volunte of vv ater remaining in ot ell(,, 1. 305 gals. FOR WATFR SITPINWFLUS OINLV: it. Type It( disinfectant used, Hypochlorite 7d, Amount of I16infectant owiti: 9 Oz 7e. Sealing materials ti Icheck all that AIIIIIA ): n Nuo ( *ctncrii Ciotti Fl Benitoutc f"llp, to Pellai 11 Sind CLulclet Gmul CI Conmic Grout sm-Cialty Groot Nixonire slorn, IJ D* U* El Dtill Culling 0 troll I I Other l,: vplilfn under -I-0 717. For each material w0cacd abotiv. pros ide mootoof (of otaterial's used: 6 yds concrete grout. Amount: 7g. Provide a hric( description of the attan(biantrut prorrillurc. Filled well with grout from bottom to top from a concrete truck. Darryl Beach Residence l7qullrIt IDA, 2657 South Point Rd Belmont, NC 28012 3/29/2019 Pit* qiz.tl Addfiets. Ctil,,, olo Zilt Gaston fat ii,i,txi (M-i� "'as jver,,� j1ho.vidolicil w I "wing al0 "PIN I fridt 1JA `,;CAC ij-( ''W6vlo, A 0 i 1) If *rP ( , 'Ifleyffnif aeopj "Phu My. "Ititudr anti Intigitaille in or devittial *kigfrrr,*- 6fwCVzrx:I(I. clkc tivIl1q, o, Site diagraial, or additional well do4ik: you Inav Ilse (in hack of flik P%gv to lomide addilitnial livil tiiIr dl:m& of iit,Jl 35.173723 N 81.020750 CONs'li-RucTim DETAIUSQF NVE"ISI REIV; ABANDONED supmtTrAl. NSTRUCTIONS rhath "viii mqulm,mw olvalw, cu 1110,40!0, AXP741 V� All tv 11� V..1- d t— i I.; ;i, 6A. *vVell 110#: #1 tilit.TotAl titictl depth: — 43 M.1 tie, Borehole dtntueter: 18 _ in.) tol, Water kvirl beforiv gruntioll iturface: 20_ (M) . jr c I Ut ann om n . COS ft CGUIPICIE011 01 tICH Ailindoninct-9 to the following Diiisiou of Water Remnil Information Prorming. Unit. 1617 Mail Service Center. RAlleigh. Nit,! 27699-16175 ItIll. bur Jokvilint Aclla. III atkIntoly W scirJoil" 1W forth to llw "Alwss III loa above- ako subian one zupw of this hnn; within .,tA slats of completion ol'%vvil abandonticto to the fl-41tioving. tylviActo of Walter Royin rvo. I ' 'odetMround Injection Control Program. 11636 Mail Ser-vice Center, Raleigh. NC276"463f, Inc. boowamr-50w)Ix —&I-1—sksihil, AMI", In xMilion to,410tog the fmol to 6c, Outer civiing length i if hnow a)-. (ft.) the addlusstes'l tilxive, also sllhtou one :Cyp,., d Illis roull "Nidlin III tlasti of completion tit IN-Cil atimidolunclit to the Itt!i1lift depinnilem of, the C011ITIN 6C Inner ca.sing1tithing lictil tit known): _ift,) where alianlor" tig. scy,cen length (if lotow it)-. Ifit.) paril, GIV-311 NoWl Ft" lycivillLnit JIA Niluirat 14r 1"IKC-i Vl WELL ABANDONNIENT RECORD Vbis 111!11r ;;Irr be II?-ett fie stiti=lr Ill niul:it)ir trtills L IN01 Crintracror li f n-inxiun: John Miller �s'rli l ln'atr:resr:l t'is,h. loI'talntrhrlro li•.0Lit h �h,uehuunc w.l,rrtrl l_tr nrr�ncaa l 4337-5 htC iv i< t t,;Itrr rf'>L-rtir":�arilxi .."dn,I�cr 2- For 11,Il lljl Uyc' OBI 'r VIfVLI)t)1NIFi4T DFTAIL 7a..wrnxtltrr of tsrtf>lrcint; ahandtrncd: 1 he` wlwf, ?la. �lltltrtaiimate vatrltrtc uC stater remsxirxin„ ill svr11{.i: 430 !g t1.) SAEDACCO Inc FOR WATFR 4UflPLV tt`i?I.I-S Type ekf disilifectaut used: Hypochlorite 1. Well Cultsultcivatt Permit tt:Gaston County Permit Application, , "d. 13 oz �irnuunt of dixinic�Canl usl:d: S- tVr1l etx• grhrri. xsr11 nsrP: 1Valef. ` lipply Uell: ElAgn:uhurtl Cl ilrnlcrn:lI'i'rrtr[tc ❑t,' ntll4rrr.;d SF3carias t'nalin_ Suppl} I XEcsidznlitFI Wi5lcr 4upph i�ineici ❑:n+ild5ttialft'tltnt€lC.r�t33 ❑1Z: It ntlrtl tbalct SlIppIv ishitre V C13x ri eat our 1 Noll -water Supply tt'clt: �Meli wnili� ❑kc )ctr- Ll,trptticr treater:;. i3rAijmfsr rtyrt e u t kr. vut M Aquiter DE-youttew;?t lie m a(au-, rlCictrt;t�nra;tl tit'lt,�:ti I<c�plal L iC'tsi7rl,,a,rrlrl tll>Kftiul''+: uoliuv, J. Mitrn'dllst.ttcntutnue.tt: 6-7-18 na. Well h,ratulin: 06wilr.d)salef Relilvdixfair ❑Salaairl linmcr OSIomsst;ater Dmitt[we DI SuhsificiKx Cotrtrol 1_I irwer offer ?r_ Sralin�r utairrials ucrti (c1Y4xt: aQ! ttrat aptrty?: r l I&II C'cnncnt t iri'r•:u ❑ HOjijtxdre (hi1)s tnF'0.11Ctc ❑ Sarttl Ccim.-Ill ),runt Cl Dn Clat CI -otl4retc Crow Ll Ddil cal in_rs 0 SpeiAly Gaitit ❑ 6m%el it pwifl ntte Slifftli rI (later{�>jliftiil lmdel 7t',I 7f, File eacli tttati'I•ittt ndcrtc'd AI)I I i e. I00'411,i4it' :ktltlantlt U1' inatt'17dix wSell: ?�. I?rrwide 3 ttrir!' drsc;rllstinn of tltc uQkaaduantrut irrxrccdrcn: Filled with stone up to 10 ft. of casing, tremmie piped grout to surface. 200 gals of grout, 1.4 yds of stone. Renee Major r3citrh'Fhera•l:duau' 1".�;jtrb:lri"ri;pppli,,lel,,,� >;,.C'rk7iiiratitlAt: 132 Midwood Lane Belmont, NC 28012 r91Fs'r.,tl ddre>S.l1h,mdi_4t Al rn(trat6�3)iwr{t urrrJkrr,n :ke'Ifhrrxa - Gaston I'MM Iti ill I V>Ill II t'r, ; I-P, I -ilk. Latitude antf tilm—litudir In etrt!nr lntimxtrs srrrnrds ur deditud iIv trec4: aiarrt fxhl.::Itc Lrithalig 1:rulires_,a� 35 10 52 N 81 1 9 6/11/2018 !+r c ;rxr{it n„trr, 1 fr: ; ,:ln t mitt t'.„t aFa .n S .r a a, n. �,� rrAc.u,.t,�,n..rl Hi .at ,a71ri')r't'1,,1'�F f� i_l ,( If,!) �,7lj60--I ,l't}(tIi-ONt „rlYi.�7i'rpau Gt.,pG ;•airy. njrt: ra; )del t r7t%f "1r a d "0, jrr , xttril le °tt 1 aft e.n,q,T lk Siti diags'attl ar additinnat troll (lrtGtilS: 11ta4 Iare ti,..' hij& of )leis tape illpeovitic ildd boil tsc►t it d titlls of '.yell {{' al etld!xnuf,:rlt dewiL. Yctu roar• ,t6 , :I(w l udjimillid t tgws if uccessiir, f O NSTRIIf-TiON DET AILS OF tVEI t (4I lirlti(: ABANDON F-D St'R tITTA1. TNSTRItf i!()tiS ;, �, x�' r rmtrr, !IIn. n ,•.r:�. �r�;ae7, Ilk 1: t.a. Well ID'i: #1 WO.Total lieu rkpth: 320 1ft. I Ile. BotVfII)IC rlhtntetcr: 6 till.) t.(l. tVatrr Icx 1-1 l,cltlu f?rtltjlld slltfjcv: 32 tWc. Siriat!Issu): 114 ffr.) h£, Iitner cusinWill hing length (if 1111IwnI: ift.) tog, SCI'tVit fear til ttr taw01: I,tRJ Y. n tc[Is. _ubnul Ilxc tcaxrn aruhnl '0 dikes ni carnplcitm, taf ti l .Ihltndt ninckii to the rnllnn•ilf, Dirisiun of 14'utcr Rusottrcm. hifurmution F'rtxccssirt� Unit. 1617 flail Set -vice Center. Raleigh. NCB 2 699t-lGl? II}h. f"r Itijectittu 1t'clls: Ill:ttlditicrn Ir+ wrrlttls; ahw feml to file: lthess Ill tlta :tbm, :- ;ako :<tlarttu tmu ccipi of Ibis knm wilhitt ?0 d.» s of 1:wIlI lrtiatl 0" is-c•II Ahillid6tulleilt Itt the Iollliwin_: Dlvisiilu tlf U ater Rcmitsrcc*, 111-ndeignauud lrtivetiuu Cnnrn,l tlrw-ranl, 11536 Mail 4+:nier Center. R dd-- h. NC 27t199-1(,3(a file, Ft,r Wa ei 4u r iir A. hY' " hktt R` 11s: Ls adtli9iEAfr 4c> rslttt the frtrns td the :Iddicsst~'aj :fktri�a, illso 5uhnle care pt ot, lhts fortil nVithi,l Ill tiYvs sq --olli ictioll of sell rthsrldanlnlcnt it- [tie coltim L %IIIIl dcplutnnew Lit' tile :11111111 w hcrr ;*inctnncd (dell' i W.:il, trratt; t •u,+tu:, }i:t.�nlut.�lrr •.rr F.,,riruan;ltcn of t 7dut�Ix[ I!-; •rle�ts _.. t?r, tsl �r1 ur'.4`;u�t r.._.�tu.w; :!c :;ed =Srl;�,tia �i?I s NVELL A13:' NDONtNIENT RECQRn p.,Icrn S,linl' oil ; llli� lamt <:Iu ba used P)r aiu0C or otldEil+id t}tith I_ Well Ciintracttlr inStrn}atistin WELL AR.ANDONhfk:NT DETAII'* Jack Byer ?A• Numl}er of rscllt heirs"„ alomidtinvd: 1 WCM t.1'I�130Elf NMIL WI',kvltnur�rt reaaulh :di, klclsdu_ t+vu,rltit,teI It,4!;w;at r rt,_ tt rr , �r �.r, a ,d, ��• {),ti'L}" � � � •, ,:rnr 4379—B 1 W VN'01 C'n,nr,,c1 r f ur t;Ji n`. `in,it,n 71}. Appro in}:lte sulun}e of i}ater relnuinin1" in ttell(st: t al.) SAEDACCO Inc FOR m`.ATvii tilippi.l•wriot 4 tINl.Y: Iolm';'m 7c I'rpe of disinfi.•rtant usrd: Hypochlorite 2. Well Cunstruoioti Permit (!:Gaston County Permit _pplication, , 1' ICI .tti i i fu'r}(� r: (��tt'r9R11 t r. ' i:7!_!,:.�A,...:. ? n uJfi.. , "LPh n1. rXY. r krb nry: ?d. Anumnt of dis7ntcctAnt used:! � J. Well ux (Ckdi }vet) usck: Water Strl}pi'v tt4IL ❑:§I;rrclttturtt C1(ien[tlema;d ?.Hcntilzs�t'ocriinr Fnppicr C3 itufustri:d/'E'utntttc:�.i:�i Supply ClAquil!6 Rectage ❑Aquifer'ittniLva1:a1RtI: ovcrx CI > gaiter ] cs+ � zgcrlturntll to inelop CIC,ca�Ebcrnn:ti {Clc"'ed 1,M111 GIC x�t1u rntni lil Itlr:tz C'o0lifiv J. D:ttc n ril fs1 uh:enttnt}etl: 9-20-18 Sa. Well loration: C141t€n€�iya:d: Plibtic MR,:idcniilti Winer Supple isin-lei DRtsidentitil Walet Supply islutrelii C1(ir,)w;dn:ucT Itclacdl:ltlurl CiS,Amily U.-urler LSiernmatcr [anti€rwx DSub:aden::e Commit I:.ITt,wer 1.14710t;t tcxplimt miler 7r;i h.. SeAlin,1 u}atcriuis uvcd (rircrl: irli grar Amtti 1: 1_1 'Nc;u Cement (imut Cl Fit;worl}tc 01111, pr PC11ct, CI Sia d Celllrui (_tout Cl Urs Clan Cl VolILT'se Grout CI Will [°hint: S'w- utlI% Grout ❑ Crinel 11 Rc113¢ llire Slurp t1 t )111cr (+::plain mwtel 71=1 X For cueh tuateriat sricrted ah11v e- I}rotidt' attoitent of matcri,iis ttsrilc 7g, pruritic a hritf dearriptiun of the uhand+rumeut procedure: Used grout and tremmie piped from bottom of well up. Tony Adams Residence rx4i 1,11 ,(-h% c1 Mq,ac G ;:iL•tr (iiS' ii a{ pfiral"I,_ 3. CrrtlliChtltln: ill South Point Drive Belmont, NC 28012 ;.,,', ":•', 9/28/2018 Pl:,, si a1 Addt,->i, ru .aai Zitt t W ❑1 V. 010wlst Dale Gaston i':Itn71r.. Rll-aCl hLnul _;Gulf N,t 511. I atitutlt: Anil 11111---itutk pit r[rLrct°vinlinattal'vct,Iattc or decitnal ilcLretw: tiiwcl?rxG.f aae Lnk=t� ts•.ul7icxtsi 35.180947 ti 81.019095 tit' S11 £ifRr '; twte, , lF.'}7'ftl' item /it,lF ,t '.r,'ii!.C� tr•;: ,•t t (r ,Ii"<t,lx,4',rJal1 Yee , ,r�i,.::.:��•,,,ri: «-r f _I,,',i_t",t)et tits ., _1. A_41nIt ,•itt`„rsrrvt;•Irn, 4r r. ,.:.,�„t, rt 'itr:rt a it j.1 tn'thi:, r it it:to ,zt: pr, weite.1It, sh t„rll inliv t- tr_ Site diul<ruto ur• atiditiouat ilcll th-tails: you flow, ILt the back ol.:leis tt:tes: tit jjwviilc adibiiatull vie11 :,Is: tFtitadts or l+sll :rlsu/1doutueru deutils. You nlu}' 111v, .11i:it:lf'1d'Ji iomtl px WS if CONSTRUClnON DET.Af1 S OF A11':1_I_ S) BEIM; ABANDONED 5URAI17TAi. ttiSTRtICTIONS tewttr v.ti i, ..v_ ,:, -,r„r, rc.n .r_ ., �,r�..m ; :,,- .,o,. ,orr 1.9 a•:n,,,r •u r.. r. e.,•.:: r.�••,,,, '—tb. 4!7A7.} All V 11 , .,h ,;+... . ::a:+, tr:r4ea,ar.a r-� ,u",:,i. t rm r,• r. ^ -ur 1 t t;•• 4:a. WCH IDtd: $1 66. ToWl it ell depth: 110 ift.,t bc. Rnrebtilr dilunt•tcr: 2 611.1 fed. Watct' WA ri helint 'hood +urfacv. 15 ift.1 u. o e >. ._4 ti 1 11111. 11U, tolm tut un .•it dots ell tnruplcumi t ucll JbItudanulCM to the fallavrulc Dii pion of W;ucr ttt-•+tnircm. Information Prueessinr," unit. t617 MailService Ceutcr. Blurs"ch. !tit' 27699-1617 [fill. lour IrNectitul %VCJls: Ill addtrkHl lu -:ZII Iotg 11W (obit to IIw irldtcss lu uia :Ibm C_ :1tsv, Submit out. copy. of 44.,i i nut witinil 11'twi� t!1 iU;IIi?leIi0FI tit 4t"ell 1INutdontuetu lit the t'olluwittIg mvision orwAter Rmurrcc., hniterurimnd iiij ibrl} ouarui Prot,"rule. 163f1 .►fait 4crvice Cent". Raleigh, NC � 277699-1636 fir. Outer cusp;; Irtt; tl} lif latttst u'r• lfh For tiA` rr $ t 11s 1c ht' on 4 uIts 11'Iddirwit Io �u : }b fro, to tft.y INid+.lt<SSwSjf Idsow illso S1lhliift oue SI'pt of fllis tt,Httl %whift III thnt, of .amplction of }cell abandn}uucnt IV, life Comm- I1all[t depuu.lttet:r tit Cite Lontur rIC. Inner r1}sin�nt 'hnpt length tit ovxn l: tvr bete nlimdar-d it't.i Sergi! lenwh art u,ttcni: Par it ti',4:at Nr„ €l, f ,uoliiae ? ktrante 1a c,t Fit, tre,Aw-,iil .oat Vtuc,e t trS, n"2i, - Lkr: tstmi oI t4'x,1 {: _innxS e" icd i%1t 4rt1 ;tt1 N ELL ABANDONMENT RECORD Tn: liven i ;tm be ilw4d for - iwdc at iimlti,zh' u.113 t. (Well (brrlr'actnr tnfnrmatinn: John Miller "VOI t t lzm set tiara n,r x I nr+tit I* rn+.ut.di, alu:deru(uc . .I n.t icr.'L t pt ,t_:r, t 4337—B NN iii,ii t'nntrtctc,t <- Ri>r ihrt, tgn'I"rt I'ir 4stemll c. U"71 'r : 1VFIJ- ABAND();+«'NIEN'T DE iAII-S ?a..Vnntlrcr of ttell. btinl; trlr:tntloned: 1 •:,: r:,.`,rr�U,��, r..m:t rna,.:rn. t. t,nvn, �._rrntl ,,a.•r.n:,a ?lr.:+�talrr�etinratc ralttnre arl' +t atcr rr nurin6n + in wsaEt,1: 350 SAEDACCO Inc I FOR WATFR S11IT1.V ti'FI.I `±0Nt_V: ic� 'Tvpc irf dkinftctitnt used: Hypochlorite 2. Well ttm.-. tiction Pertttit 9: Gaston County Permit Appatlicion, , ---- '! )1 ,Szm.o, I.. h.I,C.. i'N ef,. L. "1. ! 1'p „z 4. 11 OZ (1, ,ituvunt of di'dDfecf.tnf used: J. tVtll uw (cheek stet! 1t9eI: VV';ttct'Str1>jrlr SVi�li; C1.�eneiltnlrrt Q(katlletmrl {HcatenL�6'ntrliiv Snppl�;1 t7iial115rti:tlr('rsmancr(:ia: n ❑ikttllalCiptdi lr1-1 lblE; IMF.. idzmiiil lV:iier �Ir(�pty I�nt�_Ici ❑ResidemiM `Viaiei Smppw ioiitrcd;. rnjerrtinn well: DALImtct Rcchar? , EJGir)mJ—,tatcr Itcim--dutwi, i�Aytai,•:rtur:a!;e:ux3 hc•,x,;u; r5alnlii; !l:nritr LAi1tt(f�_r i;:'=1 (=7tiir.rit3$:71cY1)rtl[csee ?�Ltp:�nancntat li-,:larrc*iz,,,, _1�u1t=_Ider>,:• t'r»,n:,i L:IGii+ilrtrnsal if_'Ir'tyai! L.;1o1+I CI'Tt4re-Cr F I(i€etnsirl iH �itintCo,7lir,ra Roam( CI<"Ittr t r(:El}luin utr lcr (=t J. Rue n cill-O A :mdnnedt 6-8-18 5a. Well I watim): ?t. SeulLr+t tuateriais uud ((beck all drat 41t111} is 1-1 Nrcat ('anent CirrEli F1 BCraanilr C•hrlim.urPL-Al r Cl s:tad t'entetlt ([ntlt CI Dn 4- :n Cl I_:?IILTrtl: brim CI brill Cttfina- ❑ spzcmi3Grutn Q t icira Ct Roc (Iollfte:ilrim cl atErer•:aitlttrnntxlcr's.� 71, For c;g1i itrats 0:11 n lrc'tr'd xhtr t Errrrti j(tc errtlrrrrt trr nraicri4k rtseil: 7-a. Prrn idt a brief description of the atmudi alment procedirm Filled with stone up to 10 ft. of casing, tremmie piped grout up to surface. 1 yd of stone, 190 gal of grout. Dana & John Baker ircciiry:Chcrrl '•tana? i i::itrtr li?x tiF:tppli:_a^14•'; 8, C if cmirllat 116 South Point Drive Belmont, NC 28012MAL 6/11/2018 M:-,rzafAciilw,: i t lt,_,miZip Wrur m,-of-,,inic,'.'V C11Ianrr t,rulV. ?IOmf-f Gaston 4'etau+ly I'art�l I,LnI!li:ari. u No ;pt'.r 51r. Latirudr Aml bttri+itutic in dc�rrcv,'ettiunra+ltrcunds if,- dceim:d rl -treN: ;If INCV i I,I tug 1.111:! _�rv.u1 r•I 35 10 53 ti 81 1 7 ltr t �:rqy R�r �a , ,r•ht r rirr! !_ ,at .. •.n + : rr:.:' ,t ._ dt,cvr„'nn:'rl !rr r., nnu,t• a ilJ: /-t if'{(•11_f',M1Gfd „r "t r!'11G if e"i r , ;,rM,ii.nr 4P.r-r•irr„c i l rjr.,l V,� jr. `r1n � _�"nr:!7'xr ?•e•,':i;ar � s'rs�t+. lh � ':. :.,r:�r,'r 9. Site diatrimi, ,rr additinoal +veil dctaii_s: Volt heal tr c zkr [-Idof!ti1, I ,1'L'itt IPWOCIc IJ(b;w.II;II ri 11 -it. d.( tar., ;rz wrll NV ill ttt l,ttnuCri dct:rile. 1'eu 111W Illy, AIJOt a.i-Jiriunal lath if t.ceslar� CONSTRUCTION DMUI_S OFMT11-100 t rIM; ABANDONED SURMITTAI. 6tiSTR11t"Tlfl�iti .flr�:eir r.:; �- •.,.�_..r :.a. :. 1 .- f .,,,aa,,.._i. ,'•?. ruvur'i.r t:,r, .0 ,.�r.-,n,•,.. •n::rz,i� . t1, rtS1,f' u��:�r a ... , .:, •..n: t n nr tO V. 111 NV^11 (, I 1' J 4-AI, Well Il)¢: #1 r,Er.'Tutai bell dcIttb: 260 tft.1 fie. B-INIIolydianic(er: 6 fill.) If([. Witter Ictrl bclnu "!Flimill tnriact: 27 A. nr : C .. �o 11=1, t W. 101111 MI oat _ (: A%S 11! :(4n1E:ICItnta :)t (tell :Ihindi,timctu to the +idiot~ inr: Dixisiun rat' 1Vuttr RCSUttrCL"t. tnfotmutinn frtrccasiat+ F nit. tiii7 ,11aiE Stnice C1ltter. Rr1ti;lt. tit' 27r_i�t+►_tG17 (till, 11411- inietti'm WV111+: In atldnl(v lu xuJrtr_E 16.: I`uily ut llk ddlot, In Idan :Iboi,e. ;Iko :Amill ,tic :ipy t4 this film+ volhin - I +.1.r % r_l' ctl.ngiictic+ar tit' (tell Amndeornc:m III Iltc tidltaa trls, 1}ici,itltr a %k inter Resnorc, t utlef-L,nrutill 1111r~t itna Conlrul Ih trxraoi. I63ti hlitii Seniet ('cater, M&Lh. IN C 276994636 tile. Fttr V1 wit, Su t tic �t ht'' iarrr 11 ttn 11, ;iratlition act Njiililtpt III i tar i4 tic. thrrcrcasirtt Icuftb s:rt 111Isn't: 105 ifr.) the aitnrt. ;dSa snlatort title k:op.' _+t INS ftanti mibin to th)ti t,i .:01nj;l.9inu cd' (tell ithattdnatmett( to tlar :oIll ty tv:1111tt depxmnctt, :al the u;ulse tti lie re nb:)r4r,ra;d (If.Eaancr casing'tubin� kart!( of I:rtnana: ift.b t;--. ,SCreeti IM911h (it I:untt n I; tY't,b VI-Wil (il!'-,.n Fug tt, t ,rt„Ir[ Lrazautiraa :. ul.,w wft ii and Ntlfttul it,y rrrtcis - Ltrrtst�t,t t,t' i4'.u•_t !•.:,oat:C; au eied ,'srtu WELL ABANDONNIENT RECORD -Uri I,tns tit ht well at ni tl'ii e n•;11; t. Well Lnntractrrr hlfirrnlatiml: Will Keyes etl t , r, user h.,a� t++i'1�11n',rixrr 1'-•.uolt_ A vi :t. h !11 11_ Iatl?r; l 1 pi..r_za t 4420 A Id(''(Vvl;(�,v:,iri Itiv�'1li°i.'711t�1;riillltti:r SAEDACCO Inc ? !Silt Ctimtrintinn Pitmit O Gaston County Permit App, 3. 4�'ril ux ached: sscl! rise!: Water "s-lop rtr wvli: DA;;n_-Witirtl ❑firathenral <FT antr."" aahnp &lippis i Ci+iE(IT3rtrlall+t C?n713?�:ii 1:33 Cihlurit: rlx:drl'tll:'lr: xv id,:utial Miler slipph t=in_ICi ORL_icie"11111 W'14c' Sigrplt' t.ih.rr.di Non -Water `apply Well: L7'v?l'tsiiartr,,• CI Ilc::f}\v: ra Inicrthin %Vtgl: OAtrnter Rectian c Ll t.ltiln lid's ale, l'cm,:dwuvn ❑Ail;tifar Stt*r¢_!v nA I .c:o%'eIt D4illlttillU:nner L A.quif�_r 'i;;si LSlonrswim- Urtita_c DE'% umertmal ElSili_id_ ct: (Ainsml CIGe+xlicrn~<d f 1,17111CQI 1-1t 1Lvlacrifol if I ttent_'Co0i'41; RCl O"! I (!¢lira it\,)inn Itv kt ,t;l t. Dale 11ellis) abandoned: 7/25/18 5.1. Well hirmim- Carolyne Hope h:Ci lrt} 3h%wl EiA71, 1T)'" r fj appk ;dice l / �-1�1_U Far'rnr1T1ll9 '�ON1 s' L4'E11, ABANDONMENT DETAll 4 7:t. wumlrrr tlf nclis bring abaudoncft: 1 ?!a.:kilprOvinfaie t Irluare first ater reuntinim;; tit ircilispA FOR'. AITR SITPPLi' ti'I'LJ ti tr)lq LV: 7c: TA tic of disinfectant uSCd: NA ?d. Anlrftlnt ul' dbsinfcctant u.kd: NA 7C. Sr' alintr materials 11jeti (cbCCic all till, allig', I: fv :lt i` ,lien€ Isn It 11 (ict:t.nitr Chslr=. srPcli4ti Sasxl L- nskltt C;rn1u D Di\ t_ Iat CI f_,ncmte tir{_tng Cl Dtili t'_ttllim_l Cl S,brer:illr Gruel Ci tiri).,1 i1 RI tjfjointl' >htrn' [7 i_1t11%r <k dlli1111 Ili 121 'R°1 Tf. For Cacit ,Hate rfaf wcitcicti alm%C. prils We afnrttnit fir nlartriYl* utrd: Neat Cem.:3761b ,Wtr:21gal. Sand Cem.:lb ,Wtr:gal. ?�. Pro't ide a brirf dmripticln fil'tire abandonmCal prtfeedom: tremie grouted 8. CC1101cariml: Ill Warren Drive Belmont, NC 28012 -- --- Pltcs:,ul .'1drs.ias,.;letriti Stls�lunr�rrf-.ticli�4eilt:;uar_t,fn 1r14'r91Qlx1at Gaston L'•Ini°t` h,r,:ai i1LnLk.;11Y:+u ;l e'�1 5b. Larimrdu and 111164itudr ill Ifill rC„«a'ruit411 nr Ilevinial degrre�: !ii etc 17Wd 'n 14 358.181117 lt-81.020486 CONSTRUCTION DMALII S OF NJ tLLiSl B@IN(i ABANDONED t.a_ Well ili>i: ttb. `fotal +tell dclitli: 100 1It.1 ac. Br1t0iole dlatnrter: 3 +id. tit'ute'r Ie)r► bchnt-rtrtttlil earfacc: NA 6c.Oil ter casin�.lengthiifimfissuj: NA ift.f it€. hiricrcasim-,lnd>int; lenr, b (iflaiti ti): 1 ift. T G41, Screen lCal"tb Or late/, rlt:NA ii't.F 7/25/2018 "I OWN )t,1..... '.il N, ,al nt ,1_'f `.r. Site diies:ram fir .rtiditiunul srell dr€ails: Yon 111av to (k pact- of titi= hag,, fit pro i1l< ltddifl::lrsl r, ll .11.