WI0300445_Injection Event Record_20210112

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300445
1. Permit Information
BP- Former Queen City Convenience
Permittee
BP- Former Queen City Convenience
Facility Name
2650 Shenandoah Ave. Charlotte, NC 28205,
Mecklenburg County
Facility Address (include County)
2. Injection Contractor Information
AST Environmental
Injection Contractor / Company Name
Street Address 1567 CF Pours Drive
Harrisonburg
City
VA
State
22802
Zip Code
L540_) _820 — 3465
Area code — Phone number
3. Well Information
Number of wells used for injection 48
Well IDs A-1 through A-32 (A-27 not used)
B-1 through B-17
Were any new wells installed during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 48
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ® Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 48
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
BOS 200®, Starch, Magnesium Sulfate, Gypsum,
Yeast, & Trap and Treat® Bacteria Concentrate
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 7.5%
If the injectant is diluted please indicate the source
dilution fluid. Municipal Fire Hydrant
Total Volume Injected (gal) 4,049
Volume Injected per well (gal) See attached table
5. Injection History
Injection date(s) January 12-15, 2021
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
® Yes ❑ No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
9/30/2021
SIGNATURE OF INJECTION CONTRACTOR DATE
Nathan Thacker
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016

WELL ABANDONMENT RECORD
This form can be used for sigghe or mu]tipte wells
1 r WO f'4atrAe'm r lnrorrn4tion_
Brian Ewing
Wcli{ourraciar Flame (or %leiI on lief on hK lrr proper!, )
4240-B
NC Well Cbntrudor Cerl ifirailian Number
SAEDACCO Inc
Coiman> [+tame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i ird p?hQ4Ir w,eiFprrmJrr r,.r. ruurrrr. hr4Mr. 1 iri pax. '. . Vkarorrr
3. V4'd 1 use (check well use):
Water Supply Well:
❑ Agricultural
❑ GCorbcmwt (ealingaC'oobng Supply.'
❑ IIsiii lrialfC0mrr1erdla1
❑ Ihi ii[iois
❑ hlsomicipal,Ptihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residential. Water Slip JI ' tsbared
Nno-Water 4eplaty Well:
❑ 1 Iumlonne
❑ Rm.oven'
[trajection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Agreifer Teal
❑ ExpoaiuteN31 Techemloin
DGeothensa] {Closed Loops
L ICxoEhenital (Hearing:Cooling Return),
❑ Gnaumduarer Reuieiiistiom
❑ Salmi{; Hamer
❑ Stornmater Drainage
❑ Suhasidence Coin ml
L]Tracer
L OtherIc'piain under 7g}
i.Ditty ne11 abandoned: 1/12/21
54. Well locution:
Former Queen City BP
Faci1il tlwnerNinrr
Fseilels ll7dd (irimplicablet
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zia
Mecklenburg 12710204
( iiiLl Parcel IdcnliFieadmiNo. MIN)
5h.Latitude and longitsdc in degreesiminuirifsecondsordecimal dettrccs
{ifwi:1I no141, eii4 Lit.lwy i, ui1 i rCii
35.210533
rq-80.801887 }}
(:c1r STR1I{'rr{)N DETAILS OF WELLSS} BEING ABANDONED
. lrrruir yell cr'rzrJrucJion el. co jJ uVra/ k. lrr,x .r Li on or non -wader supph.
we& ONLY well rdJr aaisa wir..drro_rAak BhftlrfdurrhleNr_ yet. man sxfuiera alre feriie
61. Well IN:A1
6b. Tout well depth: 19 (h?.)
6e, BO reside d louder: 1. 5 (In.}
(irl. Waterkeel helnw prvipnd irrfAcc: Ott)
lrc. Outer casing Icn11b Of town a): RIl
8I, lnncr'rasingltnlrint knob lif knerwnl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IricrmA Use ONLY:
WELL ABANDONMENT DFTA1L4
7a. Number of wdla being abandoned: 1
t'rw ndufrJpir r.'!' itOr FJJ' rrurJ xwter air'JI.0 rrdh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd rearAlberni. our j;ir jl,
Appnrximatc rrllurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (check all that Apply):
ID Neat Cement Grout
❑ Sand Cenierae Gmut
❑ Concrete Grout
❑ Specialty Gruui
C7 Bentonite Slurry
I Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1phainunder 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm elf the abandonment i roi.c lure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50'i:fla v of C•ertiiitd WCII Ceur ter 4411 Chvir Drys
fly signing Mu form, f frere&y certify dial the xeJ'i{sJ was (were? abandoned are
ou orxhuac'e with 1 5.4 ,1 '..LC 2C .01004...r 2C .i200 [Nods' cunstrric:.trun SraraJrds
and firm a copy o/Nris record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page to provide additional well site details or well
:abandonment details. You may also :itai1Ladditional pages if ttecessat'_
SUBMITTAL. FNSTRIUCTIONS
loa. For All ulna'r: Subinii this Poem within 30 day$ of completion of well
ahpndnnmciy r0 014 following'
Diviilino of Water RI:MI[1 - s, information Pr{ree sinE Unit,
1617 Mail Seller {'enter, Raleigh, NC 276994611
Bib. Fear [aietllion Well[: rut iddiliots to sending the foriu to the address in 10a
above_ atsu submit one any of this form w'ithiin'30 dins ref eumptetion of well
:IbardanuteW to the following:
Dunstan of Winter Resources, Underground Injection Conlin! Program.
1636 mail Scrticc Center, Raleigh, NC Zit 99-163fr
10c, For Water %ty)1t' & In !cram Went: In addition to sending the form to
the address;es) above_ also submit one copy of this foam within 30 days of
comptctioo of wet] abandonment to the count', health departmeiu of the county
w]icri qbqnclukcil.
Non hC'arolJro Depanascri ofEnw iranlncni atsd N,laurai r uccs - Dlw ISLon of Miss Rf ourec Rexiscd August 20L2.

WELL ABANDONMENT RECORD
This form can be used for siggk or mu]lipte wells
1. WCn f'4atrAe'mr inrorrn4tion_
Brian Ewing
Wclt{ourractar Flame (or s,ctl onIrr persaaall, abaskilanhig,i.cll an ha Ire proper!, )
4240-B
NC We11 Cbnhudor Cerl iri-anon Number
SAEDACCO Inc
Co:elm:ay [+tame
2. Wodl Construction Panto[ 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJr.* r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. leVd t use (cheek well use):
Water Supply Well;
❑ Agricaltkiral
❑ GColbcmwt (Healing/Cooling Supply.'
❑ Irtdosiriai(C0mrr1Crdla1
❑ IIrigatiois
❑ hltoiicipal,Priblk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residential. Waver Slip JI ' tsharnd l
Non -Water Supply Well:
❑ 1Numlonne
❑ Rm.oven'
Tnjection Welt:
❑ Aquifer Recharge
❑ Aquifer Sionige aid Recover
❑ Aquifer Peal
❑ Experimental Tn Jin obis
DGeoihensia] {Closed Loops
L ICteoEheniial (Hearing:Cooliug Return)
❑ GnnuMdnarer Reuieiiistimi
❑ Salini{3' Hamer
❑ Stornmater Drainage
▪ Subsidence Caniml
L]Tracer
RlOthcric'piain under 7g)
i. DyltC se11{5.) abandoned: 1/12/21
54. Well locution;
Former Queen City BP
FabcRil, tlwnerNlnrr
Fseilils 11711(if impI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. CiR, aid Zip
Mecklenburg 12710204
C'auui, Parcel IdcnliFieailna No. MIN)
5b.Latitude and longitade in elegrecafmirrtnteifseconds or dceim,i1 degrees;
{ifwell r4I51, itiw Litliiiy i, ui1 i rCii}
35.210533
rq-80.801887 }}
(:O STRII{"Tr{)N DETAILS OF WELLS} BEING ABANDONED
. broth ,veil cr'mvJratikN rrcnrst a jJ uvada,k. 1 ixr malrr,x .r rJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak BhftlrdarrhleNr_ yet. man 1adurerr o re ferih
61. Well ID#:A7
6h. Tout well depth: 19 (h?.)
6e, BO reside diameter: 1. 5 (Iu.)