- d tail, or si'Al «' aE:uldanr[reri drGlil . 1;Af may .i13., uttaCll addition l It 1_titi ri r cr;:ti;in 41T NHTTAi GVSTR1Tf TION5 Itla. For All Well, Submit thrs irrrn rc-nhisa ;ti ;far.; Ill ' contplCtii, t;r IIA a5;nt innitTelT. n-1 rile falhin'ut- Oil isifin err Water Rt_waurc�ti. Information I'rucessin; Unit. 161' Ujil 4crsirc C'mo.T, iL►ICi; lt, tit' Z'69!t-t61 i Itch. i-fir In11:00111 Wrll.e: ht :ttldUi"ll 111 Irla 1 44-, iiitrt to lilt' ,r,$h: Sti fit 1t)n 3b"s _ 11kLTSabxtt, I'm this i1:rn3 +4-iihin ?r: u iralLii+>u f,f ;cell .1 andelnncm III the t +liim-iit_ I)tci5inn fir Wmcr R(nmirrC•. f;tulcrltrlound Ilriectiuu Ctmtnll l'rtr"r•luu. tf3ti Mail.Sersicr GCntcr. ItalcjLlt.1SC' 27b'.)')-tG3(f tile. Fiir t►'attar Surrnit .< litit'rtlon i1'Ctle: h: "IdcliOs 111co y ltejitil: tiia fill ss flit, idi i_Sq,al :ts'ive .1lsu '.111111w +tie 'tit •'t ;!Its' wall ;414hill it d,lt; of c>utla4_Inm of nail ail iadannreut n? ih, ; mntk hc-A h dct?,il_tucrli of file Ana s %\tire :ibar iorcd I�rttls[t'd`-:11 rnt31,1 .111hwr ",I1t1111t3R3+11i i1:1 l 4w,11,11.1'ir11111. f (:;'it'CCs LtiSt firrloi V/illi't ._unl '4C.yiiJ ''.1tJ:'E_'ili; WELL ABANDONNIENT RECORD Tins mitt, call b+ n_+ai for itwd m iijiihpkt orJ 1. Well Contractor htinrinaritln: Michael Wilson '+� ell 1. r rJ.i� ci is t.ltz I. r.,ell r5. rx[ ik:•t _uiall.� as eLr.rhl_ t•�.I n rit;atr i r. �ia,�t i 3351 A N(' WetI I. , ii cwr rrir!.:.�hi r i-snatn-! r n4;t,rtl i : OXI L AFlANDONNIENTDF:TAIIS ?a. VunaEter (rr ttcp, Ire iny� ah:antlunt:(i: 1 -.r.(t ONIA •,.r. 7b. Appnttintate t'r»Ionic err rt aicr retttainittw iu ttoil(stt lRs1.1 SAEDACCO Inc FOiT %VATFai kWPPLV %VFLlN ONI.V: 'r. '13"J7l` ur rltlinElYtNrit use([: Hypochlorite 2. Well 63timi`tictio n Penult i::Gaston Count. Permit Application, , .'.er ski ,r i i. :fir r r;iC . ..�� 5: ..... )rt .r•.._. r... i.. ..:_ rn r 7d. Artutunnt kill d6inreetant wed;1 oz J. Well luw (t•lieck ivtp tlrcl: Wmet, slipply Wrp. Cl.�:;rrclrlrnrtt Cl{i atltcnrtl?,f,carrn 't'ualiii Supply) iiatLht!:rri:Q: { sxunscr�i:a'€ 11rnt:9tttin ou-!Pater 4a[rph Weil: D ALlattCr ►dccluarg iJ _#jA Rlic tt'en ClAtl.nd%r list rlEaryenst�nsal i'n_bnol<±�*� t:Ir_M�[;tltr� Lur,il t �'tr,;�ti r;l t: nctttt (Jt �r.rrl:��taul t1f,.trittrrCa,lii{,? I. Diatcst'ciligyatiauidmacd: 6/12/2018 'Na- Well location: Cthluuicl;uliri'rihtrc X11c;ideriuiit Wwcr Supple i=mL.Ici i-IFt;Yi[iculiirl w:atcr Knpplq' Isiu(rcdi CiGwimduarer Remcdi ucii 11S,ilutih Dinner nStc- m iticr Umt€ci'_c 1Subsid• rce t `ontrul '' I"rr,iccr ! It-irtl;:r icrpiniu ura%lcr'..kii c. ealhi�* rnatcr ;>Jk n;w tl (cbeeh Ail ritair Od Nc:it {'uricui �rra€I Cl Rcitskrrntc C'h;pv pr F'clicr•; Cl S:itid t'ciihnf t rznn Cl Uri, C_lax CI { Groat Ci Drill Culliti t- Cl Six.craily Grout ❑ Gruel it Rcikiomrc Slurn n {lttt��r ic�plaili ur:Aci 'g+ 7f, Fter (:xc6 ni:itet'ia! a'leetrt! ahiivc. (riot alk- anu}(rut (d' nlatt'ri.ti: arsckl: Neat Cem.:4701b ,Wtr:47gal. Sand Cem.:lb ,Wtr:gal. 7;,,. Prtet'i(tc a Etrrc1' descritrtinn of tTti: aTi:nntEumncnt leaicrilure: Abandon well from bottom to Charles 6 Kim Lail (-;.-flNw.�?7ar�.a !dunu' G�ciia :-tl-iit (iFnppli.-�Iri," R. e.rtint:atitNt: 200 Mitchell Street Belmont, NC 28022 ..% jj/`%�j 6/12/2018 I'll, weal Sduh s5, r, i ,.,ut1 r'.iil .rt...r t ..., :u Pi Gaston - - 13r i �' [,.!yie i h-1'r.'n L` Ii:ul a!t: srr�L� tr• it or..t,1, ._a........,...... .. . h r 1 t'•.uui. I'nr.ci lrL.tl.1._.unn 'o. -t't\ i :!r r.,,, !r_i n rt; 1.i,3 '•.t i{.' [!_', . !, fill...- _i i1'r}!} ll ,?i i irrar7n r rin (it<ri 4 i i .. Ji,i�: ?-,-I -: i. -,t'-! J:.'!; i.[•, �.; r� , N i r u t: f �w, i ;.t.:�. Ric (.arrttrrIv arHl li Nigitnile in tilTile(•¢lnii nn U.""Ct9Ilk dl Ur ili'ViIIIA dq!lGee5: it" elf CxtJ_t:lit: farlu u: r. ,;rliis:e��k 35.181167 N 81.020339 g. Site diiii;rntu er. jdditinitai +rep dcrAW-4: 5;'uri u1:tC 1(SC tk lr�lCl qi Tltis i' itt;1 Hr pro, illy n:.ith iksn;tl ste;11 �.;1 . ila.ti?•: ;�_ ,tcli NN aharelunar eril Jcui&F Vitt uutt' i&l, ,Imicit uddiriiriull l t4so4 if [ crs;trrt F: CONSTR14-TION DET,VLLS OF NN 1_ISSt BEING ABANDONED c�?tl1FTTTAI F1.r,TRI:ICTIOVS r, ��t.: fl.Ft 1 u iH rat; t., i� . ��.� �. .,, . psi .n �..45. r. , c;..; +u. .r r�,: ,� u. � - p ':• I _.. .. ria. Well ID#: 1 i.lr.'1',ttni +cell debt): 180 10.1 iic. Wcrliq►c [#linnctcr; 3" tiu.1 I,& Wistrrlt-trl lielim -.iriivad vuriarr: WA. M A _011_._ :11)nul ME lean Ulitint ,t; ,fats al caruhlorill, of twit nt�uiulL*rnricnr lit the tiAhwIrt Division ir!'N1titer Ftew}tirce,. lnrorumtion Pnicessiu., unit, 1617 Maid Set -vice Ccuicr. RAId it, 1W 27,694-10 i Wli. Nkir Inreclom 13'e11,k. 10.11.111111 ti lu Qrc IS.Ina 10 Ilk! Ajkbras b, Pill :itsote_ ;ibis subutit oirt: ruP3 of flis iisrn, uvllrin a ci.:rs ei' cuurpletiou ur avrll Irt4w0c.1liklem tit tiiL: IUltUtvin__ niviAtin ur t•Viuvr Re%itorcc., 1.041C itlturill 111JUrtirtn Cvrili-nl Thus riot, 1634i Mail 'mice Center, "ci'lli, W 27699-163b ►ut Far W ter 4a i ih ti lixiectiou ftVtty h y:lift siin ttv S as.lift t ah: f ti, , 6e.Outer ca.si .- lenatir {it Mitt" tit: jfc.} ltic :Flue. ;Ilso snhrnsR olw vL,> _,t Ito, ti teu "drill 11; dat, tii _ollipichrnu ur tied .th:nrdwillrent ttr file c1}utthlicMilt dcpuiatucis L,r life --olli t trttcrc h rinned tit. )liner cariu:d'tuhiu-, itrna !t tie 1[ttntvrai: (,",,Screen !emob or l rtttivtn: tf'Gi f.'r,a?till`-,n NwlIJ ar,hta .): I- iv, _or lltw_,Il 11i.1 tiuna.., Ir:_, uscu - C i:.:;mr .1 :b'ut•_r f.c_unitiC, ?�, i,eJ .5tt_r ., _t!i�: NVELL ABANDONNIENT RECORD '1111t- by u<<ed for liq!L� III Imilriph., n06 1. Well Contractor Infiornixiont: Stefan Smith WC)l I'l,rnmiln 3576A !W IWO! C, WFLI, ABANDONMENT DETAII-S .-:j, Nurriberof "Ol.t hchir almoodonett: rolOpp"', h', ! 9,• -el", 0,VTT SAEDACCO Inc FOR WA'UFR SU11PL1' WFIJ_S ()NJ-V: 7, c. Type of disinfectant tosed. Calcium hypochlorite 1. NVOI Con.itroctioll Permit P,: ',ti.Aiii4puntufdisinfectant ttsed.1 OZ 3. Well 11-W f1check $%ell Usti. Noll-Mltiter Stipply ❑:�ys7ttct fist ClExpcninermil le_finLkw. fJG,x.rItCrIII;II 07117sm'd 1'.kKIIII J. Date 6/13/2018 5;1. Well locitlioll: Tim & Teresa Salmon I-CAttivilcip:1 L.-Nith.: MRjrII:nf0I liViiier Su{ ply iG)nele) 1111csidenluil A%on ElGrooji:Jisxes Wmicilixton lJOr . IWI 7e. SCAlitiff lnjtCri-.jIj; nW4I (Cl#Vrk J11 that ApI$1% W Nc;ll f"Cloco, Gawn C1 Rcfworori; Clops or Flellcv, Cl siInd Ccinvil 64011t Cl Lin Ua� 0 1 bn =Ctr Cirtant El Drill Ctitfim,_- 0 GrUtil 0 tinflel (I Nrsivinic Slkirt} 11 011lzr Ievillivil 111410 7yl 7f, ForciJell niMer1'.41 svicc(ed of Neat Cem.:13161b Wtr:98gal. Sand Cem.:1b Wtr:gal. Bentonite.:181b Wtr:gal. 4T. Provide a brirt'dmiription of the ithan(Injimcnt procediur: Stoned the lower 42' and tremie grouted 170 gallons of grout to 4 feet below surface. racilo.147hVict N,17pc rl,*.Ifriv IRY I trappir�11)h:. H. Certification: 05 Mitchell Street Belmont, NC 28012 Ph'siz,11 Addr,;is, (a, , "toZilt Gaston 510, I�Itiwllv and hillf-littlite in livLavevrill till friLwvf in & or flevilliA 11rucrN: Of IVCI" f�dd I' I 35.181817 N 81.019843 tin::?; ("e --f I fw Ill Mell I v tor, t io I w We if ( ti% I ; I 6/18/2018 D) 17, —1 th;i jww) " 11".v"If L:"I lire, !i:Iv .4:e w.-";•v, 'I '46andoo'.11 !,q Ilk IJI , t/fjA ''Wir"o ,, -,I * '12oll I n-, W'-jiVJ$ k',.W,"rI111dt-d1e1 flh- 107"1 9-Site Ilialivisto tir.olillitional well (Ictails: Yoll Iffillk I*t tl� bijd- of 'hit, raeI: to peovitic oddihomil %tiQll sii,, ca well Ab;1Itdl!IInWFL! dc(i!iL Y,,,u itwak", pagws if caNs,rizut-17ION DETAILS OF FLUN) BE IN(; ABANDONED .M,Lj'( +,cfl ew': ww"'I'v4, - OALY I 'M"Wil 1PIL' to 1: , All W It. � 1. 1 63- Well If)#: hh. well ell depth: 169 tie,Wirchole dijutiver 6 fill.) fill, Witter ItA PI bvio" gjrI;njjtI ~Reface: 30.2 iff.1 it. or C : 11 )YU, I ILS 101111 Wit till :IU UJWS of Coolplettitil iA aril to the t'olloNi vf�g Mi iii(in tji'Wawr RL*otir&:L%. Information I'voccssim., Unit, L617 Mail Strvicr (enter. Pudeit,,h. NC27,691)-tt,17 ) 11111, Fir Itlit.-Clion Welly In Ablivri to scidinij, 14., roll-t ILI lite fit 100 above_;Aso nibnni one ci'P3 'A this film' ttIlhill 70 dms el, cumplefixi kti, I%Cll *mVICIlincin to (tic (villitVine D)viiiiiii tit W'Ater RovjorcLw. Uodcrground Injection Control Pr grant. 106 MAI Svrvicr Ccotter. tWeith. NC 27699-163f, 111tv.. For Warlor rMliols tl�- Itskcliost �Vrll%: ]if Iddi�iofl W &,'IKhqg 111C f 60. Outcr Caiiil,_, IclILTh {if }molten}: 110 6FIll to -"Illmot oflu cov, of 1116 (imll %Inhol to ikm of .zomplelivin ofivell AxifJonniclit tit file Collins ficillitt th:P111:111cm ill' the --.011MIN set hf. Inner Cvvdn--'tnhing len�nla Offatown,: olf-irAnncd 4-_ scrCell lentnto tit knols n I-. I -on G'W-ilf WELL :4BANDO` NIENT RECORD Tiny I'm rti can Iw usoI for siudac of nit lfittk asAlt, 1. 1Vcll Cnntracmr hnforrtration., For iC-n;ll r u ON'll WELL ASANWONNIENT DETAILS Jack Byer ?a. tivatlicr of wells Item: abandoned: 1 eA'cit Cmltaoi+t %:.I51If fat s,dlt . v--t"'A 6t It..::1,:f I R lf.io I : tUrr!1la.l .,V' ONLI , i, Sh n74C r i hU'1Aa9 t Shlp,Vi, 4379-B pJ{'t�r.l7 t"_uninc',urt-uttis3�..tfirrri f+tuti±c* 'd>. Aplrnrxiunatc vuluniae urnatcr rerru►iuinr� in tieelit.+l: l�ai.} SAEDACCO Inc FOR WATER SUPP1_S' tt`F:.1.1.; (1til_1': t, tfltMilfll N.rl:r: ?c. 'type rrf tliinrixiunt used: Aypochlorite 1.1!'elt f.'unstrnctinn Perruit #,-Gaston County Permit Application, , 11rt .n�i ra ,-,tin it u� ie itt`rrrtlt ut �, evrur � t!r, J,ul rr '-S,ri, �t1 drL:. f.tiln u•Ir tl. Nort Ottrit of disinfectant used: 1 J. Well use' (check well usO.- Water, Supply Writ: ❑A n£ltturrit ❑Cieattal:rrrrl 4.l?rarine.H'nalinfl 5arppiv') ❑itxltntri ill{;csnuniai Ater.Supply Well: 1]Aquitcr Rcd iar�,e ❑ Agnti€,r Strsnt-e 71W [tr ev ery DAL) ttai r les± ❑ E:.pcn inertial l ec l inu lop CtCwati�rrtrtl EC'(rr;att L�fpi UG vtinztna:lllifei€nrt'Coolifit'! i, DAtc vvcillsl aFtaintm►ed: 9-20-18 5a. "'ell location: LI h lnntstD:t Ir1'f ihh;. MR;'cideunal aWnler Stir.pl% tsinglet ❑R;sirlctiliul Walcr Snpph- isluzredt ❑Cimundnaier lte:mc-dt,,nwn 13saahfnh garner, CJSU�matvatcr Lanirdt�rl: ❑Sr&in1 rccCirainai EITrt cer C100ler 6CtiNp .lirf nr-dcr 7!zt 7c•. Scaling ulatcrialc mend (ehrcf: all that jilph p: 1-1 Ni;m Cement Gniot n Helw,:tnlic Chum;. or 1c11,^:t ❑ Said C'¢s erni 6fout Cl Ur. L h.% ❑ Coli pac Grour ❑ Omit C ttlltnul ❑ S1craEtr Grout ❑ Chanel 11 f3emornre Stint II Cttkr {evpianl Illtdo ctr 'f. For each tuaterial wicc•ted abnv'i% ttrot idc antntnnt (if rnaterialc la w`d: ?8 Provide a in•iet desrriptlun of the alrarduutnent Itruce-durr; Used tremmie pipe to grout well from bottom to top of well. James Pendleton Residence rfqarf,ThVrC'I Millfu; Gg::lrte IDAilffappteattir . Ctettific:ttiun: 115 South Point Dr. Belmont, NC 28012 1 `�-.`:�' .t _1;', 9/28/2018 ('kzr.al.-tdrltG-ss.Ciw,vaiiZiff '•;' ��: r tr,rnrl4',•Ilflwarsl I).zr: Gaston tar rr �r!!z� ¢rrtn. r tt�vv;t"r �erPlrr 91"1 ;M- :rrilJt= ertr !!r 0-W01fl-Pi.-uq.wlrr(i'n:rtt sari ,, Sinai, rt r'0fl l irl Silt„ f ',-,11,d lhra heo, ftn r!C'rd tf, III, - Sit, I.alitudr Anil tnllgitudr in itvgrvevininit tv,i-w nnili fir tieritnti dlyrre s: if: tsclt rx1d. vilclnukurr ; ,ua3ica R: 35.180833 h 81.018784 to. Sitc dial raul or additional %veil dt-islils. Von near trail tk hch of dais p.tec 10 plov ide Jlddiholi tl -,tdl yilc; dctnits or nncll 1t aLttndennwra details. You nnty i&,% amwulf Jttlditiriunl pa, s d m:cc%saf? CONSTRIlUnONDETAII.SOFWEI_Id4iBEING ASAtiDONED SI-RNIITTAI i1S11RIICfION .Cn,:c it n.h c - ,.r.�,r�lr<ur ,I c.n-,:1. � e�xa;,, .,. ; im n,u'°trdc ;tttr,tlua .0 r -t u._,. ,lr;a.•h 1 t K Ail I4'•l1,• '' b 4. oa. Well 1114: #1 Mo. Tulin it dclith: 110 flt.t tic. Sotvitnicdianxter: 3 film bit- Waterfriel liclanv grinlitd "trfarc• 20 ift.s A. for d.. n moil IIIts .(!In[ 11nlarn ,,, INS Ill Corriplefunt of %tell ahtandimr nctnr to the rolinwing Vi isiun of Water Rewurce%. Inrormation Prtocessing Unit. tiff? Mail 4crvicc Ccuter. Rtdei-lr, NC 27ri99-1617 Mil, Fur, frokctlun tk'cil,v: In addui,llf Iu scidinl! tli:. rurrit to lik iddluss tit l0a aGnve. atso Sabha tuae ::op}vN tllis fitrnt %611411 ,ra da}s of walpletion of %%ell ai nrv3uruttcur to tlac iolluwilws 1>lvision nr Water RL-Aturcc. l;ndvitround Injection Ciantrul Progrpru. 1636 Mail Service Center, Raleigh, NC 27699-1636 be. fluter easing length fir 1�rrcvrri: (ft.) Inc for W ." er n n ale i lni • n % `-ltc: ha adilattvil to ti-3itn, the form tr+ .) the addldsslA t itiacrne. also tiuhutsl vane opv of this k,1e11 tvtthin in (fats fsf zolli atettau of well nhaudnnnacnt III file cnulnrc I1=111t dapinrrnem or file .0111Hi uF> rr nh�tndnrc d 6f. fnnerrrtxin,_p'tttirnp tru8th (if knttvvnis (ft.) fg• Serve" length (if krnnsui; (M) ii11'-,If ywIL I dmllta 3'e rinr fan tit Lt., lttarlbcnu .110 ,'Smut [ kaa rf:it� - Or. INwa of 44;nct.: unr_c> `IA n,Cd AltdW7 2011 NVELL AB NDONNIENT RECORD 'Pus fbilo ou lit! ustid for::wvLt or ntkdripk I%Ok 1. Weil {'norractnr iltfurftrfttinn: Robert Miller Os'ciiCflt_rdrtt:rIv,wxWtu,dImitic IIxs'uetlP,s6a.dtIII u_ttc?lsth:.t_IIwxlcn3 t 2675 N *VV01 Cbnt>:ua!,rCcni^,,: ,Iwu finals* T'�ir:nSttJiGfi t_ , Oh:1.Y ltFIT ABANDON1EENT DETADS "a. ,Randier tiY tis�cU+ ttriu{: utrtruiuucrl: 1 OV-)' *NU .uvaw vh i a+ , %pwwa, ow oi,, +. Vt d7i.' f.OYq .1). Appiffixintatc vrilusiw of mwerretuainfnm- to welltri: tgw.) SAEDACCO Inc FOR WATFR UPPLY Wri.1 S (1Nl_l: F.Pj-- ju% 1,;arttt. • calcium h chlorite 7r. '1'ti pc offlisinftxfant used: tf. YA 2.;fell Con:+ttttctiuu Pef•nlit 0.*Gaston County Permit Application, , 1n.i'iin sr,rt!!%I, ,nr,+r. i. .. '„n u._ tt ,t r., ." -u-,r. 7d. AruatrnF of rli6iufrt [ant used. 1 oz J. %Fell irw flcllecl,well wsck W.1rer'silliplc %Vvif: ', CtA+�nadtncrl C1Gro[t[crn:,-tf f.f3catir,c�{'nahn_ :tuftpi�,t ❑rtrtlrtitri:ll�{ t}[ilrrit'.r47:ii Non-liVawr Sti fil7h' DAyttitcr )tcrh[figL Driilarlfer �tttnt��c are5 !t'se.`t'cr� Gtikq:ril%r 1'vst IDE47aentrltut;ai li buctogi i It_;4ty[twa:rnttd {{'ttiScil f.awiht r.IGcotln:€nziri tflcatiriev�Cotilitir. d_ Date wellisl nttaudmred: 7-19-2018 5a. Well fatcui&)u: Barry West CJ tstrnol.i�?:rl;l'tlhlr. XR,c5idcutbI \Vmcr Suppi! 1=inpici 7R.tiic uti[al',t mci tiuppky fsh[tredi t—i. 14-c-ctivC �{:;raur-lw:laer i�.i:u[�-diatiau D4�1n6ItY 11.IrriCG DSI rntwmerLnt mue Cltii)Usid+�rtce (:;()aim) crrt.rt:er 110rlt=,i irspinin uoiler 7i;1 7e. Seating, irtmerial,s uuwd (clic.ek all rlutt Applr 1. Ot Niml C ctricut Cnmi Cl P,QwonlrC T'lulia ttr PCilcr4 D wur6c1 Celu:rrl (;full[ Cl Dn t:W CI ccll ctetirout Cl UrillCufliu_ ❑ S-,-CI ll3Grout ❑ Cicl= t t i1 Revvitirlt w Sitiffi' f 1 400wr j 111,lul Im-del 7hl 7f, Fur tacit nr:tterlal scicrtctt abort, fuv)tide arrwnrrtt of tuatcriais rrscal: Neat Cem.:1881b ,Wtr:14gal. Sand Cem.:lb ,Wtr:gal. Bentonite.:51b ,Wtr:gal. Provide a brief dcuriptiun of the attindutrmcnt procedurr: Using 1" pvc pipe Trimi grout from bottom of bore hole. i i1rA t?ttr.,t +s4uu7 11i?! (ii tt0tdt ;lilr;� tt, Cerdtlrttip)t: 1 120 Midwood Lane Belmont, NC 28012 7/19/2018 flit, si.jIAcfi1rCaS,Of.,,Juil11 Gaston ;ir sisct;ft, tins jorm 7 !f=a+br crrtrti Ihu:..z. srr.•., iI, t'attlas I:xrzzf hLitLl..aii:rtt t:u ;t'it:t 01,0iO4„ ii'- trtlY (.i i it i'1i i .,nsi rgi'f1:m ,t+'f.eri�iairl;s 40.10V1, 4 C,rj,irnf f)tcr IT. ord (rat tocn f,rovnItW ir, A4,- t,,-?l r:w'urr 511. 1 ilitudc anff tots nude. in drLrrriPintuutrcl`ucturlis or tiveitual degrr€t: ;ii=vgil icfa. u,� kwl:nt;� t. wi7ie:._t:+; 35.179226 N 81.019746 I.I. Sit, 1141:4'aat er additiouxl =vctl drmiis: Vim) lull% use On hici: of ?ltis fragc lit trst)t11 a ildthilol al Iwll ..ifs &IiII a trr dt abamlonnb ru dewiL. Vvu ullw :615c• <lcluclt tlsldittortul lrkfg:s if CONSTRUCTION DETAILS OF 11'EU.i51 BrING ABANDONED StTRmiTTA1. FNti:5TR1t9T1Q tut For All %.%'elh• Sarnil f as tt+tr[l willull ;0 c u"i if Call 1� -1 IA." 6a. WC.11 iD.#• 1 6G. 'frttaf +vrU deftCh: 95' bc. Mirellofc dlittucter: 2" lilt.( (ist. it mvr lei el train :!rruurtl vitrface: 13' ift.) t if7 uufu r .1bmulellulcnt M the Y0lln1vwIo~. flit pion of Watcr Rrmnrrccv. luffil-oration Prows vim+,=, unit. t617 Nljif !ter vice Center. Rafei„,li. INC 27699-16 1i hilt. For Iniect o" Wyfirt: III uddluot[ Ili s:ry uo, Ii.: (i01131 to 111 oldles; n1 lol: :ih, nc.:aso sultan t4tte cope A this li=rut %viiiiiu it; dap; of co-ul•lcfimi of i%r ll il'bmidoullwill fit lhC tLll1)mnt g'- Dfvi�,vlou or (fitter Reunrce-. h�ncleraroirud lnjetfl in Cantnil 1'rugrirur. 1634i 113.tit Service tinter. Raleigh, NC 27699-1636 unknown file, For Water Sunnls & firiection wdl.,: in zlddfii+ a to dill`: lht. r. ill ,,y t:c.Onirrcaxiir;icngtittjYi:[tfitvni: tfr.l dlt fddtes5(zsi :Ibll r. also sllaurtt ogle o�yy ail llm!i foltu ,tfihift lit dais of comTtcliou ni" (fell nh:u)3aauucut le, file ixatrlt &I)ln tiew ol` the x-111 A tc Ir--rc nb:[ndnr�.:d 6f. Inner rasin,lp"tuliint; tcn-gtlt (if farown): 4,g. Screen irtn;rh (if t nurrni: ForrtfU&.;n s,.sIIif_iutIft.�?)-�lr.tnu._f,i...rinrI_o+III r.;Bird"hifI,I,iii;>trt.cc,-DI-, vtvortr;i._utet:cs ac,^,cd 4uu, hti P'lls Illlio,`:w lie 11;ol for 5h2t;L: ill Imthipk %%0 1. Well tC(ultractor tnfiirntnriau: John Miller 'Nell t i t r.tciist `W.:tae_ 1,11 :,c1Lgc1{11' Ilx11vcdl, :ll!n d�etLNc h 111,1It 4337-B 11CICVc.11 Coulmd'urF .nl+• :tht=ll `inrt u � for.Mcrimlt ,'ONI -Y WELL ARAM)ONNIEN'r DET_ II:1; ia.�iltrnhercif1Fe11:6botty lmillIned: 1 rHNtli..0 ,Ar 0l-vufor ul��;.a`Y .t O Lr IttA 11RIit1,1, tl, ij4'-.v, .,'477 i'N WPI ?b..k(7gr77Lxiutate vliluiue #if 1latcr rxwnriuingin licdl(,,i: 400 kmid.Y SAEDACCO Inc FOR WA'l 'R SUPPIN WFi_I S ONLY: Coll an} tiarlu: ?c '1'} f2c of diltinkctant n!+ed: Sypochlorite 2.Well CotiAlruetion Pertllit It Gaston County Pertui.t Application, a,�r.,at ., ._.:r,r,: .�1, r�,,;. V,:1, +...._ �.� .,r,_ � n.,r.;.�_ rfr..�,1,•. � ?d.