(oil, Water level helm prvipnd lrrfAcc: ;fr,)
fro. Outer casing Icn11b Of tabu a): RIl
Of, Inner casing/whim:, knob Iif known I:
6g.Screen l4ngHh IIf hnneao): fft.l
Fame GW-10
Fe* Internal Use ONLY:
WELL ABANDONMENT DFTAIL4
7a. Number (dwells being abandoned; 1
F.r ndufupir r.'!' ioJr FJJ' rrurJ xwter airArkr rrlh ONLY "rah OW same
cau*r Iwr,ion abandonment, yr,rd ixar Alberni. our
71r. Appnoximatc *Jolurrrc ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of 43isinf4 tact used:
7c. Sealing materials ufied (check all that apply);
Q Neat Cement Grout
❑ Sand Cemwii Grout
❑ Concreir Grout
❑ Specnaltr Gruui
C7 Bentonite Slurry
I BeoMnitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutlio s
❑ Grircel
❑ Other Iviplain under 7g)
717. For each material selected abma, provide arnouat of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abaniliinmeot procedure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerlifkailoo:
Brian Ewing
1/27/2021
50rauuvofC•eniiiitd WCII Ceur der w 'e1I O,sir Dgie
fly .sagnria Mu farm, f frere&y certify dial the Irdipti was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .0200 [Nods' cunstrric:.trun SraraJrds
and drat a copy o/this record boa been provided 1v are wed! owner.
9. Site diagram or 2,14itioout well details:
You may use the back of this page t0 provide additional well die details or well
abJridrninenl details. You may also :rtiacit:dditional pages if necessai _
SUBMITTAL. FNSTRIUCTIONS
loa. For All WeEL'': Submit this Poem within 3El day of completion of well
abpfdnnmcry r0 the f01lmsing'
Dii'isino of Winer RI:MI[1 - s, Information Processing Unit,
1617 Mail Senior {'enter, Raleigh, NC 276!9-1617
Bib. Fear tuletllion Well[: rut addition to sending Ilse forest to the address in lIa
above_ also subsoil one naps of this fano within'30 days ref eumpterion of well
;ibardanuteW to the following:
Diiistvn of Winer Resources, Underground Injection Coal nil Program.
1636 mail Scrticc Ccutrr, RAIr'igh, New Zit 99-163 i
111c, For Water 5uDr)1l' & In !cram Went: In addition to sending the form to
the address;es) above_ also subutiii one copy of this form 43'iihi,i 30 day of
comptctino of well abandonment in the count', health depurimeiu of the county
w]icri: obtiridnrk-4.
Non h Carolina Depanincri efEnti irorencni atsd N,irurst Rtwarccs - Doti 'ma of Wress it aurec Rex 'sod Au ust 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! calve persoiaLI, abandasing %tell an Freon propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtiblk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Waver S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
L]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/12/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegree:tfminuteifsecondsor docintril dcl;rres:
{ifwell r4151, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse ,veil cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well II}N:A11
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lain a): Rt.l
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
cavern wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Ouir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and JIrat a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ,lees'r: Submit this !bem within 3El day of completion of well
abpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the form to the address in lIa
above_ oho subsist one noes of ibis fon" within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccutrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 day of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - Dls Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! calve persoiaLI, abandasing %tell an Freon propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtiblk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Waver S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
L]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/12/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegree:tfminuteifsecondsor docintril dcl;rres:
{ifwell r4151, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse ,veil cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well IN:A15
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lain a): Rt.l
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
cavern wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Ouir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and JIrat a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ,lees'r: Submit this !bem within 3El day of completion of well
abpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the form to the address in lIa
above_ oho subsist one noes of ibis fon" within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccutrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 days of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - DIs Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wcli{ourractar Flame (or %leiI or,. lief persoiwil, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. rsingle)
❑ Residential. Waver Slip JI tsharndl
Nee -Water 4eppty Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenstal {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiiatimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsidence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/12/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in elegrecilminuluifseaonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'mvJratikN uvada,k. 1 ixr mulrr,x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAgrBhftlrflurrhleNr_ yet. can sxfurefr o re ferih
61. Well [b#:A4
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8h. lnacr'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DETAIL:
7a, Number oiwdla beim abandoned: 1
F,ir ndidufl rJnikrYiurr FJJ' rdoN rnxrrer sir'JI.0 rrlh ONLY "rah 1W same
caurrnrcrrayJ abandonment, yr,rd rxarAlberni. our
71r. Appnoximatc rrolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Grout
❑ Concrete Grout
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Graces
❑ Other 1phainunder 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauv of C•eniliitd WCII C,eur ter 4411 Chvir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loll. For All Wells: Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Winer RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Vella In addition to sendiltg the form to the address in lIa
above_ also submit one naps of this foots within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Winer Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
1fle, For Water Sunny & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] ablydomnent to the comet', health depatinreiu of the county
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourraclar Flame (or sled or,. lief persoiwtl, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriat Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiialimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/12/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adttrcss. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can 1adure12 Wra ferire
61. Well Ib#:A22
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauvofC•eniliitd WCII C,eur ter 4411 Owir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wilier RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this foot" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the comet', health depatimem of the comity
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wcli{ourraclar Flame (or %lei! or,. lief persoiwil, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. %It'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geolbcmwt (Healing/Cooling Supply.'