�irnuuutufdlhiulictauta�d:12 oz j. 1tr'cl1 m (IchechsvrU usek: Rater Supply Well, - CI:AN t'r«li6tl lritl [I ill2ntlCil"):tlr �t lt}ID� {iCi1€IICITiE;d {,f1 Irrii! i'ilal'rn � $1i171J1_Y',1 ViQRL51itL'n1T721'tf%11mer hlippliv IFIllpflel ❑ ISi117S:i/ 11it�i2t1n12Cf��23i D IZZ!sidelitild W;i Ct `tlippll' lsllllri'd? 1_t,ttl d3Ut1 NStll-WATCr'S1t(t111F Well: DAquifcr Rccltarg;; ClAiPlifir itOni!"e':udRtc` 1+t'Ut ❑tAilmicr Pest DE%permiciftul I'LclittoloLy i_it_rl;olltt owil (Cla Sr.(1 (..00m L"1G� lthesn 11 dtltatiluz-'Cooiilsu 1. Bate 1rri1{�} sllrau#Enned: 4/11/18 ,m. "b'4'ell hicitticln: C 1i;111urr�illatLs kcrnedia[itln 1�4aililrilsilrl7rnt nSiammmer Dmitvi_•e 1(Sub=idt mx f'omml r_frt;icer 1.1C101'n;itspkirtl il000t ,t i Jeffery & Kimberly Kiser 1 .4fl.h rh rc.t haumw. t".zcilrh tU.`.%1if;12�Ch'_:Ih4;: Kiser Residence 123 Midwood Lane Belmont, KC 2801 Pir,rsraul .;dt#rLss. C n , .ai�i r Iji Gaston Prn tti idLnul-,:rniot Part 311`,1 ill. Latitude and lnntituwtt in firdeviuial Iletr el: �ii"x�cR tx1�1_+.nb: Ltll k>n: U rnfiic:a�k - 35.10.44 N 81.1.10 7e, scaliwt#; Inatcti:lk Il;u:d (ihack all ('liar app3i ): r1 Nclt Ceallcil# mi tt 1-1 iiemittnfC' Chip, fir i'cHoi ❑ 'Sim!+L'nErI11 CiRint C1 Dr, -t.aai CI Cvnc—'tc t tom, C1 DIM C_allim.,S 0 SlvCmillCa otit ❑ lAn l el U Rer'I'?ttirc sitlrt," f;1 i_ltllt.t ,ekpinttl ltislrrl �6(1 7f. For eatlw Ilia(( rial s`lvoed All t"e... prov i4c. ;Alikowlt If tnllicriAIs tlsell: Provide o hrid' dc.wriptinu of the alrandntrtucut (#rirccrhire: .5 tons of stone, tremmie pipe 300 gals grout. 4/20/2018 wtf t : i cti aft zllrwd }t L•slltl rcismilt W,. `cfivj :l ITtic i4T i il•: •t S_I Itt • t,4)rt )t r �-:a{ /ln; r r •} jra-S 1 "r'lt jlr t. UiSI Nr ff1" a e"I'1 ftii7le 9' 1-1. site. diu#fral#i Itr addirimial well derails: vote lilac n§I: tits b-ack of Ills jmgc ill lit#,ride ildditfowti dell 61" &tok m lt,;ll I4' il;tndu.uanau dclaill-. Ymu Inlly ,dxi tvat:h :I.t!lirc-,lvd lagds if tIr ces5an CONSTRUCTION DETAILS ILS OF WELL6I BEING ABANDONED -�KAit1MT i, Ik'tiTR11I TIOV4 :iraz;r Iv.dt i vx!r:a!6.r..t[xn ��r.at•i=.'�. ! :o. t.h ipri.• 91i a1.,iY .0 �. rt a.i....r rquit ONI rl'1 lb ...w ..., • r:,f 1 r' n .:.• ...rs , nrr' IliFor ill lb' 41., v i ;1 1 1 1 Ili- tia. Well I11=: 1 1,Ir.'Dital it ell depot: 300 ift.1 tic. Fiot�hole dhorivier; 6 lin.l 6d. Witter lin el hithm -,wound irtrfaee: 33 li ._IIIIl1w ! ILS i11ITTI ,1It link .±t. 1N%S 11 :01111K12n19 Dt 11c11 .ill#ndnnmem to the ti llnt3 mg Dirisiun lit• Wa rr Resourc+_3. Pnlceskhl-� Unit. 161-1, Nbill Sen9ce Cutiter. Rji16gh. ,%C 23699-l6I7, 11111. i�nr_Itr�e lint. `cll 111 ❑dlhlfoll to --.�!IrJitt_t tlx• Ik*rlit to Ilt idtliahs fit Ufa also-atllrtni# is11t: copy of ihi5 fkMlt W1111i❑ "r1 ds}`:; O raul(tleliart ui` 11? it abElla.iunntetu lu tltt: tolluoeiu,�: Divishtu rrf't mcr Romrrcrs, Gliderl;rill lid Injectknn Crtuli7ll Prugroll. t634i Mail Se(,' cuter, 'cuter, RuleiWh, NC 27fi9N-1636 llli fair wares, Solids pit & Ill tiit �Frt lla lb •.1( iiiii to #o #Eim, file tm w 6e.Outer casln�lcuLth iifi-Howtit: ifk.9 the ,dwSsi� I iibove. dso -;uhnlir one op3 of Ihis folfil ((Rhin In dn�s if somptclimi of lull ithnrtdrinmrilt tit the ,:mIllo bc;illlt &P1111111viv of 111C colu,? tit. loner eltsin=„%tullfztk length Of Inutcua: iv Ixrc ibandPrcd ift.r 6g. Sereeu length (if t nolvn l: 1ft.l i Oilt, l`r�w-;tl 11lil?Ill( 110h1T; 1i�1Y111.I'i_t11 of U.oI:o:il'i1o`_ilmil tjlltill::(It�;,�u.iC'i-[,ii}�t:hrll of 54•.I[s .i�lilEtee,. ;f�'1:ft'�:�Ir1t:r. .I?1.: {i t� ® ®® �tt 6� 4t t��(`ii ,rf�� ®®®® t�i,fr'g 'RECORD � l��[:a�.,l.. ,iB.'1lYL�l. NNIl�t� t Iit.E��l..F[' D F,7r nit:Ti:lli O';l•i Pits I''mm :jw be us+:d for sllst 1 lit lwll rokl .wlk I. Well Coutniffor in£unuari+tn: hfE:T.1.. AR' NDONNIFNT 1)F:r: IUt Will Keyes ?a..Number (if srells betntzaltandnnetl: 1 N,It 1 t I,:r.2ae•t h.,i.t� wI •,:•.'III rat I".-I�Uwl1 -s:dra.il•,nlrt_•`.....1riv7t.-,!t:�t pl.:crcra r ` r.ntA�,r�lr. 'I;r.S.,,r . . rr� t,�;ri., a {1.5.'I1- 4220 A Nt"GVait C—mmc*or t cni°ic to ti dorttr r ?it. Apprlrrinlute rtilume of M attr rent»ittirt it, %CII(SPA E :tLl SAEDACCO Inc FOR WATFR SUPPi_l" 1l'FI.1 S ONL4': tc. 'Pepe of diminftttuni tur(l: NA 2. NVclt CrJrlSlrLlctit)lt Pelruil #;Gaston County Well Permit, , .flt.,�i..�:j _r rntrf'_: ,vr;,� rt q -.NA ?d.:kluuuut t+f tliainfectaut aid. J. Well nw {ebedi well usel: Wmer Supply Nkrll: ❑. Inzil ill -A ❑ti ntllcnrzal ;11Qwm_ Cf10Iin_ Slipph'i LJ tFE[tntitflatr�f,i}Ittlsk^..,1:�, r i-Mullici;+:11.Public xF idcniiell6:alcrsul:ph milelct ❑Ri: JdCiltittl lV:alcr wllppll' villifted ;., ,N(oll-ihater Sultliky Well: iJ14 vultorm`_ ❑k.ectte2n I ❑,4q=.lifi!s ldccleaFgr n�allti.cr l�sst ❑E Imiriteut it IL ditlAmn i:I! ititlt at:;iltrltr<r:il L.00lll Clt:'r;:titotgrna;ti ill„ttali.!'C'uoliu+t ❑i.iri)lluJit:l:,!s PWIlicdi:lticiu ❑Sadinitr Winer DSIc-mmaterDn mli_C ❑subsi(ien:c C_on:Ynll CITI,Icer fit I.11 trtb;:F ir\pbm m0cr 7_4 i L I);+te sIVilisf aban+tnuc+l: 7/24/18 5x. Well Incmion: Betty Rodden I�.z4ilrhr?hrr.;I !Jgaa; 130 Midwood Lane Belmont, NC Ph izdi durss. i l ,mt Zip Gaston 11c11rtcIDk1rrPa tile:-rliyldt 3tb. 1-a01ude awl tatr;,tituil'e ill Ifely eV,'ntimlrt'sisrcnudl ur+h-eiur;ll 11cg1TC1! til,:tl'e I Ill t:,� I:urt u_ r..:ulri- i:r_<<1 35.179764 N-81.017657 ?r. SV.ijIin+, lrrate .d,� us<d ieirr rl. all dt;It app1� b: i�t4`.If l�entiU(IS �g1,ti (.l ReriavlrllFi< ("IIOp: tlr Pcltcli Cl s:e d t clrl, l,w (.-;Fnllt Cl Dn CMG Cl t ollc -,rc brout Cl Brill Cmlin ❑ ti-c-cilti (,ruin ❑ t.irn d 1. I C'rijcdliR shrl'f% [l t-tfher {e,,glll1trl 111tJo �t'r TFurcaebmmerl:0Klcctedabuse.Irutsidt stlimult(if urmcri:ticusrll: Neat Cem.:471b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal. ?t;. Per}ridr a brief dcxrilttiuit ttf" tits attagtlugnteqt Itrttrrdurr: Grouted trough tremie pipe N. Cc+'tiflcatiall: �❑ - tmi. A f _Iiai R .II t:•,nlc.a: t ro F; dLLI d-Y-rtr>r+ 7/25/2018 Ilt.� r'til sr tfrlti•' ..... ' l ' ' 'ihll ni, srr ,' s, rr.•. ii ._7..• rii+<-Aw, ,'I" ut ,•,.., t �tl: •r,l.i { r !'_�� tJ: i�fl „ _'I il_Nr1 tl r'li l • r Y..Irr1( it n, r rr! ,:I� r�" ,,%t , rlt: al ❑ r' j ':,,':In' 1 t. r1 . 7:: at 7-.7Afm. vt ..rl:u Rt: r n '!_ Sitc 114wraur nr ldditinunt stell drulik. Voil urge to tip: ti:ld n1 mit, I .,., Itl ptiwllke ilddili •a:tl tscil ,il:; d.t;I!F, or teal t1' :irmlij lilMiju IelmL. ` mu 1111IN ith;o .1mich liddiftimull I p,-i CONSTRtiCT1ON TIETATTS OEN1EL1d4} BI_IN(;ABANDON ED Sj nNurrAL MSTRUCT1ONS a i,,. �r u.:: c: r..r _;. :. .. .:..<�. �dr:�r!.��, r.. ':rrrn �L�,•trrti,ur .rr .,r.n.�,..� �i..r�, .� .._. r;•�;, u.%r.r' nr!'t rlr.. ,rn : r�; _f. r-�.r+� �r r�..tr:.� r „ .-.�,r ru n,::• r•rvr. _ ' Eu;l. For .all l4'c16: Suiaiteq illtN lawn tcilhtis _,1::iilcs ui' canlillcltuu t)l well t.a_ li'cEl 1l>.: :lNiluienruew fit the fnlimrintm Dk-kinn td' kV.ner Rvwurmt . inrot-minion Prucessiu8 0nif. (do. Total li ell dclitb: 50 i£t.l E617-'Mail Service Ceuter, Rum; lr, N(' 2,t.�9N_E617 ttll+. Ft+r Iuicrtiou ti'clls: hl atldtliiiil lu urr 9iuf` 14.: Donal ill tla :wltlluss iu Itl:t ut;utc_ :iko stiblilii cone 1p� of ibis fisnlc within r0 dmu , of wmpletir+n of stied it{, Ri,rvillHr dlaulctcr: 2 liu.l ;t>li trl.lUmer4alt tit the Iv Ilt+GFiuL, (ilt. NVister lanrl belim 2riuuttl sur£aee: NA DitiiAml ni'tl`atcr t{txntlrcr*. (}tuletlr+ruu+l to rrtittn Ccnrtml 1'rel runr. 16341, Mail Service Center. Raleir-4b, NC 27699-16jil, Uk Fnr it` err tiu t ill f u' be r l 'rllc In :u titrsr'n to i ;i4u;! She t ens gt} 6a.Outer ca+in,len2tbliflaumit): ift. > 111e iJc€td5i�t ) ,If+:,r'i :iiso st,titiliq gale rigty 4 [Eu wall M;Iliu ru dtt' of c•:aurpictinn td" sell ah:mdrwmnmt to itic co tutis t: r1t1t dcirrnmicia of the toulln sc Ilcre philnanna:rl 6£. lino casing --tithing length (if knit is l ift.i f»4,.,ticreelt length (If 1,111m 11l:NA I wl- Ci1i'--nr Nwiti t m1 Ill.} `.:'ti.anur_n7 nl F :n1sf. I ,"ll il:l k,ul I -v_tarut - L°n sva3rni 44'aiE•. ii.: utircc+ ;t�.:cd .'+u_ra•:a;".rtl NVEL1. A13AIailia' N1E'NT RECORD Pw-. 17.Iw "'m 1s: well r:n ;il elx nI nudlil4,� isti?h L Well 011u altar litf trillaritill: Will Keyes .'.111_ir:.a.1�t'e::ci�t+•r,.Jl•�,.rxrlxt'•nl_dhab�rll_tinlr_tial �t7N3'I:z`tlt;•tle=.75t !4C- VCIt I,lfntrw,if f crt ;;1irI;Nil n.,ir, SAEDACCO Inc r �.;t 11'tjtj(115 il:l`14�' n. N'CII t anstl uriitarl Permit #;Gaston County Well Permit, , J. Well u-w (Check %%t:ll llsel: Ci `�%r�arirtn:al rlficollterm'il {1}Catrlii'{'nolin_upplt) ?_r3tnSusrti.QrC2sntrt.Cr:iaa CI auliiICtdfrhINv. Xrc!iidi:nii:d t;;slCr tiutapts r=1n_IC1 ❑K.�ui_nliul tt':s1c1 'wnlsrlL}' t lusrey N(in-watel- Snliph' Well: O\tullul+rim 3- Vxi %vr: LlAiluitCr l?f:dtlt6;C Li ilwff r: twr !.'l' Ir.d DAq ili:z Ice! CIE:potiltemA Io.Amelog_. Ctt rlttl rmai?t lxlv:ii I.�nlsi t4iCilt?t tisitl Ilia IltrleCouliui? Rowli f. D;tic itclli.y allmidnned: 7/24/18 5a. 1'k`rft t+sratit>n: C & C Properties 1,%7117h:-Fhsrrl :deny; 1Cit:lurjs�.12e1 tfelf,cdlatlau GSzdurii} Uarner n5h:msss:rtcr Drtirescr �Itlb<_it[�rr:c {_'urnnll 1 It ItIF:.•t ie,AI iiti uido 7j,i 124 Midwood Lane Belmont, NC 28012 H:fsrttl ,Jttwss.l r,.ntv;'iff Gaston t'•.ru1h It1r:dl ld...tl.. _.Itr.i¢'. , AT'i Sti. E 1611111V and Ifilig tttdl' Nt fir 111.6i :rl dey_rres: ii: r1el` 1 •1.1. ant_ I:n L u;• r:. ,ulir 35.179340 N-81.018735 r tr �ta1 ON '. 15'Et.l. ABANI)ONM NT DETAII ti `:r• Number of sielb, berm., .0nindtined: 1 •i.l -, ,.. , e, -i all i,,. .=�' o.4F_! ,.O. 11r,• ,. ?lr. Apprtl►intatC rlrintuc nr ttatcr l'Ctnniettn�.; du stell{,t°1A t;;:tt.! FOR tYhTF11 SUPPI_S" iNTI-1 4 ONLY- 'f)pC it( di-iinfeetant uscil: NA "d. ',anount of tlisint"cCt tat tiscd: NA' ?C. scalitti, InatC11i:trc 111431 (e91rCli All that appl} is U INCv f'c.ncnt {ih-�-Jl 17 Rct l;xtitc f'bip,, i1r F'elt4r, C1 tiwul CcfvtlVi (,riffit Cl Dr. C (a! CI t. oncrttr 61ollt CI Drill i ul(nus C1 Sru:C;Als t.lrunl ❑ "irli 0 I I riQLKdlit"' Kltltll I'l G lllicr tiff gAltl{ U. For aat`il nlittel.f. l svlcrtc'd .ibust; ltroti V anulnrlt;If uuttfrials usCak Neat Cetn_:471b ,Wtr:7gal. Sand Cem.:lb ,Wtr:gal. „. Pro%ide a hriefdcslription uf'the atiandionatent procedinv: grouted through tremie pipe N. CerlifiC:uinn: 7/25/2018 Se,.-.:Ilis.clfr ..aicut4'tl ��ia`s_risv ,It4ri14hirrt 1)^!e alit } t, -fn 1 ).<:'.'e+l r .r'iP :11! '•1',. '1.4% .i?,ti .'+ E' ° 4f'r 'Olf„l ,1 •'i S; t it .." i a ; oll Nf Jfil', 7 , i l:. !.'.'J &,.w r r 1. •, a .,: fir If"'!,! fHl:qu.',,. 9. Site diaeritut ar additinrtal trell details: ?'•au uuit It t tic; Gael' 14 €lw, lit : It, lilosIll,! addillAvA skid sii. 11--tilitt, ov st;•II iN' il-mi di.=r mew dcu?&. 1">>u itw-N ihsiir 1,',[,'s if C ON'STRU TION DET.-1f!_S OF NN El t_i�l BEIM; ABANDONED SEE 1111 4kIII IC'T10N5 a;,+ n - - 1..:_r_-...,., ., ,. ��n,c ... :•:,r n ur.� l,J :!urti.,,..m r u, :, !,; •i•i� ,i..r•: rr.titF nti �:.. . ... . .. .. . . ..!.-.�. „. ,,.,,:., i- , .,, ,.. ,_ ,,. Lila F'nr All 1Yrtlr• SiMmit ilm-i Ittttn nillti*• ;1 fiss itl 0111leftrn -11 tt •ll t.a. NVOI 1 ti. I'll, 'fatal ttell depth 50 iic. Rllrrtu<tt: di:rinrier`:2 tilt. Ntlttct letrl bt'tlni !rf"Inil tirrfarr: NA :ihaiuii,ntnent in ibe fiilhniine, Dh isititi of 11'srter HLslmrCe., informatiam Processing, licit, liil? Milli Service f Cuter. Mllci cil. NC L76qit-tGt i Itlil. Ivlr Init`COMI N°cllt: Ill ildtitiAl lu 5 tsditta .1 .: fkilm lu 11l, addlti.s.; lit tit;l ::Lse-siibrltit Urw _op3 iN Ihis fttriv srnliin 1+ d:sr7 el cumplcti.,X1 trl s%Jl A-im cilmem lit tits IvIlowit-- M4ciylull nl' U ater 14011nrcc�. I:odr•"r'+ruud injeclimi Citntrnl Prtrstruui. I636M. i1'iertice tktiter. tit• 2'699-If3ti t:c, t)utcrca,ilag tcnrth lit lmirscn't: NA kill Fill, tt rt. r NIA Of gXIll' v iort R'iltw In :u tWi in ;o Aw f Illl i•r 00 1t1t ,idiiti::as ) AlJW. .1r..0 •Albiltgr t+nu yi?: @f Itli.r h.`Itll ItRIItiI til dint, at Cv[ilti3l•_Ilt�il nl tell fib:Inl�iUltillCtit ft'. Illy i4jrntit lutklla llci7aitlnitii iif Ille :-dnUN stil;tc ;lh:tndorzcd Id. lnnercasinn'utbing teal t1t Cif (titnsttt): 1 itY.l 6g. SCrCt:n length tit' Iatotsni:NA IR.t " iitr. t""s .:11 NO 11, 1 :1.1111 :: •i, I ,t. I'1,`.1iat iil :ttil *limit_-: ._.,. mc°u - i."l ,. ,i to : 1, ril`.tl 1W-W! .'Ol ' I)v lizi.,11 fiu tit Withi& t. %%'ell Canti-acuir Irotiormaritin: r I ON I tt'171.1. ABANDONMENT 1)FT-16111-ti Will Keyes 1, "411111fier (if is e0to, betur libmilltint!d: 1 ONI-) 4220 A NC WV I " - 6:rl 1-11101; IN to-N, 7b- A lip nlv invale A lolls site to I'Aw ate i- rvui ainirlg ill %velkspA SAEDACCO Inc I FOR WATFR SU111111-V WFLI-1; TN pc tif 41imill Most stsed: NA 2, Well Cmisinxtimi 11ci-mit 4:Gaston Count V Well Permit, . ..... 7d. A1114111111 (Iftli8611'03A tit u-.td-,NA .;. %N'vll mw tcheck well lltio: WAIVI, sopply CI fr�.rtltsati:ll,'£'aunttc^::iai 'lilt 11 , Allater 41111FIA C]Aipuifcr Rechargz DiAipuft-r Swnwv and RL-twei, 4. D;ktc T, 7/24/19 5a. Well lice lliml: Gail McDonsld X-R�idzmuol Water Stipph. i=m.q.lci Oltu�idculbl IV;act Imipply islusreJ,) DUmiudwoci lUmediximi E]sAlmt} lklitier DSlc,nit%%iAcr Urattes-u-c D-`4rybi&_-tv.x Ctmyirul 11,4A OC Wex Ctmrciv Cart-,m Ci Reuv-orluC Pcllcj� C! 21;d tcmnil 01?111 Cl L13" i. la.n Cl lf.�,Ilcrvw 6r-.±w C1 Drill Cijilin_ Cl 1rvCmil" UFUL11 0 (imlQl 7f, r4ol, VA4!ll jjIjjkj,j;tJ %VJ,!j!(,tJ ;41)11% , 110.4t% i4j, giliv,jIl Ilf mmeriii 1, uscil Neat Cem-:471b Wtr:6gal, Sand Cem.:lb Wtr:gal. Fruvittr a brief detwiripticin i4the atianditumunt proccoluivi grouted through tremie pipe H. Ces-tifivatiml: 122 Midwood Lane Belmont, NC 28012 IT. iz,tl Addt.,�s-4. m-11 Zip tVcll I AMr-,01 m ti� CA Ch%[s? Gaston Cv.wl. M 5 t, Lavitlifiv moot lnngtlutlt in thralve'vill hill FC.""m In ill IIr 111-ritiml Iles-'rCors: 11 Nc]7 35.179480 N, -81.019180 7/25/2018 .27 f - . l _!jj I L 01il I P.'W It'll' j�t err fj" !j I II �j.,jr6iE :p5 to. Site IIi4j:$'ilIll 111' Jlblilif)10.11 V%Cll 1110.lili: `1 , 011 litrit I*o: it,,, li-,jdIII' Thh F%W"III 11CkWI1L 4dLlj1i0I0I 1s1_11 sAl. ILLM!, 01 'Adl Noo LivEaiL. Vl!l 1111W AN1.1 Aff.iCil 310IFT01til J. gt; 11 CONSTRUCTION DETAILS OF NN El -Lis) BEIM; ABANDONED Los 1: All W,11, C I d A . I. , q.�I. Well llli-i: Wt, 'Itit.111 I%ClI depth: so dill 4.C. Biwatov ifi4oriteler: 2 lill.1 tat. Willer ICA el hChm '-wiltuottl Asil-fai,r: NA A. 1) : 11314-1 Itt; 01111 tl 1, 1 it iills it Clujil 01 %T_'II In the fovlkvwlloy Ilk it0im ul"hitter- RL-lomr%:L). luffirmaligm Pivcmirtg Brit. t617 M.fil Service CroitcF,. Mileiglt.,%C 2769131-tol-1 11111, 11-1 J61111011 Ili Ill-' ['01111 to IIQ dAK-M, Ill 100 :Ibm%�_ AN* Silblijll I'm zvp} 'A 111* ltmv, %SIlhill 10 da%�, el, L:Uzllvlaim tit N%Il A7131KILTIMIC111 tit the fV11111011L. Divi,ifilti 'Ir 'A'attv Reslifircv'. 11 bliet-li#114 Culitlill Ill-ut'l-lull. 1636 Mail Sevier Ccirtci% Mileigh. NC 27699-1636 tire, Fill- WA , Sol 111 , Ill- -C j!wIt %Vvlk111 rdkii6oll i,i, ,ovbkle 11w rrl,? fic- Oil let- catoim-, feli-mlli i if Mom% tit: NA (Ft.) lilt: -:11how mle -m;hitl Ill tl;i% 5 zC,1Ilpl,_-llCIII uf trek alixid,omitzist it! tire LCM114 klCV,'WIl1CI1l ill' 111e tyll. Inner caiiet-WILthing length (il'knimn 1: 1 it,(.) in ljrjC._jb.jFjfj&2fj 6g. Set evil lCrIgill olf Loom IIj;NA I titltAY-in u,"llitc,11 111.1 :jutoji.t! 'Xtl_l WELL ABANDONNIENTRECORD T)til; I;t#n1:; ai h,: lixil fear .11 npll.ipl� 1tW#1 !. Well Contractor actor Infor•tnatielnt Michael Wilson 4t'elt t Irrl ca;ar N:Idtb� Wt +,ill nl, i%r ttirill iuli} nh t.etaenlv,a .I n.111! i' t all I 3351 A w For?, -tonal I.` ,O.N'l. rABANDONMENT DETAtI-'-; ?a. `nmirrr nr 151:##+.brim; nl>xitt#ante#: 1 ONt_i" �+ l llt riru�r'. - .rir u7rc i!1, 1". k� rvl gfr.vl •G,i7y 711..Vppraesinr lte relume ar it attar rrtttaitring in »elko: told.➢ SAEDACCO Inc FOP VV3ITT S('PPiN WF LI S MIN: Con-jwt 'Salnr._ 7c- i'vllr of eliiiitkxtattE urrtL' chlorine 2. Well CanSltvcltliir Permit y:Gaston Count Permit Application, , .i 11.1! , � � cstd.. 1-��lrnrt .. , 1, 1...... ? 1? 1 ,.�,,.._. r .. .,.... • i�r„>�, ?d.:Vnurtint a!`tliarrlrrttaut used.:65$ J. VV'rll ux (rliedi I%ell u,,O; Ll.ya?!tC)tlitinki CICn_athcnrnl tHcarlul iC tiolify Suppl} t DintillsrrialrC"e=en€ta tits[ Ci lr ri cal iu t t l ort-Rater Supply V CIF Cl %111111c qx l l r Pt Itl t'_ X FcFidcntiai Vb'lucr Supph Isin_Iei EIRLSidallial A''tucr SuPPlg Islueredi in,tcrtlrin well: ElAillntier Redtaq,L €DiCinnllY.Il xel KcIni.dlaiiall C7Ayit fee tesrtLr sun[ Rclan er u5ali€liic flamer !_14€itttlayr lest CISi�:rn.ltaterUnl€&a_r DE poi ttentil itchitol•:=_5 ClSnbsidelrr C •drat I It_ics; ltumal (f7ki"ed Iaurpl I'Trul cr I,115c- 1ott;tmjl itt .€li Qfr Cnl)lin4? fSewlill I-I00wi iv\lA7in ln'-do 71,,1 1.i)atcnrll(�tnliaudanetL 7/31/2018 'a. Well location: Leroy Birmingham rrc-.11ol fhercl Nalpe 106 Mitchell St. Belmont, NC 1'liisiz.11Addt i;5,tli.,"nZill Gaston z Fs:nlrtr ITP" . (f trpP!r. 71,IG� s ?e.. St.:alin,t inatcriais 11.4cel (nccck all that appl} is 6C i"'cm CeIn nt (Imol n Retworlac Ouli, Or rdlle El Saml t_entaill titan[ Cl Dn '(alai[ l_crn,.Tete Grow. El Drill Cnilin-- CI SP*a:ndltiCOLAIl ❑ 1,ino0 i ) R4 wonitc Slurp I I a=lllir i, +Nphvn ulsdcl -7�',1 ?C For cacti material wIccCed al?en c prosiQr anioattt far niateriAk uSC1I: Neat Cem.:10031b ,Wtr:105 gal gaind Cem.:lb ,Wtr:gal. gravel Amount:1/2 yard g. Fror ide a brief description of* the ahandunment procedure: Put gravel in well up to 701, then trimmie grouted from the bottom up. - 8-��,.rujC.yc(A�rtiticat11u1: 7/31/2018 I?d.le t7 i' K1 ,�NrIS' t ('.'!;." 1 h-c. diia utY !1 i1 .... `.1'. ,: •I":'.:' 1 6 f7, : .iil? i1 - 11",1 W i'ar_�1 lit ilil _:UY I, Ni :pi'.1 J. u!; !,a i 'd 1.4't,l_If t;iiill +.-_l r1-Wo lV,-P I a i.+'.il j1riit SNF,,,,)r,:, dil.ith a7 I n)",,"Pf1 n,i',-:,f i,.JT he, r".)' I h'."lo li lif i.1i n,•.r St+. Latilnde and lontitutler in de8mcr7trlinutr+tsorniuli far dcritnal IteLwevs: is",c<'p i �Ll. <nu Fu. 1 It:� 1•. •. n h It.xrt F . 35.180691 N 81.020318 '.!. Site 11i;tt;rain far adil#tirnral ilell cftKaii_ti: You 111ok lxs,' alai hueh .)I !hi-.. 1 gi f ill ptoil'ille 111h;w"llal ttidl slli: dttilt ;aa ^.kJ1 VV' a± :arultzntlt.trlt drutiL. You nhY tdyt atfach addition l tap..., €l Itc C-i:,LM C ONS1iIM"ION DETAILS ()F M ElllI tSt BEINC: ABANDONED SER)1tITf At. IN T UCC'TIQSS .� ..sa rt.. [= rs. .....; .1a.� -t•a` �... �. a.0 .. ,'ur nrnit!pi: :.1,1. a rr :.. �. � a.v,r^ _ ��g.. , •p. , •uini �a. i n „n., e 1 �, a .. �, .:rir. - i.a- Well Ilia: 1 I'll, Total is ell depth: 128' 11t.1 ale, Bnrehtlkdiauicter:6" lin.l 6C1.11'ater lel i:1 hrloll grounel eutfarc: ik i Itla. Fnr All "ell.*. ._tll111111 Inui ([knit tinlnn , I. taN% nl CuIllpictnitt of ooll a5:1tu11,n:ucm to the roilnwln! Dlif iMon of Wafer IW%ourcei. Inrormation Procesvim; Knit. 161? Mail -Scrc cr Center, Palch.h. NC 2?6g1t-161` (lilt. por Inikolon ►t`011. lu adi4i;ic011 ill �rdm-- kv i'orttl to 11h. il:ielwS!i (it 111:3 :It741\@. 111aO sadMlil Grnr CllpT of this tt;rw %%iihitt `10 da.%s of rumpletkni of wdl ;15ituiturnalea, lit the t`u111Gwinu Divi ioo nr Water Resmtrce:-. hralerf,rtmnd Injection Control Pro ritnl. 1634i Mail ticrt9ce (,`enter. Ralel--h, NC276994636 life. Fitt 1V etc 1 rh in iltti VV'1 Et lu aI dilion ;o tohtljt O ill e._; fc. Outer casing lc1tMh (it"iatoccu;i. 60 r tilo Ow ndfj S&t,.vl :{i}t)9"e, ;also smllnitf one of , of ill[. I(tlin m;llill Ill dn%!3 cctuplut an o#' ~cell ah,tudaninnu to the cimluly lsc:alilt dcp:inflicla art` file ;4ryurtr lch re *afkInnerl CrC. [port cas#n�.''tttllinr ilngth (il' linativn): (eta 6-.Screen leo;th (if 1:r1411%ut: 14'C.) I'orru(ik'.ca Nmlttr .uirlu:a'.II Entuiimwn ii Aid daauC:! i': 'Ir.cci - Dr: vafw fit'. ,&-1 NNTLL ABANDON MIENT RECORD '11w! l:ilnl':flit 11V Iltid for staatri of ilHd@Iirli. %L'tik I. til'ell Cnntractnr 1jiforination: Michael Wilson '.'rill I', t t;a'.tul K.ve i, a s,•:Itn%err 1%-=.ncDl% ;dta,tJ cola_ ,, tl, a h:z't t pa. rtes;%, 3351 A '.li- tt`ct+t'nmr,,clrrrt-attist4 ;liirn r�iurrd,cr SAEDACCO Inc Go,t plim '{.rite 2. W01 Cunstrtictilur PertnN #:Gaston County Permit Application, 3. Well Hsc ieheck rrell ttIel: Whet wtrpply Well: DA-prrwlhurrtl 0(icattfctrnal {He trina-Caalinr Sapplf, I Giruttarri:tirt;ttnattttt:iai '41pply Well: `i ElArinifer Redtarge L]AFpFtfer 4ttsrt_C .Hx1 K..rasu3 DE>ponoemal les otakog-, iaf.�3i,rls�ru%;II t�k,;u"i1 €.i�uf» hIZtL�itt#:ents;ti tlle.lteftt��( �o41i1aV, a. Date t1'cll(}:tharrdnited: 9/5/2018 ,%a. Well liwatirsn: CllLluniir�:Ii;}'f ftat4 �Rs=uknlini W:ucr!in>tipir tciH*le;t ❑!(rtiic€cutiati ftici Siplity v4iifred) 06romi--Ji%xet Rcnitdiaricit 01SAIllitL U.-user C1SIcnr\L;�ter tartitut_�r i7StrlrsirlrtrKr Cartirui CI'rf;fcer I_It mci(c\pliot1 IIIKlci',i For frpi.rn:ll t -q- O:e'+1. F. WELL AHAYD(}NNIENT DEFA►t,N ?a. Nijinki, of 1rc1s f1c€n. almni►uned: 1 ",;i oylifoll;': "t. 'r';l. t'r,A'1_I a a,rn-Ur.;r rr,pq; n.at,. r•ur rv,rr ',utrr re..-'W", ?h. ,Apprtliinrate %oluntc or hater retiminint in iLrll(,h %gill.) -e `t•} pe of ttiwinfectuttt trscd: HYPO Chlorite "d. Atnuurit of t.161nf'evi"t umd:1% "e. 5calilt!! iltateriah4 nACd (Clrecksll that appS} is (K NrjI Ccrnctlf Cn%au CI Helluorl re C'htlr,: or FL114t, CI Ssn3 CeFtc-ol trout CI Dn t ItL Cl Concrete �rcult CI Will Ctntin-r4 CI spxtall} Grout Cl 6allel l� f3: htE,nrre Slurlyn t�ull.,t {rsptntn nt�fa ,�,r xfr For r.ach tit att i tal wIctil ed allo e, provide wit ilrnt (If rnaieriais ttrC iI: Neat Cem.:188lb ,Wtr:14gal. Sand Cem.:lb ,Wtr:gal. 'g. Prol,ide a price de3cription of the attundonincat priscedure: Abandon well with Tremie Pipe from bottom to top with Portland cement . BRENDA SPAIN RESIDENCE FaoLh'(1-mi,:r tdn„rG r.�c�ildr Ir1F'(i;,[,pit:,tzL,,. R, CCanifie:ttlrtdt: 119 South Point Dr. Belmont, NC yy 9/5/2018 Dail. — Gaston _ tsr r)g,d;rtir daa f,rrrt ! i:,rr%,9r urt,rr rt.,it :let< urif«aP ter;: ctC! ,ntiurr„r,a,,t lie t'ea:IRt, 19trx7 hLur.l!cai l:n, r:n ;1'l'�t ,N. r,l, ,' Ir,i{! !i: t '. it , 02 ,t)lf,itt ,r- 1-,,,4k1 {I r1i I. ".'mo , ftnp .flit%Jlritl ;l t lire/!i :itt!• 1;-1_ill-d il.1% Sit, LatitudC anli lutrtrifuth• in racgritrrfi11nntl•11%velrlith or dccinrai 1141-tyres: !it ntk 1' cId. uIlw 1.111::11 ,= u13ic_crtI _. 35.180868 N 81.018441 o. Site ili,t!rauf or Addttiotwl Lrell durailr•: Frio nets Ia c 114, Ira Ilf1a rmgv In pt%%still(: itdllmoIIll 1%"^II 511 uktsils is %sell a mItdolimertl dct:tiL_ You nmy iiko arlaeh tttldirarnatl pugc-3 tl tti x; .i rA C<}NS'Titift 27C}N DE'IAIt (1F1tiFLltSltiEiN(:ABANDONED 15('t1tt)TTAt.IN. TRtt[Tlt}titi . ,Yhr. f, n ..._ . ?; �r, . u-er,., . 4..�,�s. a. :.as nen£terd.' ;!b PL...rr e. r, ir;r,. � �t;g•it .rt i: r r.xr r.,r �,.r r., , c�!r: �.,a r,. , o� n; - , ' elWit Fill -All t��Ctt.' .tilnlan IttLw tr}inl tL'Iltfin itt :IircR of cltrll(.IL'trtnl of lTyl) Ilia. Well ►D*: t.tr. "►'ot$I tteil depth; 80 ift"I I.e. Hj-ovltolydlautCter:2" iiml Gel_ li'airr lci el hclnLl ,7nittarl +urfarr_ ift.i :Ihttfulaunicru hr fhc inlhttttt Din isiun of WAter RtxNunrcci. Inrormi tion Processing Unit. 1617 Mail Service Center. Ralcit:h. Nt' ,t 69±t-l6I 11111. liirr, fnlcC(1t1n WC11N: itt m1difl:tu lu IL�� I'vitit tit file :Iddl,:ss iu taro ;ft ote.:also s4nwl trnC copy 0 Ihos 1;,rm %viibiti .10 d:a3 s ur ca tipIclisn of toell ,t :HklrnlrleHl to the tollowin_. ViO iutr of 16atcr ResunrCc*. t ndCr ertuHd lrrieCiiutl Cantntl l'royranl. I63/i Mail Service Center. Raleigh. NC 27699-td36 Ire, For WAre—r k-1 tlas_A 1111CCtirut WON: la aualitiitlo to tsfi the fcW111 Io (•C. Miter e.>irtglen>rthliflaloilHi; lft.l the .deltas+tz�i rik�f)Yc t1sa�5ulatntr a)114 4'r�t+o of flli�' ii±rlu aithift All d:tsti of a>ntgt€coon of %stll airatt3n11111xttt to the CoI1111L lte:11111 tlepiHtntctli all' file -11HIx"L LL'LLiC ihantflor«Ld Gf. Inneriasin-_-'whing length (if k-wrivH): (ft.) G--, ScrCrrl Icnx+tb t1f knrranl: trt.r farts lii\_.rt Ni,3ti:1.ill i,Itt.; LLyzdtltr rrt.;r, I:;enit..0 rtlat Nnn,cl NL::tnraG -Nis Im1ri cant ba if -ell fret' iiwlJ: of hitd;i;>lt ts�zll, 1. Well C (Intracrclr iuforuratirui: Micheal Wilson ,XVII CI ll'utol;t i;atalc i; i ;t.fl n;.ri1 I+,.•t�_I,cdl} :Ih:iiel min_ ,, ail nn 7..-; I�1 ptr{r_rt} 1 3351 A �+t` V\',c1E l�•.+]iIT1+:3,4 fcnl.'b.;lltRi: :'�II11'iT4`F I,A,J-v F,r r4b•Firil ON •{ '41YLL ABANDONMENT DETAl1S 7a. Vnlrtlrer (if rtells lieini: alm"Iloned: 1 I i IC"I . ...........� 4�.'. i•�` .rlli �.. �. ill./".1 71). Ali fint.ximate s Blume of m Ater remaining itt srrllis): 1g.d.P SAEDACCO Inc FOR WATF It SPPPL►' WEI7 I.S ONLY: ?r. '1's#yc of tlesinfc'c#ant turd: Hypo Chlorite '. Well C on.mroction Fernrlt tt Gaston Count Permit App 3.cation, _�r.,.'�•'11 _.... .i ��a;ru1 n ,i._...i.0 .1,.. inr�r�.t Lr,.uru ?d. Amount ttf di51n1'iyLuit uxti:l% 3. Wull nsc (checl4 well lisel: rlA_•tr:tttrrtrst l7l0callienna1+•,El• ttir+e�t'n�lin._Gipplt.I 1[ulusrri: di"C't>emias4:i:ii dliriesiuun Nott-1tvater Supply %Yell: ClAquil!6 ltta:han c dAquifer `±terti•e all kc:v crn. ElAgwti_r l'cs! dElz: merilat le%Amolo!.n i:IGcatltCru ai (Ci,-,sed l.aol,t 1 Irjc'Ith+:rn.li tlh.lr,al+t�Co,ziitst: J.Da#cnrlllsl:ilraiittnuettr 9/6/2018 *sat. Well hicutioll: Jack Wilson Well G..-_ilrlc:'{Pere t !carve MRcaidcnliallValerSoipls i<in!ici Ciit::sidenliat W;lter Kull l- rshtrred; K tdtarmiziis.I:ci Itcuiedulirn ❑s;lhril}. harrier [IS 11,rnntTiler Urairt:we dSiilt>:id;:rwr t:'i,ta4rui CI'ftrlcer I Iftllr i I ogAiin mi er 7rgi 405 Reese Wilson Rd. Belmont, NC Ph sisal edtir�s, 01, a&ri Zip GASTON f.-t;:ilrte IT/'.' (u 7�plr.'a(slti I'al'.lI ilI_]Il.r._:IF;rIf t1.. ,1111.1 itr• t i[iciulr and lnri•,ituitc itt thtrecsrniinun+isi'ttinid+ur dreimut dt�!rrrti: •.i:,al i'XI4i:lw1,11 a is•.uhn ..,� 35.166738 1 81.012271 7r. Scahn!, irtateri4k itdeif (ehvck all That appl} I: Ek i^ cat C citicir Grout CI Reworlirr C•inli? m FIJI.Cl°i d Surs t'elti,rii #trout Cl Drs t_i:n d 0.3twretc Clrt+ui CI Drill Cuniit_!i d Sjxct;di, grout d t_iris.I it Wr4oiliieShiro 0fIlCrtivgIliilnIwJCl'v�l 7f, For eaelt material wrieeted abuse. {avnide aot,owa tit otaleri ik ttsed: Neat Cem.:9401b ,Wtr:70gal. Sand Cem.:lb ,Wtr: Gravel Amount:3/4 of a CYD ?y. Provide a brief dcacription cd tlic almn(htnnient isrucedurr: Put in washed gravel to 201below casing then trimie grouted well from bottom to top . R, f"rt•tifle:rtioo: 9/6/2018 1).la &j rr,;r rui rEx R•, ,. 1 tt_ r: t.I o irr .4},i: ri:: weh,! I 4 v., i,, t:.', ! 0,1a1tu'aard .x anv1,,..-.'u,lfi_1�+Ic'{,'! rr.r:o!,:i,1_irgA1.'i1•sii.�rirrl+ro,tir,i;,.!•11:i ,I- Site diAlvilul rrr J1,110tinnal troll th-tails: Voll nctc Ir.1. tit ls-jcl; of ¢ltc; j%M`.' It, ptaiside .11h; nIA ,sell _ii:'. 11,1 tl•, tsr %$,li 1ti a?:trulontn.`ni JcCtih_ Vole niiit14l., utlach ad=Jilx,tild txtgx5 i! t tcavlln CONSTRICTION OETAIl ti OF 11ELt_{St BEl1C. ABANDONED S[ RMl'1TAl INSTRUCTIONS : h.r��'. ..:.-. ..,. ,,..F .. _:.. •-�,... ._ u.nl,... ... !:� �.i. ;.i .. :n,r•tl.a; ....a r.-a-.,r_• ui,'rr4 :•iir. 01 . is F4— , Owl,. o: C r .• ..• .rtier..; r n. •..• kUA F'nr All 4feth' Suhntit tht lone triihi t 0 J o s of ant lettou of a •il Ga. Nell ID*: h(r. Total »ell depth: 160' Ift.j rie. RNtreh,ile diameter: 6" lin.i hd. Wilter lrlCI 1101111 zrnttiid Nti-Gicc: :Ibandellmew 141 the tiilinu ills-, Dii isitin of U mer RewurcLw. inrortuation Procemim, Volt. 161' Mail Senice C'euter, lfatcigh. NC 27699-160 111h. Fall, lnicofor) Ir aQddi.±ii to ;,ciidlrr3 ;ir: form to tine Tddl, , ill 10:j aboxe. Aso siibtatil v-11V cvin of this 1i,rw ssilhhi ?It &,15 el imayleticnt ul well ahalLIu11111elr III the tullowists. Division nt• %Valor l "cool ee . U 0141C trtnrrill 111jectknu C?,thrill llrat;ranl. 1636 .Mail Service Center, Raiciwh, NC17699-1636 tlii Fat W ret Gr 1 11% i ln' v 'nit Welts h:, ad( 411f w t iirt:: ?hc `stti ?w, tic. Outer casingletl-,th iifMurssui: ifi.> III" rddWs«i.y 3- )t e..listo snllfwt of o, � � e. al ton. tiYrru trt"hhi In d:i}s 4f toulpltvutru of si,al ilb.'ildnrtuicol tc the c -milts 1Asrlth dc)txt^.%nett or the ."votes l=f. 1[rnrr casein•; itttltina length of h7trrrs ilia i#'t.r lA'h-tc ah=nr:d 6,_,. Screen letrkth bit limit nl: ti't.? I"'pit(As:-i11 itit,_tip(11�ill,:?.k{l_IIIIf::4••-rt[,,,tI::U�1lititli,nit °illlrli::i t1;.:1 ll_�li LFiV tSt�ii ni !•1•;IIs'1 i!•.^iUlil:�: :.i�':lid ��Ilr.tY �.:I�Ii WELL ABANDONNIENT RECORD Dws folu) clati, be uml for s,iomk of multipte %kOls 1. Well Contractor InfOrtuatian: Brian Ewing Well ClImmoof N+ zlw l"'I akdl ilq,Jtcf I.Vmowill.) :111awl'olilig "dhw livi"Ixt tw.;Wfl} 4240-B NC WO CImmoor NitxvivT SAEDACCO Inc Coovall� 2. Well Construction Pertitit #,Gaston County Permit Application LJII J. %441 use (chedi well uwI, Water Supply WOU D A gm-i it ri: tra I 06cotlienwil d4carvtkv;Coolin.,- Sapplyi El industhaVit 011tignixt) lion -Water Safittky NVTJI. DMonitontig Injection Well: 11A44infer Recharge DAquifer Sgoragv aixf kt�:oven E]Atpllf�r lest DE%lxiomewol ledjnolojp� t-lGeodwroull Wk-twd Loop� 4. Date "rillsy ahandoned, 10-4-18 AAAVell location: Frank Tamberelli Residence 2011esidctaiifl Water Surp4 (FOiiglct EIRCsid—clitild WatcrSurfitky fslutrcdi 00Toundwalet Rcniedi.ttion 0salluiry Hatter ostoroilvater Dntnagc DStAni&rx:c CotAntl OTnicer 127 Midwood Lane Belmont, NC 28012 Islet sisal AddN,,5. Cit,, atul Zili Gaston JIM Sh, 1,4001de and hulgituttv, In or deeitual delves: 44'wel; rvId. um hrtoig I, sWTICa rji 35.17890129 N 81.01892897 CONSTRUV"ON DETAHS OF WEL1.4S) DEIN(; AUANDONtl) .1fial3i, odl "mMm"firw midty4r lmmllflyr III` fv10,WdA0, ,wl, (1NLk'i#mIi Mv 6A. %'Cjj ll)#:N/A tol).TwAl well depth., 300 6(t Watvr level liclo-A ground iurfAcv.. - i 6c. Outer camug, length orh-nown): 177 ft) Of. Innerrasina4ulling length (if known): _i ft, 4g. streen lcn*tb of talownf- tro For 44cm;ll Vw 0,41 V WFLL ARANDOINNIFY17 I)FTAII-1; 7j. Nunither Of w0ls heing ,, abandoned: F,k" rvidop?v oljecl;(m 'Y' ... vw 111?111�^re-Ilfll",.41,)IP'ell",1;011. $00 71P. AlilinavittlAtr I 11JU lite fit " attr rrininning In iv Cll(,jj: tg al. FOR WA'TYR SUPPLY WFt�tS ONJ`: 7cType of disintivtatit tiiied. Hypochlorite 7d. Amount of dWitiftectAnt #--Ld. 1 70 Scaling TuAteriAls uwtl (dierk all that Applc): IX Nall f7cawto Gitinit 0 El Sand civincla Ganu 13 f`,0DLn2leGr0Ht * S;xLtalti Grout * Walorure Kfurty Cl Dry Chi% C1 Drill Cuttines 0 G", I el (I #:)Fbcv (explato 1OAct 7y,7 X F40V vad, material wicctcd alcove, provide AlOollut (if InateriAN useij: Neat Cem.:471b Wtr:7gal. Sand Cem.:lb Wtr:gal. 7g. Provide a lork-f de!Iicription Of the allandowntent procedure: Tremi grout from the bottom to the surface S. Criiiii1catitta: Brian 0 10/22/2 - Brian ------ Ewtng-018—, — welt Caiftrg,*11!, b%,I." Doc B , tartsfiwlm I he,-rhtertlo; t�,Jj 11N, 9, Site dint sra"t Or additional well 41cfails: You llla� IL, (IV Lack ot'dils P%tg,r to foovi& addifiottal wail sitt, &tjjjj!. I)i tktjl abatidollOtent delaiL. Yvu Olay also Aeladl lKwitwfull ppos if act: ours r ,,jA,NJjTrAL _tv5pLLrM�L,; 1041. For All Well* Sobjuil fluj form within 30 days Of complettviii j)f rail '16111ldmintera to the rollowing- Dii'i%itut Of NNatCr RCMAIM-M. fillOrillidiftIft PrOerSSillog Unit, 1617 Mail Service Center. Ralleigh. NC 27699-1617 101). Fur Injectigo III ailiftliml to scilifing Ile. folill to lle, Wdtcss ill toa 31>0'e. 31W , I:i)nl letion of well I silbittil One C,4,)P� of this filrw within �10 s Of p abandonnietH to the following, 010,0401 of Water Rootorcm I ' lotlerground Injectiom. n Onottil Progra 1636 Mail Service ('enter. Raleigh, N('276x)4)-j6j(, PIC U'al& l(WiMIOR Mjlj: Ili jiddili(ill 4(� sooityt 11W fonji 1k) the addwss(i�s) a1mve, ASO sulillol otle cop) of lhi!i form 1,011141 it (Jays A coulple-tioij Of well allaudannictit to file h-calth dc-palluteig of the co'UHA W14rr atialidtimd 1`avls snlrxsicNfiralLif L1orjft),,,,tit4b';itst it Ile, Pied ktuaw 20 1 T t ta"s"CZ, 14 ELL ABANDONIIt121 RECORD R,rinlem;ilU%cONLY: This fdnu:an be used for single or mulfil)k webs L Well Contractor Information: 11'F'1.1, ABANDONIIIENT DF.TAI[ ti Brian Ewing 7a. Number of wells bring abandoned: 1 Well ymite:luotNamicfofatJlosvitetlxt4ululliuluuedsulhl_a"llfill lu:flslFIlvWn,I flu• 1`000l14' P.Ylhe10 ru• re:di-fu+rrr• .rlyrrn., qdb O;vl_I' ,! „ r n,•rvrrlrrry,ni ,r'u,ri, m;!,,xn, mo veto wdvrllr iNh• flm, 4240-B NC Well currincaui(cniic�tfinn NnJri+a 711. Aleprinvinute sulu tie of»liter remaining fit well(-,(: SAEDACCO Inc FOR WATER SUI'P1X %1rFl.lS ONLY: Cnnyrtnv Nilmc it: 'l'vpe of disinfcxtant used: xypochlorite 2. Well Constivction Pef'mlt #:Gaston County Permit Application, , lip r.dl u)rf4;cfd,1r. we'llp-eti I ..v. Ciwrgi, Sivh,, 1 ovioirc<- ir!h•CeloIt, .•tr:.r ri',0ffovII, 7d.:Lnuunl cd disltdcCl.tul u.cd: 1$ J. Well use (chevc w ell use); Wmer Supply Wrll; ❑Agri:ulncr l ❑hftmi1:1p;ll;1"ubkc ❑(kodicrrtail (Hc:uirkp'Coolin_ Supply] MRccidrraW Muter Supply f.=fnelcl ❑Industrial,'Comnicrciii ❑Resicktitial Willer Sapnliv iElviredi 1111ti2atiun Non -Water Supply. Wdl; n jcrtiu n Well: ❑Aquila Recharar. ❑Aquifer Storage al d R&ovcly ❑ Agt►ikr 'I cst ❑ EN Pen menta l 1 •c C 11111106% ClGcotermal {Closed i..00pi 4. Date wells) abandoned: 10-10-18 5a. Well location: ❑GroundlIp-her Renlediatian ❑s:dfnity 1)nmcr ❑sternmatcr Drainage ❑Subsiderc e Control t:ffmcer 1:1Otlicr (explain uodcr 7gj 7c, Scaling materials uxd (check all that apply): 19 Nail Cemc,a (rroln M Hcolonitc Chips or Pellets CI S:nd Cement Grout Cl Dn Glue El Concrete Grout ❑ Drill Cultines ❑ Specialty Grout ❑ Gravel n Bemonue Sinn)- Ll 01her (cuplam ul►der 711 717, For each material selected above,1wisidc aniount ar materials used: Neat Cem.:471b ,Wtr:7gal. Sand Cem.:lb ,Wtr: -g. Prov ide a brief dexrilltiuu of the :ibuncG,ranicut prtlrednrr. Tremi grout from the bottom to the surface Toney Chaney Residence Frcilrh:(7trn;.i Nam; A1ciltty Ins I if uppl�-Ib1*) Y. l cr1111cmian; 125 Midwood Lane Belmont, NC 28012 _ Brian _ Ewing 10/22/2018 Plt/'sical Address, City• and lilt r1^r.lIll ,: "ri'_: 1ll�d Well Caiilwar:;r ;rc111-hvn;r Dale Gaston If orpntrjg dus jorm, 1 l emift, .math• that the u•i-N!.ct erns (ndrer rthund4vied lit l'auuly Patvcl IetLnulL.rliuu Nu.:I'1'a ,woArdrowe mitir !.?:f .b( :-i{a PyC dopy; kip _C 4:00 if oil (�rur.Ylrlfi11Jt7n ,4'fnnr�irrr/,Y MR/doer 0 rrrpr C T! IIN rt2nrrl flocs irt47r prf1V1dW1 in Mi-107U r 0iMT ib. Latitude and longitude in degmeriminutri/+muds or decimal degrees: l if %voll 641, .life I:u "fitly 1• �pu nimvpl l 35.17905567 N 81.01875542 4. Site diagram or additional well details: You mar lose the bad of ilais page it) ptovide addiliuual stall silt details or will 1Y :lbur,dunnlcru decaih. Yvu may also aaach additional tmpp s if meewirs. CONSTRUMON DETAILS OF FYELL{S) BEING ABANDONED .rfexh nrll errzartrirrtkrrc n•Crir,lrte !P' rcarlurr:r. Fier nmlrelde 7! iedipm r r ram.+r.r!tr nrrg,h IWAV rlslLY 144h rlx' heuhc rou�etrtwalrr!r ,afirirnknrreicrir. Lvrr rare enbemt rurc• i+inrt. 61L Well ID#: (&. Total well depth: 100 Orr. Snrehelc dlaucetcr: 2 No.l 611. Water kw d liclnw ground +urfacc: (ft.) lua. For All Wells: Submit then farm within 30 dm's of completion of well abandonment to the follaiving- Division of driller R"Jurcm. information Pirucessing Unit. 1617 Mail 4cnice Center. Raldrh.NC'2769!1-161) lUh. Fur Inieeflon Wella: lit addition to Sending flee 1`01111 to the Waless ill l0a above. ubpo submli one copy, of this (arm within 30 dins ill' completion of well abandonnicm to the I•ulluw1w. Dlvislon ar Water Rcruarco. Underground Injectlon Contr l Program. 1636 Mail Service ('enter. Raleigh, NC 27649-163fr Inc. Fnr ♦ filler Sunuls & lolgctkon Mik., Tn addifirm to sending the fdmt to 6c. Outer casing length Iif iatuwni: (rc Ili; addlesstea,l above, also submu tine cop) of this form within 11*1 days of completion of tceli abandoanient to itic count' Health de-parniciv of the cosnih- w'hcrC nhlndnrecd 6f. Inner raxin;�ltubin>; kr,Kth (if kt,nsvnY. aft,► 6g.Screen length ilf knustah (110 Fonn tilt' -ill North Comllro Depouwril if Ent irotumea and Natwaf Rcwimes - fin Ismn of Water R•iuu tze-i Ile%t•ied Ai4usu d011 WELL ABANDONMENT RECORD rM TMUIVAI VSC ONLY Pit& 1`01711 im" 1)4: tism fot!4u& (It lindlipkwelts j 1. Well Contra~ Information: Jack Byer 7a, -Number of welly bring abandoned: Well Colwacief N'stiw lot 'i%ll 1'itwf ts,'nolully Atilkholill, koOl if" hN.Ul pvqlcfi I pa�' wljt�' fulv or "oppi �'Vlll ONLY �1041 f-�A' 10011 r"APtfl fb'o 1-41"w'h'w'wm, weemf v�Ampe #'~ Awm 4379-B NC A" It CcnqrW.UWr ccmfx;Iion Nllork"I7 SAEDACCO Inc Coil'rzoNaTnw 2. Well Coalltructirin Pctmjj #,* Gaston County! Well Permit A _A 10-wowe. etc-, #kwovo 3, well sew rcheek "cl) use i, Witter Supply wxql. ElAprizoijun.1 00coffic-Mial (11catakr"ClAing S-opph I SullpkV ClAiltakr 11ccharg-c 13 Aquitcr Stonlrl! 