❑ InchistrisliCornmercia1
❑ IIri:I[iois
❑ hltnnicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriai Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlonnIe
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tnchnoloin
DGeothenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reureiiialiour
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/13/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
if well r4141, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELL(S) BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrfleoThWeNr_ yet. can 1adure12 Wra ferire
61. Well II}#:A6
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t inner casingltnlrint knob lif known I; (ft.l
6g.Screen length IIf known): fft.l
Four GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurrrc ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilaircofC•eniliitd WCII Ceur ier 4411 Owir Drys
ffy .sagnria Mu form, f frere&y certify dial the weiilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:tdditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this Ibrni within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wafer RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, ]w C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this fon" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the court', health depatimem of the cocisv
where abarrdnn il.
Non h C'aralmo Depanineri ofEnti iranincni and Natural. Rcsuurccs - Diti isLon of Wrass i f- .',irec Rex reed August 20 L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wcli{ourractar Flame (or %leiI or,. lief persoiwil, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. rsingle)
❑ Residential. Waver Supply tsharndl
Nee -Water 4eppty Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenstal {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiiatimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsidence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/13/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
C'ouut, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in elegrecilminuluifseaonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. 1 ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can sxfurefr Wra ferire
61. Well Ib#:A10
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwter sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Grout
❑ Concrete Grout
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Graces
❑ Other 1phainunder 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauv of C•eniliitd WCII C,eur ter 4411 Chvir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Winer RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Vella In addition to sendiltg the form to the address in lIa
above_ also submit one naps of this foots within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Winer Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
1fle, For Water Sunny & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] ablydomnent In the comet', health depatimem of the county
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This form can be used for siggk or multiple wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourracrar Flame (or 'act! or,. lief perviiwtl, abandasialg,i.cll on hicdrr proper!, )
4240-B
NC Wc1I Cbntru lur Flrunber
SAEDACCO Inc
Colman Name
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. ruurrrr. hr4Mr. 1 iri pax. '. . Vk'rorrr
3. V4'd 1 use (cheek well use):
Water Supply Well:
❑ Agricultttral
❑ Geothemwl (Healing/CoolingSupply.'
❑ Industrial/Commercial
❑ Itrigil[ioil
❑ hlennicipal,Ptiblk
❑ Rcsidenri:il Water Sapph' r: ingle)
❑ Residenriat Water ••iirtply.tsbaredl
Non -Water So Fay Well:
❑ 1NumlonJte
❑ Rm.overr
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Teal
❑ Expo riuteN31 Tecliemloex'
DCeolhensa] (Closed Loop)
L IGeothenital (Hearing:Cooliug Return),
❑ Gnaumdnaier Reureiiislion
❑ Salini{s Hamer
❑ Stour ater Drainage
❑ Srlasidence Catiml
L]Tracer
L Othertc'plain under 7g}
i. Dam neIL(s) abandoned: 1/13/21
54. Well location:
Former Queen City BP
Fabcilil, tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
C•ouW, Parcel Idcnlifrcalimr No. MIN)
5h.Latitude and longttade in eleglxeafminuteifseconds or decimal dcl;reeN
{ifwell r4151, ei Litlwy i, ui1 i rCii}
35.210533
Jq-80.801887 }}
(:c1r STR1I{"Tr{)N DETAILS OF WELLS} BEING ABANDONED
.iam.rr vref1 cr'mvJrucJrare uvarra,k. l ixr malrr,x .rbJrur or taus -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrflurrhleNr_ yet. man 1adurerr o re ferih
61. Neill IOE : B14
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (1u.)