4110 110:0 �Cl N r-LAtImfia 'feet OBWomenut Tochiiolop DGeorlic anal (Chmwd l"pt Ojeaa 9-28-18 Southpoint Landing xPCIllik-rifial Water Stwh !tingle) ORes-i&irtial Water, Supp4- jsharcdl OSubmile-Tice Control UT tar LIIC--Itl—,Ct-iC-VPlain —Mvitr "et 1b. Altirrtivineittr volume iff "ater remaining ter rteflij I, TER SVPPIA"WMIS MIA. 7c.Ti tt(diNinfect,4nttiscd:Hypochlorite PC -.1 1 7(1. A"Urtull Of d1li1l(IMAId uwd: 1 7r- ' Sealing tuistrrii;ls tw4 (Vht,*k all that applA): (-,I Nvol Ccalciu, Gtrliji 0 Hemorritc Chip,,, (it- I'Llicts 13 Sand Cerucm Grotit 0 Div (Ur Cl Coix-retc Groat 0 Drill Cottillp GnINCI fl 110molore SlurA 0) Other (eNfAam lowel 7g) 7 C For cwh material iiefee" abo, v. prosirle amorint iff inateriat,4 ttwd: 7Z. Provide o brief description of the abAnclountent procedure: Washed stone to 10 ft. of casing, grout to top of well by tremmie pipe. rxljrll -0% tA:f Nom F:w-041 ITO I if VPW-1bk" 299 Lake Hill Court Belmont, NC 2801 10/3/2018 Ptr* f4al Adkis, 0*, atoZip ltzar lot of W01 (M tv'r Gaston Wn fo" ons'Jorin, f netvOir Cerfifl, halt I&' win flrerv't ahao'loned III Ho' i'I'Mi wlth ' 15�1 VC-1c o2f -'C OAN Weil ( "Wilm, w"i ondillixt if cvpl� prirvidedlo Mv we/! zap pnT :qk Latitude Aml longitutle in tltl tx ftgrinirtt tr xintia fir decimal d,-jrVc%: of" C11 rxki lioc It Site diagraw tor it4difional tia details: �trtr ltuw me the back of this piw, to pfovidt adtfiijotul well site lku& or lid) 35,172953 ry 81.023732 - Won Atena detaib. You truly a[vo astach akfitiottal _Wj ims 4�ss A W jbj if w,; LQNS-FRPfj1-jjN QETALlza!QF WELUS) lid INI; AHAND,(INNED 5 1 ON M LU I -NUS] RE 0 19-N -1; drib ANJIL-Aek: Submit thig faun within 0 dms fit complefloir ofrrCil 6a. Well ID#: #1 ibantlourtlew to the rolfouvig: obTotal'sail lle-fith. 340 fft.11 tat. llflrchole dhiawtr 6(L Water kmel Won grimmixurface: 60 (M) Cie. Outer casino, length i it Wrn a), 100 M) tip Sea lc. aols (if tims"ll): (W Dh Won of NVAter Itesourre*. hifortmtt3 ftt prorcs4ug" Unit, 1617 f8lail Service Critter, Raleigh. M'276"-1617 1011. ULIAIMMM& 11, additiot, to SCIAllr2 lix form to Or tidies it) 103 above.aho mthmit one txV3 of this forin %vithlo 10 days ofconiplink8ft of AetJl abandonniclu to the 1,411tirving 010*14111 Of Water ttC5t4UrCt%, U 'uttergrimad Injection Contmi Vrogtrtuo, 1636 Mail.'iervicr (cntrr. Raleigh. N('276"-16N, ha Adifiaji to scoding the fornii to I the addmilitest Awe, also stibout one CM of Th6 Alan within In &vS of compl,clion of "cil alrint&umirtit to the coutity hmith &W-nnuctil of, the c:OHISV sAwt its rrintled M-pomcn of Fiji wounlemi afA Natural lkwitxxi; - Dn ilwit of wawr AalitiQ 210 1', WELL ABANDONMENT RECORD `110s form p;oi by tt.%A tot stark 0j niultiptC i4elk 1. Writ Coot Information: Fot Ifftnut Vw ONLY WrIA. A&CS'DONMENTP -A EL_JLI� Jack Byer 7a. Number of wells bring abandoned: WrIl Coviniov.4 Kum wi "JI oaA mt mulh U01 oll bil,'taff pmpmo t r," wuln ' 14v mm-1,fo� '- �fA"ll-i"Iyer nqqfi' 4379-B 14C NVOt cumnaor 71). Alitnuximate enlulue of vvatrr remaining to urlbsh- SAEDACCO Inc FOR WA SUPPLY WEIA-S NIN. 7c. T�jx of dignitectant vied: #Mochlori te 2. Well Can.Antion Pertmit 0- gasten qoRnty Well ?a Jlv all 4pp4co.4h, weiipwmlis is v f'vofoh , Ntw'." fom'm-" vy-hokl m-' 44!n>v J. IWCH use (CISCO. well U50. ElAquiier Recharge IDAituifer Sunape mid kc%:ak'cq r' lAtlinkt test Cif. nra€eratsl I-0:finofpp (Mmsed Lco"Pt 4, Date vkr"(j l abs"do"Cd. 9-26-18 11minucipmt?t1blu; X11milctaii)i Wmtr Stu5nigic i ofti-idruhill Wn'ter slljmt ' (Quaw) 06vollwivalm Remedumou 0slamm-titer Dn' om-w 0slibsi&-tv. Lfrmcer cnLlc — , I 7d, Amount of dWolett"t awd: 7e..Scallng materilil,4 uiwed (threk all that allilll), * Not ccownt Lies n i3cutorate mp" or NIL-ts * sand CCIM-1w cim"t 0 D* Clit. 13 ("OuLlery Grout 0 Dull cuttinmi 0 Gttiul D Lira' el n WrAmine Slum oxplaol flixiet 7C For each material let allove, provide almount (if material.* mird- 7v_, Prxmitic a brief doicrilition of the atoottlonment procedure: Washed stone to 10 ft. of casing, grout to top of well by tremmie pipe. Heather Glenn Fixilro'+0wrl Nanx r=0v1v JDN 9. Certification: 2424 Point Rd. Belmont, NC 28012 10/3/2018 Ckji.Illd Zip Im "T WC11 Chi Gaston Per ua nr ou'A''ffirlo, I tiemn't terk"t, thin, if I W wefl!vt wal fueret rt east toastaFr In I'mixi No PIN I mvjnA1'fwr RWf 1J'-1A'4 'AC 0„'f " , W 0 'r '( 02off ffi'li ir m'.rj Syifg4mh ,111, / thas a 4 opy q( dim 1-n- ard hvat becippnmded to Me well (m ner 5b. 1-4titu4c and fouxitulk In drgre"Iminutr-N/Wrooth or docimal itegrrm i iludl fi41, olic lif."Wnz r. kilirkn-ro t 1). Site 414 gram or additional wtil details: ya" Sim, use fix back of this dap to p1mide addifiowl wd) Slat area ils 0, r troll 35.10 46 N 81.1 19 W aberr otinkw dmaih, You om a6o xudi iddiriotm I jxovts d uccvssary L(-)N',1TRVLM0% DETAII:S J)FLMJA�j LIEING AELANDONNED , artKIT N vy" , wmim, ume teitw4Pm i" otAhd*k- Pio mulople wellYONLYNnul Ows,)(me USA. 3Dr Ali Sublun this funn within 10 davii tit co Ictlon of -ocil 6& well Itm: #1 Sift, Total %rd ticpth.* 345 il<. Mirrhole diatmetm - 6 in.) 64. Water ICS,jj below groan. J surface: 25 abandonnicut to the Pia isian of Water urem, Information ProceWng Unit, 1617 MaHS m-irr Center. RWntb. SC276"4611 tot). Epy-Inj fAhuL)&:r& to adifition to scoillog dr- Al"Al to 'IV Almss Ili Ilia ,#-Ov v. uh&i 4-mbuin one color of this Iona %vulan if) den 5 of movidion of 'veil abandounlem to the fallownig DiviAto tit Water Resourm%, Under gnmed Inj"llon Control Proltorion. 1636 Mail Smim Center, Raklph, N(.' 276'P)- 1636 late. In addifion SO sowalg flic Rim to 6r. Outer cliAng lcjWh I if latilwa)* 151 k) Site Wd ressit:s) jbovv. alse submit Lim COM (if ft kmm %fthio 11-1 dm%'4 of compkinin (if ocil abmulanniam to the cotunly fizalth depalument of dw 'xmity of. Inner cavingAulling loigth (if Joann): ft.S NvfxTc *u4mued 6g. strev" length of two" ul. (ft.) Fam Ceti' --41 Noah ("4mlmo D�*Ptlllvm ofuln'troumaw trA NantrAt lle-wumv� - DiN rum of Wavy Peswut Ro riiA Aiiliom 20 11 WELL ABANDONMENT RECORD of "Itiltiple w01F' 1, Well Contrartnr Inforitaitiow, John Miller Welt I"firgtiluol Nwlilef pzvxuoull�s ;Ib_wk1'1AloI;z udl III) Il' Ltf I 4337-B !,I(- 1w,11 Col"raclor INItlibcy SAEDACCO Inc Coriviol+ N41"w 2. Well C'o"Itruction Permit #- Gaston County tioI�zj _,�pp J. Well use (Clicd. well "wk, Water StIpliky Well. n-Apzuttrut I 0(kinfic"It'll (Hc"ning"C" oling J? " 01vidustriale'Contillaercial Non -Water 0N1EIjawriI:i ElAiltider E]Arluiky r7IAqWkt'Te:;A OExpeitumn(ol I.Date wrifl(Oattandone,d: 1-15-18 5a. Well kwatiton: James Hood Residence Fall: 0tiN ,Cht tics Nwtw F-AllorcipaliTTIbirz X11--skicantial Water Sopty i5ingle) 011c,"ticktittAl water limpph I (--harcd) DGrinjudu aier Renteditawn Elsafirlitv barrier Dr;iivamc ISIAniffewc Control [I-Friver !:100wi if:Nplain tljwjf `7 _gf 1219 Armstrong Road Belmont, NC taciil Addjuxs, f7b's . _ul Tilt Gaston I"wittlY IDN hr vpbz;lllts Ertl Ne. WIN) 51k, in kgrvilvininotm1wcowl., or dMaral ittlyrev"i- alj 1402 f'II:1fj' vItw L11Afig it 35.177727 N -81.027523 I- For frifcmwl t. 4x ONTY L% ELL ABANDONAIFNT DETAltS 7a. Number of ivellS beirito Alkarnioned.- t""dopi'e iflM';j'I4 ,rj 0IM-01,11t, "efif ONLY id, &� "A"Ic a10411 , Iijfekhun, r t:. Qvw o4b,n 7b. AlifirrIvintottr iolunrr of nager rentaining In vvdhs): FOB w'8TFR Slji,pl.v WrIA'S ONIA: 7e. '1*ype of ilimetfixtArn its ed,.Chlorine Shock 7tL Amoptint of di-Mufmant moll: I Oz 7e,Svoling mAtcriAs ow,41 (clierkall dwatiffisly): * NIC"a Cement CIM10 F) l3cutorint: Chrlis or Fleltrix * Solid ("tirwilli GKIIII 0 Dry C III% 0 C-oncrew Glorn Cl bAll 0111411P 0 sixcu&A 6ruol El Gravel C1 RoAwote Storm w�plwo owwo 7il'0 71" Foil, CACIN Material wiectetl Above, P"wide antonot of Inatevials nsed- Cement Grout Amount:12 Gals 7g. Provide a lorivif deserilitialt ft( die nlianrlxinaia.rxt linwrilurr: Tremie pipe method. 8. CE'rtilkadmi. 1/16/2018 A'dt f."atonwtvi w tvOt0itimr Ditic law a�4"Jlffw dlna fiowl, 1 hen-Ift cej%'o, tha, dire in rfljs, vWS ilpellej iflldrjil:owd In ival; ki; t V( it 1)24, , 0100 or -,'4 0:00 If,- 1.11 f 1'wjxpfqfrj `°4,wd,,xdx 41nd doll 'o copv q?'f)1Iv rr(,ird hv,t becw Irr-, rt'I0r,!(/ rro fiykvi-V m4wer 9Site' diagrawn, tor a4ditirftwl -Aell fle'tails. Yoll fww usiv Ilk track ,A' Ifik pgge to Inovide Admorral well sric &witt; ok "101 81' Vol I 11111k, also alladt Wit iould tm'w' it lwvs�iam CONSTRUCTION DETAILS OF WELLAS1 REING AHANDONFO _j ai�jaj_jt"INSTR IC IL NS J_ Q__ 111a. For All Wear: tiohjnif 41115, krInt Witilln '11) dMIS Of Cant Idioll of well 6AWell 1_04t;i: 61I.Totat well 41VIIIII. 85 _f. (f.) 6c. WjrV-.Iwlc 4114meltr, 2 jimi 6d, Water lejel below 84 ft. 00 OlviArin of Water Rcwurc4:*. Infortnation Prowksiftig Unit. 1617 Mail Service Center, Raleivii. N('276"-1617 1041, For taitgaloll III ildtfilk),11 10 S0691lf Ilk (01111 10 till' Wdtess Its 101i abovc. 141A Sublith ofic alpy of this fond wilhill 30 dz!i of 0,I)IIIJACtion of II,ell ;Ibmirlontlietil to rEll: follinving. Of% Won of Water Rmurre,, Undmtronwl lojernbat Colitrof Program 1636 i,81ail "k-nive Center. P.Arigh. NC 27699-1636 Itiv, F_or & Ijw�• �111: III irdditkol W VOIdIfIg IbC f0flo as (w. Outer casing! length I if known), lft'p tire, ,addles es) sIboven4lt ",tthriot one cvM of Ilms forto wiihio III tkAyti of cord pletian of well atrindonituent to the coLiniv frelifilt tkPartincrit of tire C01129Y (if. Inner earifinWiathing length (if Wawn): 01I) 6g. SCITeir length (If knotic IIIrfLi - rovo Gw•Ift ati NIIE141:11 IICtA'loTCS -- tyltimlkwof koc icd Angwz 20 11 17u•_ Iarna can b; n+;fl f+r,htitlr nr ntlthilth x�zfl> C. tt'ett ('irntractnr infer•nutti,vu: John Miller t •i.I (+f +ralnt.cx'r iu_r•. %ally :drt.cl.uuu_'.. .1 t.r a:-:'f-I t r_cre r i 4337-B ..:" 'a1`r.l: I S uOn[:..-I CCI1I' :.4 w I; :'i tnrl,c r AFt.4iiILlNNIENT DT r II ti ?:f. Lnndfircrf rtcll> bchtl::►lrrnill:Inta1: 1 i.t.v;:-V�o- ..��. ni. t, q, rri •nisi ,F•i �..^r� ?rr. ppna,cimate iislumc of water rc ummin;' In cveli(sip• 2 SAEDACCO Inc FOR ti'.-t'F R Sltppl.}` tt'Fi-! S ONI.V: f 'inci:anl Fia'U.: - �c.'1'vpenf rlasinfixtuna vxeat: Chlorine Shock 1. Welt 6m.mrtrctiuu Pernill 0, Gaston County Permit Application, , 7tf. Attioutit uftlivinficl:ttit u..itl: 1 oz F_':yell n«e acheclt %veil usct: tt'ater `+tlpply Well., CI..n:tail%rtf ED %.uri•:li?aI:III Iblic LD{icntherm.al till`::¢tt e•{'nalir> 4uppi} i XR,-;jtl wwI ` ;iier stir -ph isinclea �?txlEt ra:rlr"t;auun�c:iai fJR ialeniiA tV:ticr yuppz,V I.dLiflad:• hair.-Warcr stipph• tt'etl: tJ r�llftrt:r _Stl i;2'_'l' 9I? Cl� L�1Lq?tiler lest Lt �. :purl trl[:rtt8t I�L1.:hOt7lt%L: CI?�tsitl�antsll?C'tt,r�i:f I:nnnl Lii�,gtu u;vu it;fi ,Iriltr 'L1;,?lifii; Row) !, Mile, tvrllfs?:tb;tudaneft: 1-22-18 9a. Well location: Jesse Littlefield Property rKecvvi: Cl i�il';,ni'i:lt5;(it:? ltellicdl>I[It'll t 1s:31ilaiv li:uocr rlStsrntvr,ter Ordtct_'c D-Sltbhithrr:r i'[,rAWI i] I rsfal, C a a t r ,;, rp4un nr,•dcr '��i c, tic?aliri t rn:dcriais u; ,41 redtrcl. Al rftat altCfiy y: CI �icn t'e •ntnr {;m<[i C� Rctst,xlt[c their; ur Fcllla=; Ci Siis i t' nt^rf t._nnit CI Un C in CI ( oll t-tC 4-Irani ❑ linll C`?lthflas Cl SpLcfaht Grtult Cl a.irf% el i ] PaTrt<>tnre Klttrn r 1 I_tthur Irf of ?f. For each tivateriA wicc'tcal alrr,vc. I01'1119% V :rnn)urrt rll 111311 risrlt, WWII - Grout Amount:14 gals -q. PrnritCc cr lrrief ttescrilttaan td'nc� itlrantEuunieut trruri:Ilnre: Tremie Pipe r,,«ilrfrrfY,tralf '',n,nc r.,::ilrlc tl-J?' i is apptr.�.,hL; < H_ f= •rtiti •;ttlrtft; 1303 Armstrong Road Belmont, NC 1/26/2018 f II.cKdi xiQ6.55, t i iltU 'ip �:r:x anr..d C: Ii(i�t? tt �-. i.vr,.i:ati rn �Sc!Is M,i:I I.4no- Gaston _ ,i-abl x ttr �Pr—..»....._...a...,aa..............m,_,,.— —. ....w......,. i:,I 11 ,il Y{'.` .�. fl .... 1 Ii.U• Mt ':1'I..t Ili': 1 .. ..112 li -ill .'U f, i, rip , ;, n. i iati ..,-a. •, its lh: it: fir .i u.,. •. 71 r._ 51t. Latisudc Irnll t„n-'itutkr ill tletrccrimiuntn,l.croriilc,rr dt�-eiutiiC dtym,c�ti :lard° +ail +.a4 fit t,u.'r:. 35-178298 IN 81.026380 r. Site 114pl:r•sttII or atiditintr:rl %I Of ilmlik: ?'trtl nugc t: t fk ltatf III =.'tfr, 1-1ee III i.tt.tvade Iddl;fowIl %,:It ,Il.. ILt:iif. of x=.•11 It' at. nditnart,.nt au[ail- ti Itl nfiac it>u xtiucll ttf Iltesna rl hill% o t r s,an caNwrRuc-TioN DETAILS OFtt'ELIASI HEIN(; 'iT f3't{17'T4i t\�STRT�C'Tlf)\4 ;. rtttr „ „,, r.• ._ ,.•i , it , �. �.,.:,, lUt Fur All V4+• w liilIhI` Wulf tvnhi-,,t 1,�• 'i • � i' II r:a. Well ID4:1 Ltt, 'T'utal ,t rii rlclttii: 85 I ft. tic. RorOwic illatrnctcr: 2 fiat, Witter h; v r1 hchrvv :!nsuml +at riacr: 53 at•arxlanr€fen; In the I',tinil,Ite. Division itt' Watcr Resource,. InCormntion Prucc+siu; tiuit. If,17 ,Nl:ial wenice Center. fLdei;;h. ht' ; 7C,99-CVL7 toll. Nnr inlrctlon VVVIIIs: In :Idriliwil ICI _Y:Idaft;' ika IL-1-m ttl fly: ,Idthi,ha Ih toLl atril+ti ,abo hstbtstit trnt capg •al this i6rw .%Athiii : lr dmt, ul' vi t%ell a mIttltFnnlellt to thetnlLau'i,t_ Divi itm of NViiter It's nuret�. G11[4101lritntill lnfedhill 01111tr7A l'I-eH;runl. 1634i llaii Service (;enter. Ralcif h, NC?7699-t63b Ilir Ft r War. t .`timely & llticttlittl tir`ON ilk :0di;: 4fI w i ne! the a:aUuteriellrvth Iiflalawn): ter.} titr .td+tarsi _[ alu;%'t aC o shl:fha: oll ,% of Ifn4 iirrrtt ,%.hill vn _czmp4_1tn11 Ili wcil ahaazalnfnueu[ ni file _imili%hLI1118t clepf intleltt of file .:-a[t n to hcrc :ibananr�d irl. Griller casin�a%tti binl; lengnh tfl' lumvrtrt: iti.l tit-1,so-co, leriath orwiti,%itI: efts 1 nsl' C&-ill 'v,o1.1 afofit:a L%dllviir r: [n. , l :n IAwml"-,f .11 1 7JaftlUt I%:::i'n;ud L'i. t,wa n1 r;Ib.f _40 WELL ABANDONNIENTRECORD 'Pits faits))) ati 15t ust11 if•r' _,irrlAti rite n�hl=i rla +i'•tliz L Well Ointractnr li fin-jim iin: John Miller ,«ell t r 1�r.n_ar r<.r.rs_ i. t �.�.Ii r`•aebr l',.t ,t:ulij .tl, r,rt•I:duc •�`�.I .i .r<:_Lsr 1 r �_-.�7 r 4337-B r ;r f.r Scanai ON t4'i: A. ARANDON 4IEN'T Dr r ails 7:t. Nunllter (if sells I ill: almildtmekl: 1 U•t'l_r ,... u. ?It. AI'll nevimatc k inutile of lsalcr rein: ismig tit weelld.st?65 SAEDACCO Inc I FOIL WATE It 1;UITi_ti' WFl-1 S OIN1,V! f?:.ntaa+ 4:r=1k 7c. 'i'} pe of rtisinfeetalit use€): Chlorine Shock 2. Wull (mimnretiun Pertnll ":Gaston_county Permit Application, , €L :Arn€,curt tjI' elisnttertaui user); 3 az S. Well lrx tailed: rcell klscl: W.Ifel' Supply %N ell: ' LA gTt-;: fltIrtl atie null ?ala Ilhh_ ❑tit=ntllernaid tiHcotat;e�t"ot?lin' Suppl.'! }A I?,^;-.iticuiutl 141sicr �nt;p3s i=1nLlei i1i!ulutial'll(;<t!ulk�rciai �R :=it(clln+I44;11er!tnpph idutreJ \crri-warm- Supply Well: DMle'laksruy_' DtZt.=:r. W1r DAilimia 11CLN rgc 0Agmv_r also:!_c wui k a sell. 1r rzq!1tRcr -lest Cll_:slxcntllcn#at la. •lntcl�*�;•: Clt,�t�riletna;ti tt 1t1..ct1 C.tulill Ut;;;ttr, �rnal ,l lt,lril>r_'Ctn)Ih1t; (?r,.ns¢I J. Date trrfl(ty:rltattdrukc€tt 1-22-18 5a. Well localinil: 06t,mmyd11iltet Iterac-di: ovil Ds:Illlal} Hamer O'Slomm-klcr Drittt3_c �� i`+labsiilr_r�,e CCm�rtrl riTail4'�r ? 1 Irlii;r irll?lazn ulalcr _rrl 'c . Sealin!• Itluterials 11,14vI telrrck skit) rlk;u .ipltt� ) 1 i Nc_ti fCwmcm €gin-,€ri Li Rcl.t,mue; C'hiir oil Cl Silt u tCC11F rti f _rrr!u CI Don t Llr CI !_ ollcrele tilmus ❑ Diill fC!11hn_• 1-'! R@iil'tid€lrl: Shim i t ? Itllgr 1g4t1lillii m0el 7A,1 T£, Fill. vaeh 111.1wriA H'Irtsrrcl :Ibll%e. ttr•nside alln}lrrli (if' Imtttri.ds, itscil: Grout Amount:380 gals -lt. Pro%idc a Itrief dcurirttiaa of the attars€hramcut tm€rceilure: Tremie Pipe Jesse Littlefield Property ha�rI'll., hn �r `!am"' 1-11;:1l:u iN. f'ertiliaatirw: 1303 Armstrong Road Belmont, NC� 1/26/2018 fL,cit.rl Addrss, tfi.r?14' if„n:rr tr,n',bi?Iilsrua Ch: Gaston i91 ....,..N-....�,_........A�.m................•..�».a-........ .i eit� �:' 1"„7)11 ,. '11'i, l't. _f„ 1 f`f J. ,!,. sl'r'! �: ,...': �1 _� ,Ft�. '., ii �. . r: it /ft ,.'•ou�i;, I.a::cl L1_nl t:=:J �.:,. ,l :?.r r,n.. h... a aria ) �. i r '.J ,altar! , _'i .i_'arl ii'� ii , -, n:r'ir.Ire r s. i.r„'1; W'.'Yi:. A .1 pr t,ar,. 5tt,. L.161n11€' cmmt Illw-,injile ilk 'IeL eetiltlli till FVNII w elAlps ttt' rll'Ukllnll lIctrrvi: cvn� lut,ur a. ,urn ,_t,�1 35-178298 N 81,026380 +. Silk- diaenim nr addilitmal +sell € utaik: Volt Ilwk n 1 1, t!aci it Ill., va _c ht ps.,t ade �Irititv_wti lldl il., tit' t?�1!ntlantllrant dct,!il_. ti'au uult' lit;.• :Itdat;il :uIJirsol{tit 1c, ii _t•e�s;11, t'ONS'TRIlt-TION DET:i1Fti OFW1:.11_tSl REIN(;ARANDO\ED S1,'6111TT81 tN. TRi4JI[ONS ..,...... ., V. AIi W It- I I I , , . I -+ -i. A; ° €.a. Well ili.d:2 I.h. 1'ut.d 1rcU ilcptb: 230 Iit,l ur. Hi.evimia illamelcr: 6 litt.l €lot.1%;urr' Icsl�l britnl "rittillrl snriace: 53 Or a r. ,.1,311111 I At (.fell ,ill n.1 �., ;ilS 11. :CHlit!iet?O11 •.el "Jii 11urir?rurlcn? lu the itll5nhntz Dhisimi of W itcr [Wmmree:�. hiforomati€rrr llrwcssin�-, Emit. L617 ,flail Seniec ('enter. Ralcigh. M, 27699461; 11111, Floor lrliecdorl In.nikiiti:nl Ill ,,9KJT 1, -L.• 101111 Iu III;Ildluss to I-:1a al-uvc. also _,4A 1Iu mil: ,:upt of Ihis ii=n11 %%ithill ?o d {, s el, cu,ntl c6oat ,tt sell i hmidcliji:ln Ili the t `llimita_ tlls'iTlnn r11' �t;ttcr Ilcstmrm-. 1Clutergrollnll 1111v -thin GlItIlll Prot'riml. 1631i ,Mail Service Center, i2'rlci; lk, N(' 276994636 tilt rur�tii;lt r llr tlk' r '1.kk'4 `tl(w h : iltr oil {t, tGjilt: O to €u:.OtitercasirrttletiLgh lit'iatemnt: tft.J . (iIw ,IdSt;w�gt ._I ,1!vrt'L .rl_U e;lthplt# t111C pi)l:, ;(` #1114 ft:4'Eu :t ltlfitl In tit t5' _-01nPLIlnn tit Vre81 .lhfnidwilnalt Ri itle urilt€IF tk_1111i1 t1'plmrllew ilf' lilt. IIIM a'h_re ahaMoiticil bf, tuner rasinpltutrin;; length ill'lestnitat: tti.1 €i;l, Scree n Icrltt111 C if t:rrulc n 1: i tt. } { <:,tv 'W.;II NCall.1 ilr ll adtLlgit,."r.1 (1; l :r•. v it its 11 :it it ^3:11u12d !Iz::34t:1u iti. v 11, 1 'X;ii_`..:•._ufU_C% rltl aid :�.tiJr^^ �Oli WELL ABANDONNIENT RECORD Tbet I'mm c.an 1-w 11;ed for -dod< m 111tikil)k w06 1. Well Contractotr IriffirtnAtimn John Miller 'Nall CiI mmow Natl-,- 1"I � J I, m, mc I to =eIU1I� :dv i.'Lkwl I Ig a d w) lh,,�:L I tif"!W I �% I WiiiNIMFNT DETAIIS 73. 'Navillmr of wells twin{! Abandalled: I qq4l -el", 4337-B Cc"01,�;Twm Nim-Int ?It. Approximate volume of rater remaining in w0100; NA galt SAEDACCO Inc FOR WATFR SUPPIA WFLIJS ONIN: 0,jf�mmr N.lw is PC tpf jji.NijjftTtjjnt itself: Hypochlorite #-Gaston Count y Permit __.ARpliSation.. NL "notot of d6infectant umd.* 1 Oz 3. Well H.w idleck "ell U.S0, Water Supply Well: F-Ahawnp"114111blic LICkmlicnmil jHcatnig,Cooling, Slipplyt HH-siderifild Water SuppiN wn.glci 0 DiRc--idwital kVmcl Impiph- odiared) Dlrtiu, muo Non-% Ater Smilply WCIL- DAquii6r Riccliarg.- L'Ailnificr 1'isl DExivunternal ltchrtokog-� tmlC WN11AA 1A1011i 2-8-18 54. Well kwalion. DSImmalcr Dtl iwwc D-Sub�ickiv,:e (2owrol 111xier 7.gf 7 I C. Seatims materials nwil (viteckill that Appl,8 CI Nwl (011CF11 (irout n Hemallic Chops tit VA-TF, 0 Said C--mmm ("Imit 0 D-( H� Cl Colxvre taout C1 Mill catfilla�i 0 *X:C;At" Grmn Cl ( im% el Hemollme �hkrj) tCxpliltfi 1110C.1 7f, For each material wlected aboNv, Invvi We amming #if materiAls med. 7g, Provitte a brief dc.wription (if the allandinintent procA.Aurr: 10 Gallons of Grout. Tremie Pipe from Surface. - - ------- ----------- ------ - Jimmy Thomas Property 2080 South Point Rd Belmont, NC 2/16/2018 Ph siz.i I Addrei, Ck6, Swmj m-of :Well owmet, m W01 0,ivmrt hsxL Gaston 81 01,; Awm, I "i""whr "'I'tak ff1lf lit, av oeef'�,,t tihmj&"wf1 w ".1" NN 1"'i i VC P 00 Wcil i ,wy01e"ww �md#wt 31 .oj*l o0bl"', rvi ordiPlj4bccn pr"i'lebw-10 MT- wcY fmwr 5h,. Latigutle itild knigiluk ill tir tirchnal Jetlry". , it wCU ra:ld. am,, 1.11, 1 km?�, 1, tlllfic,-x-v t 1-1. Site INAL-1-4111 or Atlitfisnal we" dtfails. votl 111m use (bC bjd, of thk jm.g�� w Incvide ;tddiimmal ��wfl 444- tkuiitt, of �,%dl 35 11 35 81 1 23 addiFimml jp�, if CONSTRUCHON DETAILS OF A'ELI-jSj BEIN(; ABANDONED �BNIITIA , �INISTR �'T_IONS fif,�,fp 10A. For All Welts, Sithmil Him forin withm -10 davk fit:xImpicluin of udl 1 ;1blilderimcm III the following fba Well Ilia flik Wool of Water R"mircm. Information Processing Unit. (tip, Total null defith; 53 Itil 71NUI ScrVice Center. Raleigh. NC276,�P,)-161" ; (0h. Fur ftlicrtion, -W-06: In adift1k)(1 losel0fig 1bz fmilt to 11w ;ddic-S!i m koa Ammo -Aso !;irbutii mic copy` of llli5 fiqnt mflan 0loll S tyl, cwtlph'ion of weil ipr, Horchole diaml-ter: 2 fill.1 ill kMannicul Itt the I'LAIlowill.L ti(L Witter Its el griltionj MirfACC: N/A ffcl DiviOn" tit Wmer Romirco. Uinirmtrimuti Injettion Gointl Vrogrinn. 1:636 M440,15wrvier ('caner. RAIcigh, NC 27699-1636 111 tic. Outer Cw*ing lcnL,(h J it lalown).. 1C. &(�Llyalrt -�H IV & blivetion NW11%. 114 xkli(km w sovjw� the fin file advjwss'es) above, also whims mle cq)� of the, form within III chit C)f compIction (it, well atizindrillmant to ills Colusiv 14111111 Lk-Platmew rat, Ific xAllZ to tack erbllrabnra7dd 6C Inner ciisinWtothing k-,nl,,tlk (if knimm: 6g. SAVI'Le" length l it Wool* to I: F'orfl: (AY -;I! 11v!wnyzc" - U1% lfivw m :V;&,r mcd Awtwl -10 F! it Inam nr b." Ifwtl fflt ,wt)z III millripk 1%, I,., 1. %Veil d nntramir InfornmOstu: John Miller t%'rfl t ( I,t:1. ;Jrit It.I k J I I -,i1.Cr f I. I mIh, :11 rt�kl•.I11111 . el,nl II:A I_( to+trf,;ti 1 4337-B NC Vvr.lf C-,Ialtrr '.ot C m0lr ilwld Numb" 0c`:1 ��,._,.... WF.Ll_ ABANDONMEN'r DrLill_'. ?a. tiumbertlf %%tl!> Itcivir abandoned: 1 r. ,r-U r r 1 . in:, I.'-, I I -.rX, ' ?St. �ltltrft.cimatc %itlttufc nr Hato r nufittiti tit %ceflts)t 0 (gal.) SAEDACCO Inc ! f1R tt':t"C1 R 41±1'Pl.t' tYF.Li_` {1(ti t_Y: r`,m ,r„•, n.tnta 7c '1`lpe+rf afi�auii�#.tttt a ctt: :. Well C-immi-vedi ft Perrtfif 0:Gaston County Permit Application, , �'.Ilr: .II:.I;lYIf,�I,,it•r,.L I-, s'• rr 5.hb�.1:.i.u::_� .t.,.,.I ,-:Irnvrr ,d. Afntttint of disinfectant usttl: S. tVrll uti ichecic %%ell use}: tt';tter' oplilr Well: �Acrr_itfturft ❑wltutlsf�:llfl'nh1r+� L7f;cnfftcrrnd 02'earina"Oldil>,7 Snpph"I Xfd,-,idemial Miter Sii ph i=trwlei 73clthtsrrialyd"asmrrrrCi f �ltc icfcudltl 4t alcl `Tipp% . rf<lwrcds i ltl4n,,uull N(Ill—Water 511ppIy, Well, D"OvInIo'nni: Cikf"i-Il% �r: jAiladd IZCl:If1Yr ❑Atl:ti :t furt_e {f:al Rr:s:;`u} D'Atititicr l'cs1 CIC�i;i,[1taent�f1 4Cl;lw;d L.aonf h, itvrcur atiriitl 1I 1...If+ior 'F•Uglil+t; Rull nt 1. bafc.rrllis}alsutulnuetly 1-24-18 Sa. Well hlrutitnl: Kenneth Bicki Property DC.ifrrmidn:tier RQmcd6tivii DIS'llmil3 tlatrrcr 1�'71�•tlailtiiler �1t`.tith:_'e :lSnlasith�n::c t `�lwm1 r 1'r,,lcer 1 If_gl!,;:r i t:+<I?lain mxlct'. �t 2096 South Point Road Belmont, NC 1'IIr5f: 11 'l4il(i�:.y � (., ,11!!t tyl'ji Gaston `:I.IIttY C%::Ihty ID!rIitntip (i. d±L•? I':mia111Lnuls_aixln I ', iI1E,I ill. I atitufie and Itltt ritudr its tfcstreeslntiimtc,hrruutls sit, tweimal tit fire» �iftvcl61-:0d, m. l:aiknr" t.:ul 35 11 32 1 81 1 20 '0. tiaaling mateli:tl i usell (ellreli all drat .111101% 1: 1-1 Nef fl Cvalellf Gn-lali F) RemillitG Flliv-.r.trpelii;p. El iSFkt t_Cti1C3hf 4srRnt El la', Cl i..r'llcMfe itrow Cl Drill d: 411hi1` !::[ Rlt�1;�11ffC �!ISiI"t1� r) �It1r%t,�t:t111ast❑ IIfSt>dl �VU 7f. Fht' e;irif nma ri;0 Klrc'trfl A1tn%t+_ Ilt'itY111t: a�t�;ttnt Ytr ar mvrw4 ttwtt: Grout Amount:ll gals - . Proritle a tfrief dr--criptinn of the uttandriu eat procedism Tremie Pipe Grout tt, c tlnla: 1/26/2018 `^ s;lnerutt_:Iifr.del tlf�znfr_Iel%Irut'i;',31s`Tarx:I ita±e 11 •.l.; Lri' !uF�7r: it ,r 11 i.., iii!- 1 a .... '.I I ,fr7•, rl ,ll ih.��rh'ri !N . I•In. !: n,IJ': ),!_r .. I i1 r .!l1 i.;! I _I.�.II-'r:U ii'�•ii t ., r4ivl•rn, rr.Lsrr;;;� il. Sia ilia, runf ter addltbllt:d %sell tfd tils: Yam mats I !,r tile- lfacl, air t1ti; putt., fit lilovitls: i113[1iiii>n:d cl 'll :.its lktm1:� tli 'Iss,'ll tP 1tmilti ml its 1'nu may i4w'i icit li ddimilrrl latga:: if ms :tsslm CC)NS'nitiCTIONDETAILS C)6ttELLIIS1OLINC:ABANDONED S1'11At11TA1.INSTRUC'TIOXi ,I ,:-.i 14:i ,. I...1. .•. .i•:. I r. !i .." J... ,'.. 1.: ,1' Ilalri l_i �11• i!I, {�. (1„I .I If! ,I :. .... -14�1.'ll F All V2 IT- 1 I EIf l . A... tea_ Well It$#: 1 hft.'rutul arell delittt: 63 11t.1 fee_ &irdwic ifluufettr: 2 W1.1 fell, WM('t'tcrcl belim ritcintl imf#•acc: Dry ift. I u. Or a +. �uritat I ne Ittun tU1 ❑u tr atis 11, _nngAeuml :,t uell ubittAt men, n1 the tnlimstttw: Di%isfna t.if Water RL-4)nrc�-w. tritimnutian Pn)ctsaittg unit. 161-, 8161 Service C'euter. Mileialt. hC' 1.1691?-1bi' tplt. ,:err Inirctlna N'04; Its atldtficnl uI dltl: 11W I'untf to Ilk .lddlctis ul kla at ltte. sf;s sahsrlis tsne CuP3 l Ali.,; fixm wilbin zit days of t:umj)leji.,m a( tcsll A%milauttfem fit file Iv11u%rifts 91%4 i14r rif Witter Rv4mlrec,, linttetl;t�rund Iniec1lim Citntrul Pnt}:rstm. 1636 `1:fi1 Streit% Center. RARE;! i, AC' 2',619-163L t:e. Clutrrctas9n� icuwtit 4ikl¢nrtftt}: jrt.r file. Fear tt fir 5t t 11% .i:' 1n` I • intl t 0tv tit lddiO n t(% wjin.: 11w form a.,. ila .nldtes�r,. t IfC+:tt'c. :11SO ulsfntt t+nu 4.111 =4 iiu� toull millin 11; dn%ti o zollIPlcrlml id' %%,M :rh:ltfdnitimim to file i,rutafr liclilllt demimllcl:l ill file collan It hcrc ih:mJi r Zd bf. Enncrcnaln�'`tuhia;; ItnBth tiflsta%vni: (ft.s G�,Sctlria Icregikf f.lrl+atYt%%n1: fftl I'•II.1?tr:4'-iI1 hf,r',illtAlOtiw,'oollw1NY.S71 I, 1;11I it=list :l{:Ilui Jrul.1 p, 1't:ciS . L11'+.Nt,Iam :i:ILf i.�oiiicv; :1.i,i,;Cd %aLv.'21}11 \VELL ABANDONNIENTRECORD 'Pill, be linell 1`4 OXI Y t- kkell Viontractior hillitimuriiiii: John Miller 4337-B Ni, WO! �llrr. , —Ail-liN1110", WFI.I. ARANDONMEN'r nvr_ui ti 41, Nfilliller of 11 0J." betnt: almllillinefl: ONI-1 , 0 71). Alil)virvinute s colurviv.ir iiatur renwillifig its %vell(SI: 354 gals tgal.) SAEDACCO Inc FOR Ti Ile of 4liNintectirlit viselt: Chlorine Shock 2. Well Cmimniettrit Pernilt 41: Gaston County Permit Application, .\I rriq, tit jj'tV..,j jgce Ij III Liseol; 3 oz J. Well ljx (01CL:k sell IfNef.- NVA let, stipple %VvIl: CIA!, 'Noll -Water sillittly Well: DAilitita RCLIKU,%e DAilaw.r.-itorli!x _wd ev. R(,-Iro 1. j);jIC if 1-25-18 ,s;t. Well 141cmiort: 17A,ilaillijim"Cif H�:1m:dIx fell OS-ilwil% [Mirier OSI..-mvmittts Dmitrivc f I Wfrtl;.l c r%J)Ixrf 111"lef _.t:. 710. NVAlifiLf lftjtelijrs ",cot telicrk ;tit r1lat .31110% NLi fl CV211cw (irl-,111 CI Rew.,-Wiilk Clilliz, kit, Pello;. 1:1 Saw' Cclll.11t (omit Cl I.) P, (- 1 1 i.� Cl 4- oljc!t:ft: I iroll! Cl Drill 0 _S,,x:,:r.IlIv ILIFL101 0 6niltA I) Ra'I"Illic I I 7.1','l For c:jclt material %vlvv(ctf Alime, 101.4nifiv 411011AIR011 rrr ltt;jIvriAk lowki: Pri, We a altAndrintitent ltroceiltirr: Used 2 tons of 78M stone in well to 10 ft. of bottom of casing, then tremie piped with 160 gallons of grout. Kenneth Bicki Property 2098 South Point Road Belmont, NC 1/26/2018 WrK JW, j", jj: ''!;l- 5b, Lildflult, and tilli-illiftr in fill tc%,, , Ivet,11114 fir flevittlat sNj_1tTCN: 9ri,%CF i-a:61 a!11c . 35 11 32 N 81 1 20 %% 1-1. Silk- 11iiirnst1s tir jiblifiliff4l it ell livrails: VIAL net, is re di�, 11-Ick of Itit- I%I.1._'v it, ljo%,s itle ajLli!wlwl lldl •il.. IL(mt�, of 'l, ,,If j!°;trdemiw-w JvIltiL, V�,tl 11mY ilso illjol :IdJirFvwll Jqgc, o CONSTRII-TION DETAII-S OF NN ELLOO BEIM; ABAN'DONED 41. 1 _NNTR 1-1 (7T 1 (-)M- i 110, lO In , V , Aft I A oa. Well 11)*: 1 hlo,Total nell delitli: 305 Ift.) fiv, BorfrOMe 411411lotc 6 1111.1 f,d. Water IvN vl liviii" -,prittroirl svirraix: 69 .1: 11 1111 i Oill 'All Hal 11 c(lillpo1011 .31 tlr.11 In the I"ollollm"v, Diiision ijt'W;iter RLkintirciti. lrifiwtwitioti Proce.,xiflu unit. U, P Mall Service ('colter, Rjlci&.tit' 27699-l6l7 IiIII. Ffir In kmitill Is; aLlill1i'm I" ,ztdrmt 11r., lklim Iu life ajtlluss Ill IOD ;Ibme_ akil -A)lqfll ofle capes of Ibis liril. lV1113111 u-1, rualgilcli-ml tO' troll 11haidellillerri to 11IL: It'llilwilig 010.,imi -il'Warr Nv%mirvL,, fillectifill Gulfrill 11rilgraill. 1636 Mail Strvicr ('eritcr, Ralci:ih, N(' 27699-106 life jjr� (JIliter C3Njjj!! Jelin,Th_ rilt, WAter ""tillilk & filievillsil MR%: bi aO;JiTillt ao jiflarrijV11j: 100 ifiv ;Ilso smlijfjk€ oIle ttwtr +f Illis I-Clof -millill Ill th%5 -A 'Zotlifik-Ifoll kil, aMildlijilm:11t [v file 'lelmilliteir, '11, lite xllms' 44. lioncr casin-W'Whing Irngtli of liumsi it): tft,r1v6:rO tn-,. Screen lerigili Or Limit " I: I R.,., Kwlt t;w--,(l r-Al. I jhltlu. ...I Ex. lf(,Jwcll ji.1 Llr;Sz .. lot ARMW7 �0 WELL ARANDONINJENT RECORD 'Pill I'mm :ml be used for snt,�[- tit fnnlfifrle' ii lls L Well C rintractnr Infirrinatian: John Miller 'X01 CMNI t OLA NAUte 441'Adi i+a4a x �lmat wpcf,�.I 4337-B NC `W-11 I' mrricum Ccrvt-, ;Ifor "3airivT Fru mim it i .A� ONLY - VVELt„AMSiiONNI NT DE:TMt S 7a, Nimisber (if itelts heinr! Abandoned: 1 �•qswid 1G' t7t1,.,t+wt ONLY ,rr.' sratFr;. t t res t`¢ n 1 -�rGAa ter. > .,. , r hx,itt f irs: P'Wmt 7b..11rptttainratis iitluure cIl *i atcr rentatnin y iu reelidslt 215 (g.d.i SAEDACCO Inc FOR WA TFR SUPPLY WVLI. S C}ftiLY— a': iiicaar, Name 7r `frlreif(ilbinfretantnsetl: Hypochlorite 1. it L41 C'anstrvcti+tir Pernril #.Gaston Count Permit Application, , r iti rays .,y,,s,u.�fe .sr�<ca•hiav n. aaarh, .l .Nx4 s,us,tn i'± cJrrrt, .si. rW,wo .6.5 OZ 7d.:trrtirunt iIf dlslnfctlant usax#, 3. 4G'e41 u:sr rbcel Ncfl usel: Cl:.f+rt�irltnt;If ❑Creii.lr:tnr,tl f I�lcatirr~e°,�'( noun_ Srrplih; j ❑ :rxfu5tii^rllC�ciniitactc:ial ❑Agiaiir RcLitaigz Elrtiluthr Sionipe mA ftt ii m DAil rifer ftsl DBpntrnu mat 1ex:hmiloy,s #. Ilratc vi'ellls} abaminncrl: 2-7-18 5a,'OYell kwation: Cl l,llusis:ilt;il'3'ilb€ta MlIcWritnill Water Siippi} t=niLlea ❑lteskicntial Walca Snirph.- slimcdy CiOmflrr3at-31er ketr¢wtliatlml Ds'lliriity f3nmcr Cl St. rm r m cr LrrtimtLe ❑wubsatletx:e Uvivul Effmcer Becky Carter/Miles Carter Property F.v it€1i {1 rx r Nmiu= Fa iltty MM tiraritdi.i 0e, 2625 South Point Rd. Belmont, NC Pittsez,,1 Adduras. Of,, mW Zip Gaston t`..tauits I'.�za�cl9ti��atnitr7rt,rttSt, t'r:wir Mr. Latitude and Intrviturfr its Irr firrintal de !I . 7e. Seating rttatetials tr, clil (elreck all that apl)le Y: f_l Ncw C'cirlerii Gri3ol C f3c loofnre l7dlrfra. tie vellct CI Said i LIneltl Gralit Ci ft Chri ❑ L' irlcrete C 4mil Ci Urill Cutt na- ❑ SNCIAY Grow 0 tanivel I1 kis>aamin SbtrA n drake+cg)iarn umict 7 g) 7C Fill- c+arb material wli aed AbiviI:, pilotidr rnrutrnt Kii Itlateri4%itself:. 7g. Provide a brief dr:*ssriptinn of lire atraindonnicat Irrtrcedur:c Used .5 cyds of 78M stone to 10' below casing then tremie piped 135 gallons of grout to surface. li. iLrrtttlratirni: 2/16/2018 WruiraF L eat l w'.ztei"na4 %w,4t`imlrr,l�irar :4.c31 & iivx.:r T F,al bI c ,;r,,ra;, rht: ti-w'm t twtvbr r. , 01(i ,,a. IM.- et 4 Y ..• O te. r1,.' rrher irl��tir°t1 air .rr „swlat."h? 11ifh YJ'i .'+".-ft'r)-,( t: (a7t1 ,r,„a `. i-Ncf ll ,vli f:ttc'irdrtt .�`r.iss,; tPStt,y 'nvif1m;41 cojniidthis „Lvwdildlheo:pr",tl.-d&, h.-ws,-i unr,i- ¢ idh dl91`. ftl. ens I a h tti: ae.>atlYiczF:.r t 1, Site dfsrLratn ter addittnnal well derails- y1m l 1111rc' The lka beef nr'tbis r*n!t fit iImvidc ,rslttiiii-mml iiell sale. &tmis o fi U 35 10 35 N 81 1 35 klitalr,nriir.rn details, yto flimi alsc, itidrach awirifrn.rl pzgws if axss!f€av, CONSTi U-171ION DE'T:itt i OFWE:LLJSf BVIM:,kHANDONEC! . iitiutt nIP. �w,rr,a.r P raa ,, t�x %eu uat�s^� l::v nri,aepl`c° .I,a�tJui7 or r, u,r,aJ pi,�,1r r aes"I+Y'T'i'LY rsdfft t'_ wpw t71 "Pi.citw—pt „r.-.m.i ,. plo c.r, ii; rr", ltfa For All Well*- Submit ilms tcnrn wit#nit 0 Jais of 'n t6a. Well to#: 1 61r. Tirtnl Nell defith: 180 fft.l lid.. tltlrelnrle ifianreter, 6 1in.) 6d. Water tesrl belivu imiosid iurfarce: 37 - d tnlr C tin9 a. yt�. :tba vtrlm rncm M the tniliiwukg ltivisirtn of Water 11esrrrrrcm. itifnrmation Imcessin8 bunt. t6l7 Mail Service Center. Wrlciah. NC276919-I617 ttlti. Ettt hilettlrrtt A jl,�: If; .aldltiztn 11i Stlrlirt f AkZ ttitiif In fire tbi:as rri 10:r ,Ibove. tilst, Submit true a;etpY of ib.s inure wilhilr '0 dav` trl t:Urriplaicsrt ill` wdl ubirttdc arirtert3 tii [tie tndlraxiin�. Divisirrrt tit Water Res"urces, UmIr trantuil fnjectiirn Orntrul Prugrant. 1636 Mail Service tenter. Raleigh. NC 27699-I63ti 80 ltiv, File !4' r S r iv lli r li lls, Ill 1(kliuml Ica s irdsng lbv form w fe,C}utircasirrl seat tirdiElatrtrini: ffC> ibw 1dltllesaicsl ,rbrik. aISO ntillm cant. ,.tip to dust tolm, ;ii€bin it thm 4 comply Lion of %cell abiaidimrrivut tic file caatnriv h�alllt tteplaailuail tit lite t:auru , Where .ab nxlniswil 6tf. Inner casin�,rtnitittl; length fit' kiniirn3. d#Y., 6 g, Screen tenldh (if Iarrricnjt fft.b kmp (r1i`.,tr tJrtstt i utiati[o of t,1, mouRti,tr t11%1 N'llu l Lai, i,,Km m ".V,jr, . s?y,oarrcAo tied Ateua., 201 ; WELL ABANDONNIENTRECORD 'Psis ft tlr crest he tisjM for sflkgfeot 1. Well Contractor Informillbon: John Miller "VOIC1,oaaul"t Na%ll-� fol fill 4337-B W01 Coiuncior l4allibr, IFor ZrTlencil V,QN1 V I WELL ABANDONNIENT DVI`Alf-'4 7a. Number (if wells being abandoned- 1 b'o voldol'I'r 011el 7b. Approtineur tjiluute tit water relluaining tit weffjsf., 37 gal.) SAEDACCO Inc FOR 7e. 'Cycle of dr'xinfix rent used: Hypochlorite 2. Well iCongruttkuk Perujil #:Gaston CountV Permit Application. 7tIl Amount of t"nfi:ctaut wicti., I Oz 3. Welt use (Chedi well U.Wt: WAter Supply Well. ElAi;ixiiltuett 1-1 N111111C qxt LTI lblt-. Watcr supyth I F110 EJ Wato, Sappiy 4shireif) liftlimuoll Nan-W.krer Iseippli, Well-, Dfitutjudii4ita Kcinctliatiiiii 0.1salinky Hatrict- L 100tet (,v-\'jyJaoi myloF 7gri 4. Date WC11611, Ahatul"fled- 2-9-18 5A. INCH hwation: 7C, scallilig, ulatritiafl; owd (Vileck all 014t iljlplc)- 0i Ne;ji Ccowng Gimlot 171 Helvorlitc Clup-tir Micas 0 saxyl C'eutcol f;rolif El Dii ( bA Cl (' "oticMw Grow 0 Dfill cwlitu!5 0 StVctafrs (haul Cl Ctlrncl F) 13,Jiloltiro Shtriy [71 00wr tetililiioi jilWel 7,v,,i 717. Ftw eadi amtellial selloctedabitiie. piloO41v antolant (if nititeriAli; sli%ed: 7g. Froisitht a brief dvieritstion of the almenhaijuent procedure, Tremie piped 100 gallons to surface. Sylvia Duckett Property 2738 South Point Rd Belmont, NC 2/16/2018 Ph, Lizal Addii,"— Col, 2,W Zilt '�milivvilc of WON Otltr'alvl lit W01 01e r'Ll Ditia Gaston Hl Ljgfq'g if"n"hi n6j" "he "lvfl!si """N J"'fh !j i "Ve, 510.1-41011141v mul tougitutle, its or iltritital degre": 0i'vel? fxtj, 014 1-1. Site di rant or Additioualwell details: You lifilk, Ilse dia back of1wi fltp, to ptqli'l'llle ilddillowd oell Silt cl taift, Ili ace 35 11 35 N 81 1 22thMate;naslwttiYou flilly lilyAxqach Mklitiollill jxlgos if CONSTRUCTION DETAII-S OF WELIASt BVING ABANDONED Allia"'t odil ivo-vje'! j'1"_,"Jl'Q'?': l"' OALF wiol '&�mw r . ,r_Ow, ai.'r" Ilt- For All Stilinia thoi fartit within -,0 day%' tdcat- I t it )f -it 6A. 'Aloft ID": I (11I.TotAt 14C11 depth: 66 ift.11 tic. Hombolc dittawterr. 6 thill.1 tid. NIVIlter Irl 0 behim around wrfacc: 41 ift.) ;ibutelaoinciii in the following Dii,'Won at' Water RL'wurcri. Information Proces.silig U "it, 161" Mad Strvice Center. Raleigh. NC276TW617, It'll, For Inic-Clititt Il'l""Vjj , III attillikiti to -,,clOiag 11w kilin to Ile, ;ddie: s to kia abi)xv- abi) sabinn one zop� of This flMu wilhill .11daY5 Lff 1:Uiripirflon fit wdl abarklouluiciv. tit the (tillowing: Divi,iiou of Water Resolaro". I Injection Ciontrul Prxigram. 1636 Mail Service Center, Raleigh. NC 27699-1634, Ic (we, Outer cjsinL, length j if latenA tt,'n (ft.) k". ,", .14" juiliclialt 3�N:01%': In a'dditkill tot slier Form ILl the iujdlessttasll 4?iWI!, also millitio Lille ':fro of thei fontil Within III daNb of szoitiplcljon ofivcell abaidon=nt to the cxicust4 6cafifi, &-painlicig of the ::01111CV del: Inner casingliething k-nZh (if knoi;,u): (fit) uh.-Teab.-iteltimil 6-g. screen lennh (W timollit n)-. (ft.) 