(rii. Water level hClnw pound miring:: ;fr,)
(rc. Outer casing Icn 1b {if lain a): Rt.l
8h. lnner'rasingltnbinp kn0h lif known
6g.Semen l4nuoHb Ilf known): fft.l
Fame GW-10
Fo* Iriennui Use ONLY:
WELL A BAN IM1N M ENT DFTAIL4
7a. Number of wdla being.alrandoued: 1
F.x. ndufupir r.'!' icUr rJJ rrurJ xwrer air'JI.0 rrlh ONLY "rah OW same
causrnrcrrayJ abandonment, :wire ixar Alberni. our j;ir jl,
71r. Appnrximatc arrlurrrc ref *no remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials wand (check all that apply);
ID Neat Ccmcnl Groot
❑ Sand Cemwi Grant
❑ Concreir Groat
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Conlon
❑ Gomel
❑ Other Iphainunder 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description [lithe abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certilkatlnn:
Brian Ewing
1/27/2021
50rauw!:Of C•eniiiitd WCII Ceur ter well Orsir Drye
ffy .sagnria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:fc'ewith 25.4 ,1 '..LC 2C.01O r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You slay Also :itaL;lt:tdditional pages if IkCe ,a. '_
SUBMITTAL INSTRUCTIONS
loa. For All Wes': Submit ilia I`nxm within 3tl day of completion of well
abpfdnnmcry t0 tr1i fgllmsing'
1}it'i lira of Water Resrmrcrs, Information Processing Uaii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. Farr [aietllion Well[: To Al:Idiom in sending the forth to the address in l()a
above_ also submit one naps of this form within'3tl days of completion of well
:Ibardanureni to the following:
Dlyistnn of Wilier Resources, Underground Injection Coal rol Program.
1.636 Msi1 Scrticc Center, Raleigh, NC 2709-1634
1fle, For Water %Dl)1T & lalection Went: In addition to sending the form to
the addresses) above_ also submit one copy of this form within 30 days of
completion of well abandonment In the court', health deputinieiu of the county
w]icri r.dm rd4ricd.
Non hC'arolJm Depanarcri efEnti iranincni and N;inirat Rcsuluccs - DIw ISL41n of Miss %olLrees. Rexeyed Anon 20L2.

WELL ABANDONMENT RECORD
This form can be used for niggle or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouiractar Flame (or s,c1.1 onirr persosail, abandainigacll an ha Ire proper!, )
4240-B
NC Well Cbnhudor Cerl irralian Flaunter
SAEDACCO Inc
Conway Flacon
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i ire p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vkarorrr
3. V4'd t use (check well use):
Water Supply Well:
❑ Agricultural
❑ Geothemwl (-lcaling:CoolingSupply.'
❑ Industrial/Commercial
❑ Ihi ii[iois
❑ hlennicipal,Ptiblk
❑ Rcsidenri:il Water Supph' r: ingle)
❑ Residenriat Waver Slip JI ' tsbared
Nno-Water Supply Well:
❑ 1NuntIonnne
❑ Rm.oven'
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Teal
❑ Experimental Techemloey
DGeothensa] {Closed Loops
L IGeothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiistiom
❑ Salmi{; Hamer
❑ Stomiwu! r Drainage
❑ Subsidence Caniml
L]Tracer
L Othertc'plain under 7g}
4. Dam w'e11(r) abandoned: 1/13/21
54. Well locution:
Former Queen City BP
FabcRil, tlwnerNlnrr
Fseilels 11711(iEimplicablet
2650 Shenandoah Ave Charlotte, NC 28205
Physical Addrem. Cr!,,, and Zip
Mecklenburg 12710204
C•ouW, Parcel IdcnliFrearina No. MIN)
5b.Latitude and longttade in elegrecilminuleifseconds or decimal dettree ;
{ifwell r4151, iriw Litlwy i, ui1 i roil}
35.210533
rq-80.801887 }}
(:O STR11{'7'r{1N DETAILS OF WELLS} BEING ABANDONED
.ramie ,veil cr'mvJrucJrare rrcnrsd a jJ uvarra,k. d ixr malrr,x .rrJrur or non -wader supph.
we& ONLY well I aaisa wic,rrro_rAak BhftlrfdurrhleNr_ yet. man sxfurefa o re ferih
6a.. Vs'rll IOE : B12
6b. Tout well depth: 20 (ft.)
6e, BO reside d larnctcr: 1. 5 (In.}
(iii. Water level hell% pound wring:: ;l{,)
frc. Outer casing length {if Mum a): ftt.l
frl. Inner easing/tubing knob lif known I;
6g.Screen l4ngHb IIf know o): fft.l
Fame GW-?'
For Internal Use ONLY:
WELL ABANDONMENT DFTA1L4
7a, Number of wells being abandoned: 1
,`'ry ndufupir r.'!' icUr rJJ rrurJ xwter eir'JI.0 rrdh ONLY i rib OW same
caurrnrcr,ion abandonment, :wire tearAlberni. our
71r. Appnrximatc rrrlurniz ref water remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
lc. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c, Sealing materials used (cheek all that Apply):
ID Neat Cement Groot
❑ Sand Cemwi Gmut
❑ Concrete Grout
❑ Specnalry Gruui
C7 Bentonite Slurry
BerJtanitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Grar'e:l
❑ Other Iviplain under 7g)
7f. For each material selected abole, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief dtscripticm rif the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerfiflouiloo:
Brian Ewing
1/27/2021
50'i:fla v Of C•en fiCd WC11 Cgmr oer well O,so*r Drys
ffy .sagnria Men farm, f frere&y certify dial thexeJ'i{sJ was (were? abandoned are
ou orxh:fc'e with 1 5.4 ,1 '..LC 2C .01004...r 2C .i200 FNada' cunstrric:.trun SraraJrds
and firm a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :itaralt:dditioneal pages if IkCe 5a. '_
SUBMITTAL INSTRUCTIONS
loa. For All Wens: Submit this Ibnrm within 3tI day of completion of well
abpndnnmcry r0 tbo fgllmsing'
Dii'isinla of Water ResemrErs, Information Processing Uaii,
1617 Mail Service {'enter, Raleigh, NC' 276994611
Bib. Feer [ulettton Went: rut Addition to sending the form to the address in lIa
above_ also submit one naps of this Fuom within '3(t days ref uoinptetion of well
:ibardanureW to the following:
Ditiistvn of WJitcr Resources, Underground Injection Cool oil Program.
1.636 Msi1 Scrticc Ccutrr, Raleigh, NC Zit 99-163fr
1flc, For Water %Dr)1t: & lalr:ctian Went: In addition to sending tale form to
the addresses) above_ also submit one copy of this foam within 30 days of
comptctioo of well abandonment to the count', Health de/minim of the 'county
w]icri qbqnclukcil.
Non h I:an:4Jro Dcpanancri efEnti iranincni and Mauro!. Reaolimcs - Doti isms of Winer Itolirces Rex iscd Anyeun 20 L:i

WELL ABANDONMENT RECORD
This form can be used for sigghe or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ourracrar Flame (or „ct1 onirr persoiaLI, abandmuaig,i.cll an ha Ire proper!, )
4240-B
NC Well Coulrudor Carl irralian Number
SAEDACCO Inc
Covian> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd 1 use (check well use):
Water Supply Well;
❑ Agricultktral
❑ GCoibcmwt [HCaiingCpoting Supply.'
❑ Industrial/Commercial
❑ IIri :I[ioil
❑ hlennicipal,Ptiblk
❑ Rcsidenti:il Water Suppi' r: ingle)
❑ ResidenriatWaverS pJI'tsbaredl
Non -Water Supply Well:
❑ 1Numlornin
❑ Rm.oven'
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Stahl a aid Recover
❑ Agrnifer Teal
❑ Experimental Tochemloo
DCeothensa] (Closed Loop)
L IGeoLhenital (Heating:Cooling Return),
❑ Gnaumdnarer ReIIieiiislion
❑ Salmi{; Hamer
❑ Stour ater L ral:n ge
▪ Subsidence Caniml
L]Tracer
L Othertc'plain under 7g}
4. Date neIL(s) abandoned: 1/13/21
54. Well locution;
Former Queen City BP
Facilil, tlwnerNucor
Fseilels 11711(irupplicablei
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
Caron, Parcel Idereikaidme No. MIN)
ih.Latitude and langttadein elegrecilminuteifsecondsordccimal dettree ;
{ifwell r4151, eiw Litluriy i, ui1 i rCii}
35.210533
Iq-80.801887 }}
CONSTRII{7r{1N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare rrcnrst a jJ uvada,k. ru malrr,x .r rJrur or non -wader supph.