'Awill Cillolou L"kinflocni �'l uflw'woetll al-4 "4111"u'f Helaitinc% - Do t%'m t'J`Wiwr llo 6,Cd All!!I'a _,fi I WELL ABANDONMENT RECORD This farm can be used for siggie or mullipte wells 1, WCH Cpatragwr lnrnnngtion_ FOT lrkFrwl Use ONLY: W E [.L A BAN DQN M ENT DETAM WA-Coumeacior Manic (or s,¢tl onlrT persoiwtl, abandmurlg, A an hK lrr prapcny ) 4379-B NC Wcll Cbnlnscior Carl ifrrlliari hlaunber SAEDACCO Inc C0111vaTly Mama 2. Wal Caastrtrtion Perm t N. Gaston County Well Permit L,Kr<Nr qr p� karble w ?Iprrmiex G.+'_ i•rw,reii, `:: 4. 1 uriam . 1,ga YJ 0M. N .. . & Wd t use (check well uar): Winer Supply Well; ❑Agrilraltkttlrl 00m1hr,mwt ftalmjg C'opling 5uppLy I ❑ 1ndu51risIK'oFnmcFr. ial ❑Irripliois Non -Water SaI" Well - ❑Aquifer RecharDV [:]Aquifer Slonkge and F C�OVM ❑Aquifer Teal ❑ExprAincn191 Trelrtlrpbe-v OGwihenikal (ClosixdLoopk LIC,eo(hemal (Hea0ngr1C'oo1i1kg 4. DMM wgIL( ~) atgndpnM- 9-26-18 Aa.'V'VdI hwation. 11hlsori0F Klil'tiblic ®Rcsidrnrial Water 4upph- f-,ingle) ❑RcsidlenrW warn ��upply tsharodI ❑Gnamidualer Renredimiour ❑Salinii; Hamer ❑Stornm,dicr Dminage ❑Subridnrxe-'orrml l7Tracer LlOtlki:ftnplain under 7g) 7a. Numlrer kriwdis brio%ahandourd. 1 F,-y nrinfupie OiNiViLUr ru• WN xwter S1V1Jf5- caasrrlrcriai 4aurdrurruerw. yr,w rxar,vb mr me j;jrai. arlh MLY wig Oke save lip. Appnrximatc airlurric rrf %atrr remaining in well(&): (Rai.) WATER SUPPLY WEL[S O I.Y; 7c. Tvpt irf 4iaofeet:int uaed: Hypochlorite 7d.:ArtuMnt of i ibinf4OAMt UKA. 1% 7e, Staling msktcrials weed (Cheek ik111lrat apply); Q Nest Ccmcnl [rraikl ❑ 13cntonitc Chips or Pellets ❑ SardCCnreW Gmut ❑ Dn C"las ❑ ConcretrGroui ❑ DrilJ Cutiiogs ❑ 5peeralry Gruui ❑ GM,;e1 n Henrouile SlkkM, ❑ C)ther lexplainunder 7g) X For each ukxterlJ selected above, protide amount of InowAals use3: %, Pam'i& a Irrlef dcscrilitian of the alranikknmrot 1prrr4x4um Washed stone to 10 ft. of casing, grout to top of Well by tremmie pipe. Highland on The Point Fxilils."vrrcrNiim Fxilils lDN (i[oppluaNel 8• Cirlllkatloil: ` 1362 Armstrong Rd. Belmont, NC 28012 10/3/2018 �� / Pin -sisal A4&as. CM}, and Zip rfir W wol U++.Cor Dole Gaston liy .sis7urig this jwm, l Irem'!ly eerrijy rlhar the xell{sJ was (*ero abandoned in COMM.$ !'arcs) Ideru "LiDu No. (PIN) iruxvr&?&v wilh 1 A ,-W'AC 02C .0 00 -ur 2C .o_w rven conalrrlcfran SFimJrirdz imd 1J'ron a copy of Nrra record haN beeir pr oWded ro the wef! owner. 5h.1�wfiojdeand lonfitpdcin ilk +ceafmirru#cilsCaindsordccimal dcucm { ifvk:11 I'KAO, 4)I14 Llr•'ltrlrig i% 4w T3;:pU l� 35. 10 43 N 81.1 18 9. Site diagram or ad41t[oilalvvell details: You may use the back of this page to prrn•ide additional well site details or %V11 W abarldon mig detail,. You ma-v a1w :aMIL:dditiOM11 pages if IkeC&M(V_ C,ONSTRIIITION DETAIN OF W£LLtS) BEING ABANDONED SMINIMA1. rNSTRUCT[JU .lrGuir vrf1 cr�mvArucJrare rrLnrs��u �b �Vml�d,k. Iru m�lrr,tr x�rr�rm rxr rae�a-wx.rdrr xup� mxlrx ONLY wjrA The= &Wet i+w Liam nr�mvi Lore firm I Os For A31 W011SE Subnril 111i5 form within 30 dsrv� of comrpletFon of well 63L Wril [b#: #1 6h. Tmal tkrtl depth:. 505 (Ft.) Coe. Bp rehrrle d larmew: 6 flu.) 611. %ViAttr krel hclnw pukind-mlrfmc- 39 m,) abpndanm¢ry tg the fgllmsing- Divisiro of W irr Rcmiuren, Jurormaruro Procnsing U61, 1617 Mail Smicr C'entcr, RalriKh, lh (7 37699-1617 mb. Four Ililettinn Vri'ells: rik addition [a sending dke forikt io the address in 10,k above_ atsu skrbodi om oops of This Form nvidiio NP days rrf uomptNion of well obandonnreW to the fnlinvrmg: Ditiston of Water R(aou rti`s, Underground Injection Ciral rol Program. 1.G36 Mail _Sm-igc lvcotcr, Itairigh, Ntv 276 "J-163d 1flc, For Water Sumbly & Intention Wells: In addition to sewling tale faro to fie. fluter ¢acing IcngFL {if I:aim aj: 161 fFrA the addFessles) above_ also sub -mil owe cop- of this form wilhin YU daYs of comptetioo of nrll aburdomnent to 1lo coumy Imtth deparinLriv of the irounly rr]�rG aia'C1r•d4rrCd frl. Jnncrs:asingltnbinp ienjoh lif knrrwnl: (ft. 6�,Semm l4ngoHh IIf hno%a):. (ft. Fame GM-10 Nonh Carol= Depannion ofEm ironlncnl and Narurat Rcsuiaccs - DIti Isuan of WiLerRL'50urns Rnkscd Ayeusi 20B WELL ABANDON"INIENT RECORD -PHS lbfw,:.Io bV ll-cil fairlId'e ill IwINJAe w0lt 1. Well Contractor 111fornlatio", For f'r4onal !!�: ONLY ONMFNT DETAII-S Stefan Smith 1 aqql(l -,ilb ONT) "ioi) Aw "w", 3576A NC Cimmulitt 6116,-,Itilm Nwli"T SAEDACCO Inc CwIvy'n 2. Well Colutetiction Permit #: I!." CrVoh. SW4,� bq,,pwu, vhw 3. Wr4l um (chech, swell u.*c DAgnzidtond 0(kilthcritud Supply I ClAqwf& RxxIwpgc DAipifcr SionweatO kc�xwcrt L'Ailuffia Test DExpt-unwinal ruchnology (J Cko0kxinal ickowd Ltwl, I 1crorhao-tial It IvatioWcooling 4. Date 3-27-2018 X Rz,iikrjtinl Water Supply 1 Fj ligic) n- Ru�idc-wial Watcr Smppkv tslutrcd) fit OGTpundwiwr Kc-inediation os'llilliiV Ilamu OStenr%vatcr Drotw-,c DSib-,jde,mc COnAml U-Fciccr r 10ttlej (j,�\plpqt tll,,klcl 7_p 71). Alsprovintate voluint tif Rater rentAhnn.- ittivell(N)l 6 (gal.) FOR WA'MRSUPPI-V WVIAS ONLY- 7c, 'j'Npc jof divinlettallit used. Chlorine 7(L Anuount of divinfcoaut wied, 1 oz 7 'e. Stating JuateriAs UWtl (check all that apple )- f2 Nail Cc2"eut Groot EI HcWmorc Chips (,it pc: IrPs El sand ("Clucui Grout El Div ("Ll 0 f"011co!tc Crow Cl Will Cirrtiws 0 spectility Grout 0 Gras el U) Hcm,'imic ShtrA- F-1 ortICI; IlliIjel 7yj X For each avatirrial swicoM abovc" pro% idc aloott"t of Illaterials owd: Neat Cem.:941b Wtr:8gal. Sand Cem.:lb Wtrigal. 7g. Provide a brief dr.,wription of the allindtinment luxlerdurc. Tremie 5A. VVell locati4m- Fairly Dawkins VxCHY 14, 106 Wildlife Road Belmont, NC 28012 plI* -ki!l ALddlr "_ Cil', and Zip Gaston ltan:IA 11"It'i 5b, 1 " -alim tic lind loughu tic in te-dwcouth or dexitual dolt re it wd; I'xid, illic LIIA'mg n "I frknul I 35.178037 N 81.019425 3/30/2018 G-liflad, W01 Glfut,,8%If tir wall OiN mf lit V)ignwk�,, Artafiwm, I e.,tyn fhm' rh' wCh , t - , - i!,= "i"IN 'ib�MiRMi'd W qct"'unlipiry 'Ve'' it, I),*(' ,Wial op-*(' il�%Itt jfi�jl ( , 'tinyttiii fwIl swnilw-e44` 'Irld it rop"v :rf flmv rv, ord ieus bv,-v;prm,(kd ftr thir w,.,8 f,,Anwr 9. Site diau-1-401 or Additional well 41cfail-S. You Illoy lAse the back of ffik pxig- to piovide addifiotud ssdl soi�, tk(mb or ,wll NN, You it lav al'yo mudi additill lilt I jra�i if IteCL--su" (,,*ONSTRlA-nOX DETAIL OFWELUSI REING ARANDONED "Mai.4 uchl "),UYUX—e Vilw"ho, ", Wifl-t,04:r ,wft, t,?.VLYwfA Ow .,Iomar wwjrw, I0- For All Wells, Ivullnut tuts forul "Vidull -,0 dav%� of Coto detail of ucl] oIL Well to#: tier. `focal Rell depth: 110 tic, %rchole ditntleter, 2 jin.) lid. Water level beltim ground "irface: 1 —jfi.) jbioelcmulcm to the followolg, Diviiiiiju of Water Resourctnt. Information Processing Unit. tfjl7 Mail Service Center. Ralciah. INC276"461" midilkill it) SCIAIng 11w Will it) lk-, addless ill 10,11,1 ;IL.A) sublod one cops of 111i'i fiMu %vilhill -1,0 dm ", el, Completion of w0l ihatndonnteru to the follulvill", Dis-kion Ot Water ROMIM". Undcl-grotind Injection corand Program. 1636 ail Service (`entirr. Rakich. NC 276"-1636 I fit, idilig 111C femll It) & lowelk)o Nvelk, 11"Id4litioll (0 �m tic. Outer camjini,, length j if lawwrl): (ft.) 114L addlusstsl Axwe" 'Aso mitillill, ogle ctlpV of this fonts widlio !!I days of -otoptetion of Nvell abaudDlioxilt ill tile couniv Iwafilt depallinew of Ific sCmw� (. Inner caNingitubing tength (if known): iff') MY= 0 60, Screen length of tun)" h,Joj, (iW.U1 Nollh ( lutlitu Em nowitinii and Ninurat DIN two pf"Walel Act !ricd kwjEz WELL ABANDONMENT RECORD This f4mlo C&I [IV wolf for ajiltpk ill 11-niffitAt w0j_-� L Well Contractor Information: Stefan Smith wd I 0,12raoi) I K"I'mc w I �vt I w1!�f pQlwwfl7 ;lIvnChloll Ig t cm luvi-v. I ilivoinIN I 3576A NIC*NVOI C-amoor SAEDACCO Inc V�Iwm , 'jim vwetu 2- XN�Cll pertn't P" J. WIL41 low (Olech Ivril tmel, Water Suplot v Well, 06collicrMll i llcargikp� ('[,)oil fie suppily I DORC-yid Water S111T4- ooligle) ORLsidoilial Water Suptiky ishared) DAquitcr llechaigm DAtiatifcr Swnig.v , :ijxl RvxvcrN El AijtftfLr Tes$ DExpcitineutal 1-oJimilogy t-16fewherfold (Mfso(l Utopl 4, Diltv vvell(0 Allandoned, 3-27-201 5a. Well location: Carl Beck R1CilvoXhvw'1 Nillur, 107 Wildlife Road Belmont (71h "110 Zip 06tvilodwilet l(cl=th"AlUn DSafillitv Warner llvipc DSlA33JdeTCv Cim-Awl r-1,rr,lccr T,,6lrj1v IDN i irappikahle � 28012 ON I v I DONNIFNT DETAII-S 7a. Number (if avils ficing abandoned: 1 �w ?iqwi, -vh ONL) t"w #av", 71i. Apprirtitnate %Muiur of water rrutaining inxse9CQ,#24 FOR WA'IT.R SUPPINWEI-I.S ONI.,V- 'r)vc of thintectwat tvicti: Chlorine U Amount of 46infectant used., 10z 7e. Sealing materials U-4"d (clerk all that 4ppit l: IX Nall Cement Gli-Au (71 Bcotonitc Chips or MICt., El saglif ("Clilem Grolit El Dry Chilk El Conc-ete Grout ET Dlil) catfin— 0 spoxill* , cifoul 0 6'ral 0 U l3cm1inte Shirt) D Other (cq)h1lo moot, 7g, I X For each material wlected Abitiv, lorovide atuoultit (if waterijis awd: Neat Cem.:941b Wtr:Sgal. Sand Cem.:lb Wtr:gal. g. Provide a brief dcAcription of the allandontuent procethire. Tremie 4. Certification: 1a 0l ('%Illtnomf "t W01 0" wr 3/30/2018 Rm4 Gaston 1i1 vignirkg fyn'. Ifirm I h'-whr ro'PIrt ow lizi- kj'efl", -,I as N1 '7n =)r'ABwv wa#: lj: i _'V!-K q- �Imolwfuw Swyja'41TC4s 5b, l'atilude 3041 liougivitik ill tle recsfrnittutrslresitrttls or decimal tivLyret-c iifwcfl r d' *1w hu'hilig 1s sIljbcvjvi It. Site diagrats) or ailditiowd well 41twils: You may use tl*, back of zlkii paygv lo ptovide adl.lifional i%dl Ali &(vok tat ,NvIl 35.178249 M1 81. 019244 AN' dewiL. Yuo may A-wi,slack wAlitivivil pp�s it C'ONSTRUMON DETAIUS OF WE11.441 HEIN(; ABANDONED _jLi 8 NJ I TTA A JUN5_1 Lul 110 N S .Wadr "r"'bv ONLY 'wh th" upow wq"Ifh 01andi"mi'vq, 1'w'. "w z117'wfj "liar, IOA For All Welbi: Submit this twill within 30 dav-s fif �-.am ilctujjl of wdl 6a, Well I0#: MP.Ttititl wt!) de tith: 177 ift.1 tic, fk-*tvju)lc &atjjeter; 2 Jill.) 641. Witter kn ell beloil graund surface. I (fto abandkkimiew, In the rnflowmX Division of Witter Resimi-cra. Information Processing Unit, 1617 Mail Service Ccater, Ralevith. ISC276949-1617 1011, liar Inivaltill Well : In a(khWo it, selAilqg lt� forin to likitildress ill kin ,ibovc. alw el, f.wilpteion %if well ,rise? sarbiou one capy �")f This f�-'nu �vitbhl .10 abandannictil it) the ralltilvill" Divh0o" of it ReNoorco, Usiderg!round hijettloo Contrvil Program. 1636 tvltit .Servicr Center. RAIduh, NC 276"-163ft M, fiLrMr. 1M_.Sgpvilv & Ittievition NVells.- M adtfirloo w satoiligg the flrm w 6C. Outer caiing letlzth i if hnow H). (ftj tile aklv'e' also "a)how olte (xv} of tills ftwol will0o tit dav!i of Completion of wal cab audallivic-tit ra the cintrav fiziffil &punillem 111' the coulp tit. Inner casin:Vtubing hmgth of latrovii): wtic-re ahaWor4d 4-" S4!TLC" l0n4b (if I'dioli ill' . (ft.) Parm (AV-311 lixvii ot un'lyfawlicsi aj Nalaul llcqowcc� - Do 1"t"m of Mt.r RvsoltlLx-;- 1#o sed Allow 20 1 NVELL ABANDOOMEN RECORD Puts rb, m :;w 11V w'oj for :Autte-1 tit ilikillipt'. w,06 1. Well Ctintracuir luftirinAtutti: Stefan Smith ',VA C11jxr:1ot-,1 wic ("s Ainwiti lifi$u, at01 mi is la 1 tiwpx31l I 3576A SAEDACCO Inc 0IT"gion iuIqw 2. well Permit 0. I' li4 A 'I'Ur p"'Idie mr «wol, S-!,Lle I al ojlc,-, tlq-ho't. .-h", '! Njoll.,� J. well uw (Chedi well Usti, water Supply NNIA11. 1lAp,,rF:WntrA El(katitermil supply) N(in-water D,Mvilltonn DAquttef RCdlal'C rjAqiufcr SwraL�c mA Rc%xwer% DlAqtatet 1ct4 DExp-cuntental l'o.Airialog-v tActw0wrinitl ick-lxcd koopi 4, Wteivell(s) abawhinell.- 3-27-2018 5a. Well kwation: Cynthia Rogers Ru;ilpjy�hwwr Nmrw X,Rt�jdculiiil Wtocr Stillph, (miglej 17111csicktilial Almet StiptitY tsturcd) D DGwillulwmet IkentedwOull DSafiiiily Karter ElStemil-mcr Dn,itet= DS11bSfdeTK:C curawl 11-11-c.1cer Fwildlv ITO i tfnipplk,ihlv i Belmont. NC 28012 Pit., Addris�5, Cth—M Zip For I rttwwl I zl!w ON L Y I wrlj, ARANDONMENT DVTAll-S 7w. Number (if uell.- being aWndoned: 1 #' .-•trJrci ,,pptl ow,, (:'ill, 4t4iwi 71). Approvituste %-Munte ittvititer rc taining it in gal.) FOR WATY R St I I'M -V WFU -1; ON I �V: 7c. Type tit thiiintertaut u-sLif: Chlorine 7d. , Amiou"tufdL,infLcta-otttwd.,loz 7c. scithulf litateri4b. wK41 (d1cck;A1l drat apply4: (k Nrw Cciticto (-invt n flk:tvorljrc flllp-, tit POICt's 0 silid Ccriwitt Ufflut El DA Cbit El f btaLr iL 6roul Cl Utill Ctltlina!, El SIx-LnI11%, Grout Cl Ono d 11 sWriv tl (lr9wf tilWol 74,) 71, For each tiiau,631 wicia-M abov'r, pr0% idealwitiont (if Inattriak used. Neat Cem.:941b Wtr:Bgal. Sand Cem.:lb Wtr:gal. 7g. Provide a lirid description 4 the abandixinneut procedure. Tremie 3. lucilitkalf(in: 3/30/2018 Gmified Well Vawmclw ot W01 4hyrat Mlu Gaston tit wglatig th;v i""N 1 ert M1 mal tm, Iwfl!,V, Wf4v rkt.r�r .1hWjd0rhV M No, ANI rr, e rwdw)ce It Ifir fJ 'of,' ,,f yfrm lJoij Sf'imkjr("x snjd ffwl 4 vep'-, iql thm n-Y(10Y hO V NICII ITMIWil"i'lel 11ii- 11WH f1M MT 51k. t,ttjtutiv atoll 1"llgitutle- in or tirvirnal degrers, if .Yell rvitt, elta Litfitly, M,111114:wflt it. Site itiagnuit tar additional well do.41-s: You llitt v l*e tly. li'lel, 4 thk p;iev to pioviik adthiwiwl isvll _iiv tkmil-,i oi eldf 35.17770 S 81.01842 W CONSTRUCTION DETAII-S OF WEI-14SI BEIM; ABANDONED �Jj,�Nl S TR T �(N S �r-k I �N j0v'r qdi„wmmof-e 01j..-th(w k11 MW-6?C!q,6 a mJ,r ONLY wq'?i t&,,..w rq —trmn, 'b.n4memv f- 1"t, —w whw"11 104 For All We[U., Sulitput thui f(Trul 'xithin 10 Jao, ill, ca"wicittill of hell 6A. Well ID#: cBit ;,, , cehi)jo tfiAltwer; 2 jio.i 6(L WAter to'd behin grounit mirfa%i cc: I ( jb1indo"mcm to rbc rollowiniv: Division cif Water RL-wurcm. luturinution V rut, 1617 AlAil Service Center, Raidgh. NC 27699-1617 1011. V-1 Ill additiott fit wWwAt 4w ronit tit ilitt Willeiss to 103 :lbiw'.- lab'o m1butil (itle zupy of this form withio art 41m5 tifewtipletioti of %vtAl kwdulitatem it] tile fullowitii., 010--0oist of Water Rotiorco, Underitrituad hijection Cmanil Progratu. 1636 MailScrvicc Center, RaleigfiNC' 27 56"4636 fk*. bor Wal, lilt} V,VULSgwx A 111h3ahko Welk. ill 'jd�litqm w S440 ; the forme ( w. Outer c"uj! length i if h-now Wj: 0`t) l Me addtes*a'i kwie, also smhttlkl olle c . opk of this (owl l011141 Ill klms of completion of ivdl allmidwituctit to lk, L:otuitv tar Mth depiunnew of the coullIA 0. tuntrcasiniVirithing hen jif known): (flo t.g.Scree" len"th ft') F41 fit" ('W-11 I "iwlh t ,mortal U'm 1twit-11,2rif ilml 'Allfulw PCtvj)YCC,; - Re, Ned rkuttiw WELL ABANDONMENT RECORD This faun can be used for siggie or mullipte wells 1, Wen C'U"tramr lnrnrm4tion_ 170T IrMemul Use ONLY: W E [.L A BAN DQN M ENT DETAU Michael Wilson 7:L Numlrer rriwdis brio%alrandoued. 1 Wclt{'ommel r Kom (or vLdl onirT persmwtl, A%uwk hig, A an hK lrr prapcny) F,-y nridupre OiNiVicur ru• hrJ HyA1`fY etrppA- caasrrlrcriM rxar.vb mt cwe j;jrwi. 3351A NC Wcll Cbnlnscror Carl ifrrlliari Pfaunber arlh AI'LY rrYN3 Oke saws lip. Appnrximatc airlurrw ref %atn- remaining in wdl(s): (Rai.) SAEDACCO Inc FOR WATER SIIPPI.Y WEL[S O I.Y; C°71v tn' Kama 7a T, pe ur diaofectant used: Hypochlorite 2. Well Ctastraction Pei ndt #. G_aston County Permit Application � , 1.,xr<r♦i �,irr.6lr weiFprrm,rr G.+- f'rw,rrli, `:: 4. l �r,um x. i,1auY,r,rr, rl ... 7d, rirhirant of disinflCtaat uaatil: 1 oz & Wd t use (check well uar): Winer Supply Well; ❑Agrir.altittlrl ❑Cieolhcmwt ftalin000Ling 5up,ty I ❑ indn51rial(Comrmrcial ❑irriplioll Non -Water SaI" Well - ❑Aquifer Recharno [:]Aquifer Slontge and 1kC0 M ❑Aquifer Teal ❑Expr incir191 Trclrrirrk+es OGwihenlial (ClasixdLoopt LIC,eo(hemal (Heatingr'C'oollug 4. DMW wgIL(1•) atgndpned: 6/12/18 Am. T''rll hwation. Mary Sheperd FxHH.% "wrcr Nlnrr 110 South Point Drive Belmont Pin -sisal Adtcs. Cti4, and Zip Gaston COust.$ 11h111nir-iFM11FVhlic MRcsidrnrial Water 4upph- f-,ingle) ❑Rcsidenriat warn ��upply tsharedl 00irumidualer Renredialiouo ❑Salinii; Hamer ❑Stornm,dicr Dmirwge 0Subridn3xe C'orrml l7Tracer LICltlti:ftnplain under 7g) Facilps IDN ti[aDRltzNel Nmcl 1&0:1 6411. Na. (PIN) 5h.14r1i0u4ealnd lonotsrlein r[eglxcafmirur#c iwmn4sordccinriA dcuccN {ifvk:11 E441, itiw LitllriLS i, uiff4Punl} 35.181340 lti 81.019100 7c, Staling msitcrials used (Cheek all that mpply)- 12 Na it Ccmcnt (matte ❑ 13critonitc Chips or PCllcts ❑ Sard Cenrerd Gmut ❑ Dn C"las ❑ ConcrelrGroul ❑ DriIJ Cutliogs ❑ Specialty Gruui ❑ G0,;e1 n Henrouile 5liitp- ❑ Clther lexplainunder 7g) 7f, For t glch nkalpri;il w1pe(C4 Ahnrc, protide 3mnnnt of m41Mria1x nwr(T- Neat Cem.:141lb ,Wtr:10gal. Sand Cem.:lb ,Wtr:gal. 7g. PkVdac a Irrlef dcscrilitian of the alranilunmeot pnouLtilum Abandon well from bottom to top with grout. 8. ' 6/27/2018 9-- . "c By .TjA7rrjg thes)brm, f fremby certify rlhar the wLJ1fsJ was f3rerO abaNdoNed in rrux,rykF& a wilh 2 (4 ,V': iC 02C . k9i oo , x- .fl20fi rNaaa conarrlcfian S imArdz rinddivacopyofAriNr-xordhubeenpro dedfafirewef!owner. 9. Site diagram or ad4itEoitalvvell details: You may use the back of this page to prrn•ide additional well site details or %V11 W abarldonuterll detail,. You ma}• a1w 1112CIL additio3rll pages if IieCrssa(V- C,ONSTRII-CTF ]N DETA11.5 OF W£LLtS) BEING AMANDONED SU11MITTA1. rNSTRUCT[JQ .lrGuir vrf1 cr,mvArucJre,re rrcnrst�u �7 �Vml�d,k. Iru m�lrr,tr x�rr,r,n rxr rse,a-wx.rdrr xup� mxl'rx ONLY w id The= &Wet lad clam nrfmtfr Lvre)efi 10a For All W011#E Subnril 113i5; form within 30 date of comrpletFon of well 6a. Weil IN: 1 6h. T&I&I bell depth: 86 (Ft.) Coe. Bp rehrrle d larriew: 2 flu.) flit. %Visor kr¢l hclnw pukind -mlrfi4cc- RI) abpndanm¢ry tg ft fgllmsing- Divi:lina of W irr Rcmiuren, Jurormaruro Prod sting U61, 1617 Kail Smicr Center, RalriRh, Iti C37699-1617 14b. Four [lilettinn Vrrclls: tit addilion [o selsding the forth io the address in 10ik aboir- atsu sirbodi Otte cops of this Form nvidrio N0 days ref IfimptNion of welJ obandaninetil to the t'blinasmg: Diyislun of Water R(aou reps, Underground Injection Crral rol Program. 11G36 MIA-Sm-igC CCut[r, Itairigh, NC~ 276"-163d I ft. For Water Su msl y & In lertion Weiss: In addition to selyding the farm to 6c. Outrr casing Icngtb {if loim a): I l the address;es) above- also sub -mil sue cop- of this form wilhin YU daYs of comptetioo of nrll abunlomnent to llin coumy Imi-th deparinirim of the C'UUF*y rs]3CrG �ibtirrd4rR"il (it. lnncr casingltalrinp kmjoh lif "rrwnl: 6�,Semm l4ngoHh IIf hno%a):. ffi.l Fame GW-10 Nonh Carol= Deprannion ofEm ironimni and Narurat Rcsuiares - Diti iswn of WiLei—R550urCtii Rcxrscd Ayeusi 20B NVELL ABANDONMENTRECORD -pli� follo'.-Aot be lined fair t±«i=1ti fir 1. Well Contractor IntiorniaTion. Stefan Smith Weil At!110,111111-- lin 11�t owpejv. I 3576A !�4(- SAEDACCO Inc Coff,44f"m NIrlu: 2. Well Cowitruct"'Jit Fernlit #: 3. Well flvr (vhcdivril us,0: Witer'soplity WOL ClAgnoffifird L❑-16calliermil 0-1calilla"Coolill, Slippivi D Non-Wilter SuppitykW11- C]Aqztiicr Rcclunge FiAtiptiferMatagemA Rcovcrk DALI'ltfcr Tctil DEX"Inleflial I-L%:Ijl*k)gie Rcm;iiif 4_ Date 3-28-2018 M kcnik-titiii! Xlialcr Stipph i�iaaeic i 0salroitv DStenii%atcr DramaLc E)Soltsideicc Citi-Artil I'Tri"Icer 'gf INA. Well taxation: Joe Avery ExilovOwt-Cr 110 Wildlife Road Belmont, NC 28012 Pit, �,kal Atidt= s, Oii,md Zilt IFor!r10,11,11 �A, ONTY I WELL ARANDONNIEN'r DETAII-S A. Nutillifer (if WCA. bring Abandoned: wipi, -v!e, ONL),Xt, vvrltf12 .55 gal,l FOR WA'rFRS-f!IIPI.V WULLS Oft IA: Chlorine oz 7C, Scaliflit Iflaterials "'W41 (dirck All that Apply) ix INC-al Ccalclif (5ormll (71 Heivi"iflirc 0op,, or N'llet" Cl Said Coliteltil C-411111 Cl DvCh% Cl ( oncrrat tiTollf El DMI Cotilln—", C.1 S;xclall+ GrOtil 0 Gno CI X114.,im loxiel 7".Tj 7t, Neat Cem.:1500lb Wtr:128gal. Sand Cem.:lb Wtr:gal. 78 stone to bottom of casing the 7g• lirlivide a tork-f dvikcription tit the altanditinatcut It"itcedurr: 78 stone to bottom of casing then tremie grout to -1.51 below ground surface 3. Certifivaliort: 3/30/2018 Gaston tyuv 1-o'), i herobli, Ihol die wI.8".-o 'j as o,!rel 'd-4h),kojed !te Vomit, ;PN `fWVMI'holl ywmiard,4 )Ft;! 0m; ;I C01!1 -,MtIN ITTOOY iPM fhi- W17P Sh, Latitude and hillgitude ill fir derimal tkgrecs: 4 it wdl i aril imc liffloty to Ifffio�!rj 1 9, Situ diagratit or AdditionAl well dviritils: Yoti may i2st! tbc back MAEk pug. to peovide addiiiotuil ,vdl -iiix tjy.%j&, of t%dj 35.17831 N 81.01803 W kalideolw2til delifib. ytlu flim, ako !IMJOI alijitkillill pagg.4 4 mxtr-titan CONSTRIAVIOLA MAILS OF *VNE1-jjS'l, BEING: ABANDONED supmrrl'Af, INSTRUCTIONS vfwdt 4'41 reowd%,l "Awt'U"? i,l MiLY IN, wjm- 11w,"Irrvow,i.Ohbfjn!W?h Of, W.v , jw 11 VC, •1,1 Q h , .1,g, e,.-- tV.,hill i(} Aer, ilf I . if if It,-Ij 6A. Well tDit: t-b"TotAl %tiell dcIfflu 200 -j (14 tic, Borehoic thattleter: 6 'llill.1 fill, Water Irvel helitin 0 plit1l,ill Mirracr.: 25. 7 a. air C IN* if Ill I C Ef i i abandoffinciii to the flilloiviikg� 116+don (if Water Re-wilf-CM. Infortuatiort procinsitt.. tj fut, 1617 hail Service Ceuter. Raleigh. INC 276T)-1617 Itill. Fur kiyuhm Mi tila, Ill addition it) Soviing Ilt-, 6."fill to the idduc.ss in Ilt. abovc_ aLso m1butil olle Coo, of 11wi f'Urfr, +tilthill as dlvis of 1:0711ptelio;l of w'di ,lbandollutcal tit tile fit'llovVille, mviaioia of hater Romerc". Utiflivrgr4mad Injectloo Co"mil Program. 1636 Bail Service Center, Raleigh, NC 276"-163if Imo. Ur W41V - Suctijiv & •Illsirctioll Writv Ill liklizit"o) to sokfilqt dw forlo to 6c. Outer camile length 4if lialawn): 82 (t'at tile liddivsmes) above, also salloliv olle cops of lhj.ti 6mvi within 111 d-,AN!i of cottipletion ot'Nvc1l ahmidonflictlE ill the Comfit- lwalth departmew of the -z11HvVk 6f. Inner caliin:t tufiinu. kagth (if ItAlown trim tig.. Serve" lortutti (it "It" (ft.) WELL ABANDONMENT RECORD Tills fimw c;w lac wed for mmgk fit twiftiptv 1. Well Contractor Infornia fill It: Stefan Smith WA V1,12tivoc'I Nwulc i4xtsivlt,m vul P.-skolull" ;dvlmloillm: t+kAmt 11m:Ll tin -po") I 3576A "IC V I V'JI SAEDACCO Inc 1. Well ("onxtructioll Permit 0. ho A,q,ps,u�,fv -0pv,wU;",wvl, ,A nc-_bqe, ejme, eh J. Well 11w (ClIC& "ell uwp: FlAg.multriml _q(;CutltC=, if lliewIlIeWooling slirvpk1 DAqutfr r Recharge les! :DE.% ",sucinal Tedjnalqg� 4. Date Mell(_ 3-28-2018 5j. Well location: Ricky Hartsell MR-0d'Iffild Witter "Supph, mingle) DRLsidcolial Wwct Sippiv islutmd) r�`Skiinxfil• fluffier L'StonilAvater Diruinage (_'WvInA CITsIcer 000wi t plrtrtt turner 7gf For ;fit onti 11 `� ON1, V WFIA. ARAND 4RMUNT DuAlIS 7j, Nunnficr ofvil:*8 filcing allandoned: I "'I", 0AT), vol, ;-'&, v FOR WATFRSWIPLY VNIVIA-SONI.V: TN tic of dritintectAnt toted: Chlorine 4L Aininint of Jj,*infccfaot ww& 10z 7c. Scaling jttittcriiils wwAl febeck all that iippily) 06 Nlejt Ccalcul 6rmill r-1 Helvolorc Vlllp� ot Micts C1 Sind C'entria Grout El Dn 4- Ia.% Cl concrete 6will El Drill Culliti_s Cl Spctall3 !,runt 0 GGIV, %!I I) f3cmomic : ltirn i-1 Oftwr (eq)lilol fliwel 7g) 7(. For eado titativrial swicctetl above. prIpside awoont of atitterijis nsed: Neat Cem.:941b Wtr:Sgal. Sand Cem.:lb Wtr:gal. Jg. Prot isle a brid de-,wription of the Lilloanditinincut priticrilule: Tremie R;rihW(fNktCI Nilth: ITO i Cerflikation: 111 Wildlife Road Belmont, NC 28012 III, ��ii I A Cos, aid Zip I _1w -,I I fa—d VV c—I11 _3/30/2018o wr r ra� I I " r W v I I 1� t Gaston bl w'I"ning rhos 1"whi I "Ierobi ertftf' Mw rifh- 14",8110 Wel.,' jh!"lle: M wdh 1,7A !)_"C,e0Hi0 ,,-V 0 leh) if"'Y" I "tu'vy"n"Ifoo ""wn'biroN .511, 1t(ifultv and hillgitude in or devitual ticTrc", 4if"'k,11 1,xkt, *Jtc LwhmW e_illllicx:vfl 9Site di4grow or additional it -ell details: Voll Iluo, Ilse th'-, back of zltk ropw to !astride ;Iddigiowl 1wil �il_ dmill", of srJj 35.178280 N 81.017709 W dcmfli,. Y,u fitilv Awl Ifqjub :xMirro full pi-C." o . uece61;n, CONSTRII-HON DETAILS OF V4ELL4SI BEIM;ABANDONED SUBMITTAI, MSTRUCTIONS ONLY ,wn "Im ""I"w A 1011. For All Welk: Submit thks t , ann wittun _10 davk tit' :,urtipicitfin of ix%:Il iia. Well Iff#: to the flyllawing. Division of Water RL-Auttrcim. Information Processirig Unit. Wo. Total nell deptic 65 list-, .81ail Service Center. Milcigh. N(1' 2709-1617 I tit). J1j!Lr ItIggL(itt, III iuktkoto sAu.ttIII-. motif! to Ili: i4S5 tit kia f6rw above, Aw 6c. ffi)mholc t1jultincter,� 2 in.) ,44111111 olle i�ops of dwi w4ibin 7l k daN s or autipIction of wdl *;imleniftern to the fullijAxing. 226. 3 DivkJotof Water Rexoto rvo11udorur4w nd I nit-diou C onfrl piagrall. ilti, %VAjer jej,el lictiltinul 1630 Mail Scmicr ('ender, [WciahNC 27699-163, [tic, Ftjy N : in additkoi lo t�vvjikg 11w forill to . UjtL Wel1% tic, Outer camns! lonoth i ir hmirv, n). fft,9 file addivmws'l *,Lwe. :11so slobtfut one ani of Ibis (oral w1l;ill 11; loss of Zoltiplefloo of well ahandonlocill tv file Conn"- Itcallit Ltepiltinletv 131 the z0flieN 0. Inner casing/taking lengtit of liwttvvn j: 01.0 6b s4me" lenjoth (it Itnnnn j: Y,rt.l Foep, Gw .;I Nonii I 'It"llir, t1i 1:11., wowifinilatx! Milut:iii Lie, tfiv-m of Wilw:, "to -led Awwrz 201 NVELL ABANDONNIENTRECORD -]!its fbio) :ali ll%t auxt for A#ge: ot ioqjrip.006 1. INCH Contractor Infil"IlAtion.. Stefan Smith "VA I 'otv-nloci NarltI. folr ,Af ", 1.":f Am all Ill it:,, oll ptip"M I 3576A Cwflraola f ii:kiivtl NlotivT SAEDACCO Inc M. Welt Can"'ll-tietil)" Perraft #: Sh,'h', 10110w,, 3. Welt uw tchLek ivrll kuwf, water 'Snppty 8velp Fj Nou-Nvatcy lsijppl�• Well- MAtfuner RMurge 0 Ailitifer -Sturlige, 3M Its ewcti L'AtIalifer -Nva [AGCoikumad (flimtittiz,17bolintz 3-28-18 5j. Well hwatill": David Auten FiTrOtt'l 'Ch% Wr 'N411114, 112 Wildlife Road Belmont, plit'sicjI Atidws, co , ,Jd Zip Gaston SM FAItallcilml.nibliz MRcsitictilial Water Suppl-v 15F'111:lcl EIRL-siticlitim Water Stipply lshurcdy 0 1-16jotijidttatei KLuteduficiia 104Aillily flairier E-Sterruwater Dru taux DSubsitleuxx Cuivirul I ITracer 11100wt of xpioiti Mailer',[;) NC 28012 IDP vifaopfi,;�-iblo L, ; "rewiltal U!� ONLY Y I rt-L ARANDONNIENT OFTAII-S f"", umfolp". o", ",Oj 14v €.vw -t,wq= o-ij 1,10, V0, ,,4y,in "0"'1 7b. Apprioxiniate tiduntic of li ater rrittaining in FOR WATFR SUPPLY WFLIN ONLV. 7c. Type of th-Ninifechutt ined. Chlorine 7d. Artunlint of fitinfLctatit wked.' 1OZ 7C. Sealing InAterial's u'tl (Vileck All that aliplyl: IX Ncw Ccillefta Croul Ft BCraorlirc, of Pohl is Cl Said Cclitel" Cirout Cl Un t1jv • ("bixrete 6TV1111 Cl Drill cwtillLm • sfxcialp, Groul 0 Lien el 1A Hritlolljfe 1,jltrr I7 Orlkzr iV-Npljull Ilixtel %�,jt 7C For each nutterial wlvvted aboitt. provide Antoortf (if trutteri4ls nsvtf: Neat Cem.:941b Wtr:Sgal. Sand Cem.:lb Wtr:gal. 7 7g. Proxitte A In-irl't1mription (if the altAndininlicin pnivedurr: Tremie 8. Certifleatitin: C-airlild Welt folitrwim "t W0,14hym:j 3/30/2018 I-X—ol hi Vk"Iniag th"'; J'awl, I b'Mbl' 0114 fhal lih' 14WS- Y1 MkJIM$ Jrdjowe it Id., !J. i IC it-*( W(0 ,,, 2f , Y)20o jf�.a; Stqn,4)Tfh� ou"ifffid "i 9 opl; raj riot rn fwdho buen prolwiiJte, fhiH'a5a.% imnor Ms. !attitude And liatigituilttr in tir docitual ;kgrelim.- rX.1d, ulk, IxAalw, i"111TIL41-Al 9Site diAgrain or AilditiouAl well dcraffil: You mll1% t6C tbc bad of lik tmlgc ill plo011e ilddifittilal apt it ti lklatts ol iiidl 35.178240 N 81.017092 NV kaidetillwra dulaill'. You 1114w also tuack additiowil jxqtes if iiccws,air,, CONSTRIWTION DETAII-S OF WELL(S), HEING ABANDONED SURAIMAL JNT �VCTU�NS oo;h ONLY 'wil Mm rretirc w1r4l-w0w, 'o" dIulwr,l -w „Trail 10- For All Wetls-, il-bnui ilim forril q1ttall, itt ja%.,� of Carl, 6a, Weft ID*: tiff.Ttttat itiell dcptli: 97 1 (t.1 ffv. florvillole 411tilintler; I � , — . -- . I-Aill.) tad. Watcr kid helotsgrilkInot artefact; .: 26 PC u I C 'Iblowhitlillcm to the rollowilig: 04 Wou (it Witter ke%ourcr% Information 11"writsing If nit, t617 Mail Strvire Center. ", cigb.1SC276WJ-1617 [till, Eur. Ittimthin %N *Ill, - In atidlifull 11) SCIAl"I't 0w, rotill tit des wdress in lon _ abovc. 111M) sabl(th olie col)3 of flli!i firm 4V1111ill .10 day5 tit' ontipttlion Lff 'Ibiuktorulitto to the follli-wila,. Divi"'on tit Water Rotiorcew, Undergr4aind Injection Gritrol Pnigriull. 1636 Mail Service Center, Ralcieli, W'276V9-16J6 Mr, Ettt-)Y&r-,,Sw1 Ill'Alitioll rot rCliditw 111C folill go 6c. Outer ca5ijiV IcnZth J if Lao" a)-. (ft. t tile nddiussli!sl Axwe, also slibilm olle t..Opr of 111iii kwil uithiri Ill (hwi of zouirilction of "ell ablaudoziniont to the coinal, flealth &-purniteig of the ttf. inner clasht:�tuhfttg length (if kattwn): i whuc l)ttaildomd di„. Serte" IC"goth (If tnif" ni: i A. ) 1-'31 (Ilt ( iW - i I I M-4 it ( At n I i fill a)_ pat I lw w (I I trait I ftl "low s.l .text `A tit "Ut tlx suaccs Di',' lilxf u o ( 14'aw!r itr-ioa fcc+ Roticd Atkaw2 NVELL ABANDONNIENT RECORD Pits I'mm';aft lie, ou'Al for'Anvk Ot Ij1OjFij)k w0ll' 1. Wdl ('Ontractor Inhirniation: Stefan Smith jol 'kd I owjwf I 3576A NC W,01 (',,Mrwo�a C,:nvwApIi Ko �ibry SAEDACCO Inc C.'Tmpam N41FII. 2. Well Construction pertolit 0- J. Well 11.W tcfoLck well tvw' DApmofttual 0Q.-orlicniud ificanuIp"'Cooliqp" slipplY 't S "Upf* V D Aquiier 12cchjqge DAhinter-Stanu, eaj)d Re%:Lwet3 4, Date 3-28-18 54, lovell location - Travis Jenkins Facilrtit(_hvwt Nwiw 113 Wildlife Road Belmont, NC Pit,* siza I Adttwsh, Ci 1, md Zio Gaston Cl LiE[ntsilsr#rl'1lbtic MR4-nicknital Wairr Snpphf15m0c) L❑ORL -sick-tifial Watei Soppl- I shttred Dstom%matcr lininaLc DSubsi&ix:Q Cw%rol Ffframr icxpipin toxfor 7gj FwArIIA: WYY i For VW ONLY WYLLA-DANDONNNIFYr prrAHS 74, Nunifier (of ooellx toeing alnuoiloned: 1 t' , ,, imyc 'jq ox -, '.",Fa • '414b ONL) 0'41 ow „4'6?wl ...... ;"w"i 71o. ApproxiinAte i-iolunte tit m ater rrinaining in oejjj_sj3,80 .a. 1') FOR 4N'A'rFRS1j1'PI.V WVIA.S ONLY: )e of 41J.-.riorectant to.-,ctl: Chlorine 7d, 60Z 7e. Scaling InateriAls irwd (Cheek all thar Apply). 2, Nem Ccutrai Grout 1-.1 f3cminirc Chipi or Nflicts Cl Sand Ctmtrnt ( tout Cl Dry 4_121v • ('01Iatac 6mul Cl Drill Cuttings • it vcfaffil 6rout 0 GGo el 11 13mootre Slortv 0 Other jeq)?"un fAndef X For each auturrial mqected aboivlo"1041c Aruattrtt Of rawrials used. Neat Cem.:15001b Wtr:128gal. Sand Cem.:lb Wtr:gal._ 'g. Proi-idi: a tirief druriptian of the aliandounkcat proceilum. 78 stone to bottom of casing then tremie grout to -1.51 below ground surface 3/30/2018 C-aiifir-d W011 Commvkii rsr W01I Chvmt F)m' 1311 Vj'Spufk%! #2;'vpwn)' I Mot ii6akido'I"d )11 ILUIIII�qlxla No.; NNI 40:40"VkVjf'It"A' MJ A' '-I(1'0Y " 0))W'w'A -, 0�'00 li'f.i? ow I llwt ;j trf fif tv nrard iNJA h0t,'14 PTYAWi4-d 10 fh�,- 11-41 fMofT 'Slv, I atiordr and Ittogituttv itit th fFrrcvitrtinvtrKiucitrtti ,Jr deeitual dciftw%. eH`WCH 14"titfir, lt°,,IIIY10=0 to.Sitediagrain or AiJilifinual w0l detAils: Yon 111118 ose the back of dik lmto litmide addifiotial tdl 6tx� e#ettrla sett odl 35.178255 N 81.016802 NV` Ab%odemoern deiaib. Yvu im", ahxo attaradditmItial trages if Iwctssll� CONSTRUE-17ION DETAII-S OF WE"IS) RrINGABANDONIED supmn'rAt. INSTRUCTIONS uq'P'l avffy. ONLY ,4H3i Ow "oaf e ...... y'rw IUA. For All Wells: Subuto i1jis foun within ;0 daiN, ofxii1pictuni of ovil 6IL Well IDik 'IbIVIVIOnaticra in the filllownkg- tofvWau of Water Rooturret, Information Proceiising Unit, ('11.'Totail Well detall; 300 _ffto 16i7 Mail _Servicr (ruter, Raleigh, INC27699-1617 It"If, For InkKO(kit V_k%j_j - In additivo to s,,iAntbt ih4 forin it) III-- addiess in l0a k. Horel"Ac 41fitan-ter, 6 141.4 abp��c_ also sabion one caps; of this fiofi rni wiln .'I' slays Of :mopkfiou tit IVA atlatrrultrutrtcru to the falkiwilm, 01%kion of Water R000reo. Undergrit" till Eudora coatnil prograt". 641, Water ln'C_j I)Cjon grinind .4jetAcr: 35. 6ff1,1 1636 Mail -Service Cetiter. Raleigh, NC'27&)9-(6Y# 6c. Outer camne leng(b 0f latown)- 91 114v- Water 5141 ""ht, 1-I&Jitionlos,41 4og qlw fonil to the sailinal One cojwA of this f1myti wilhi" III dnv!i of C0111p,U1011 Of INCII A1133003anclit III f[IL i:ounw 11calift &-plaintent of 111e wOIIIXV 6f. Inner casingitulAng length jif kntov")- ift') Vollit (AV. -,A �m'at) C'11roIjul oi El'% Im"113will itIA Nlittwil. Do tqtml of Wmet, Rw�wlocc,to =.qcd Amu, pz till: WELL ABANDONMENT RECORD This faun can be used for siggie or mullipte wells 1, Wen C'U"tramr lnFrii—gtion: 170T IrMemul Use ONLY: W E [.L A BAN DQN M ENT DETAU Michael Wilson 7:L Numlrer rriwdis beio%alrandoued. 1 Wclt{'oll melm Kom (or vLdl onirT persmwtl, A%uwk hig, A an hK lrr prapcny) F,-y nridupre OiNiVicur ru• hrJ HyA1`fY etrppA- caasrrlrcriM rxar.vb mt cwe j;jrwi. 3351 A NC Wall Cbnlnscror Carl ifrrlliari Pfaunber arlh AI'LY rrYN3 Oke saws lip. Appnrximatc airlurrw ref %atcr remaining in wdl(s): (Rai.) SAEDACCO Inc FOR WATER SIIPPI.Y WEL[S O I.Y; C°71v tn' Kama 7a T, pe ur diaofectant used: Hypochlorite 2. Weli Ctastraction Pei ndt #. G_aston County Permit Application � , 1.,xr<r♦i �,irr.6lr weiFprrm,rr G.+- f'rw,rrli, `:: 4. l.,r,umx. i,1auY,r,rr, rl ... 7d, rirhirant uFdisinf4Ctaat uattil: 1 oz & Wd t use (check well uae): Winer Supply Well; ❑Agrir.altittlrl ❑Cieolhcmwt ftalinovoLing 5up,ty I ❑ indn51rial(Comrmrcial ❑irriplioll Non -Water SaI" Well - ❑Aquifer Recharno [:]Aquifer Slontge and 1kC0 M ❑Aquifer Teal ❑Expr incir1al Trclrrirrk+es OGwihenlial (ClasixdLoopt LIC,eo(hemal (Heatingr'Coollug 4. DMW wgIL(1•) a¢gntlpned: 6/12/2018 Via. T�'rii hrs-aliirn. Angela Shrome Facili0.kh%-rcr Nwr,- 11h111nir-iFM11FVhlic MRcsidrnrial Water 4upph- f-,ingle) ❑Rcsidenriat warn ��upply tsharedl 00irumidualer Re1nedi idiDur ❑Salinii; Hamer ❑Stornm,dicr Dmirwge 0Subridn3xe C'orrml l7Tracer LICltlteftnplain under 7g) Fxilps IDN ti[aDRltzNel 114 Warren Drive Belmont, NC 28012 Pin -sisal Ad&as. Cm, and Zip Gaston COust.$ 1 red 1&0:1 6411. Na. (PIN) 5h.1�wfiojdemnd lonotsdcin du1uvcsAMnutmiwmnd&ardccimal dcl ccN {ifvV.11 E441, itiw Litllriyg i, wM;:p4i1} 35.181634 lti 81.020372 7c, Staling msitcrials usCd (Cheek all that Apply); 12 NCat Ccmcnt (craw ❑ 13Cntonitc Chips or PCllcts ❑ Sard Cenrem Gmut ❑ Dry C"las ❑ ConcrelrGroul ❑ DriIJ Cutliogs ❑ Specialty Gruui ❑ G0,;e1 n Henrouile 5liitp- ❑ Clther lexplainunder 7g) 7f, For t glch nkalprEill w1pe(C4 alsnrc, provide 3malmt of m;iMriplx uwetl: Neat Cem.:235 lblb ,Wtr:35gal. Sand Cem.:lb ,Wtr:gal. %, Cr did a Irrlef dcscrilitian of the alranilunmeot pnoL lum: Grouted well from bottom to top. S. ' 6/12/2018 By .TjA7rrjg thes)brm, f fremby certify rlhar the xei'1{sJ was f3rerO abandoned in rrux,rykF&e wilh 2(4 ,V': iC 02C.k9ioo , x-. w wtv conarrlcfian %mArdz rinddivacopyofAriNr-xordhosbeenpro dedfafirewef!owner. 9. Site diagram or ad4itEoitalvvell details: You may use the back of this page to prrn•ide additional well site details or %V11 W abarldonuterll detail,. You ma-v a1w 1112CIt additional pages if IieCrssa(V- C,ONSTRII-CTF ]N DETA11.5 OF WELL(S) BEING ABANDONED SU11MITTA1. rNSTRUCT[JQ .lrGuir vrf1 cr,mvJrucJre,re rrcnrxt�u �b �Vml�d,k. Iru m�lrr,tr x�rr,r,n r,r rse,a-wx.rdrr xup� mxl'rx ONLY w id The= &Wet lad clam nrfmtfr Lvre)efi 10a For All WEEL#' Sub3ni1113iS form within 3(l dwx of cam letion of uxlJ 6a. Weil IN: 1 6h. T61*144V1J depth: 100' (F0 Coe. Borehrrledlarriew:3" flu.) flit. V4'sittr kvcl hclnw pukind -mlrfi4cc- RI) abpndanm¢ry tg ft fgllmsing- Divi:lina of W irr Rcmiuren, Jurormaruro Prod sting U61, 1617 Kail Smicr Center, RalriRh, Jw C3709-1617 14b. Four Imlettinn Vrrclls: tit addilion Eo selsding rite forth io the address in 10ik aboir- atsu sirbodi Otte cops of this Form nyidrio NP days ref IfimptNion of welJ obandaninetil to the t'blinasmg: Diyis{un of Water R(aou reps, Undlergrou ad Injection Crral rol Program. 1.G36 MIA-Sm-igC Ccutcr, Itair'igh, NC~ 276"-163d I Ac. For Water Su mbl y & In becdon Weiss: In addition to selyding the farm to 6c. Outrr casing Icngtb {if loim a): I l the address;es) above- also sub -mil sue cop- of this form wilhin YU daYs of comptetioo of nrll abunlomnent to llin couffry Imi-th deparinirim of the C'UUF*y rs]3CrG �ibtirrd4rR"il (it. lnncr casingltalrinp kmjoh lif "rrwnl: 6�,Semm l4ngoHh IIf hno%a):. ffi.l Fame GW-10 Nonh Carol= Depannion ofEm ironimni and Narurat Rcsuiares - Diti iswn of WiLei—R550urCtii Rcxrscd Ayeusi 20B