we& ONLY well l ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. clan 1adurerr o re ferih
61. Neill IOdl: B10
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(rii. Water level helnw pound vprfAcc: 010
lrc. Outer casing length {if Mown a): ftt.l
8h. Inner casingitulrint knob lif known l; (fr.l
6g.Screen l4nlHb IIf known): fft.l
Fame GW-10
For Internal Use ONLY:
WELL ABANDONMENT DFTAIL4
7a. Number niwdla beim abandoned; 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns Ode same
caurrnrcr,ion abandonment, yr,rd ixar Alberni. our
71r. Appnrximatc rlrlurniz ref water remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7c, Sealing materials used (cheek all that Apply);
ID Neat Cement Grout
❑ Sand Cemwi Grout
❑ Concreir Groui
❑ Specialty Gruui
C7 Bentonite Slurry
t Betibinitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other Iviphainunder 7g)
717. For each material selected abos'a, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50ranaw!:Of C•eniiiitd WCII k cur ni r w ell Orsir Drye
ffy .aagnria Mu form, f frere&y certify dial the wer'ilsJ was (item? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.0100 r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/this record boa been provided ry are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also :itaL;lt:tdditional pages if IkCe 58r1'_
SUBMITTAL INSTRUCTIONS
loa. For All WeEL'': Sub]mii 1111S I`n rnn within 3tl day of completion of well
abprJdnnmcrll re the fgllmsing
Division of Wilier Resemrcrs, Information Processing Unnii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. For [aietllion Well[: rut ideliliotl to sending the ford[ to the address in lIa
above_ also submit one naps of this form within '3(l days ref completion of well
:ibardanurerd to the following:
Division of Water Resources, Underground Injection Cool col Program.
1636 14iai1 Smicc Coder, Raleigh, NC 2709-1634
1flc, For Water 5tlorrlT & in. edam We11t; In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
completion of well abandonment In lire count', health depatimeiu of the county
where abarrdnued.
Non h C'aralJre Dcpanineri efEnti iranincni and Nanurat Rtwinrees - Dolma of Warr It %eil.rces ecd An on 20 L:i

WELL ABANDONMENT RECORD
This form can be used for siggk or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouiractar Flame (or „ct1 onn'r persoiaLI, abandaivaig,i.cll an ha Ire proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. %It'd 1 use (cheek well use):
Water Supply Well:
❑ Agriculttrral
❑ GCothemwt (Healing/Cooling Supply.'
❑ Industrial/Commercial
❑ II t ii(iois
❑ hlennicipal,Piblk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residlential. Waver S1rp JI ' tsbared
Non -Waiter Supply Well:
❑ 1NumlonJte
❑ Rm.oven'
injection Well:
❑ Aquifer Recharge
❑ Aquifer Siang a and Recover
❑ Aquifer Teal
❑ ExporiuteN31 Tecliemloe
DCeothensa] (Closed Loop)
L IGeothenital fHearing:Cooliug Return),
❑ Oiuumdnarer ReIIieiiisliom
❑ Salmi{; Hamer
❑ Stour ater L ral:n ge
▪ Subsidence Catiml
L]Tracer
L Othertc'plain under 7g}
.1. Date neIL(s) abandoned: 1/13/21
54. Well lunation;
Former Queen City BP
Facilil, tlwnerNucor
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
Caron, Parcel Idered carlmrNo.IPIN)
5h.Latitude and longttsdc in elegrecilminuteifseconds or decimal dcl;rccs;
{ifwr:ll r4151, iww Litluriy i, ui1 i rein}
35.210533
rq-80.801887 }}
(:c 1NSTR1I{"Tr{)N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .r rJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrdarrhleNr_ yet. clan 1adurerr o re ferih
61. Neill IOE : B2
6b. Tout well depth: 20 (ft.)
6e, Bp reside d lamctcr: 1. 5 (Iu.)
(rii. Water level hClnwpound miring:: ;fr,)
(rc. Outer casing Icn 1b {if lawn a): Rt.l
84. lnncr'rasingltnbinp kn0h lif known
6g.Semen l4nuoHb IIf known): fft.l
Fame GW-?'
For inknnel Use ONLY:
WELL A BAN IM1N M ENT DFTAIL4
7a. Number niwdla being.al,andoued: 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns OW same
caurrnrcr,ion abandonment, :wire ixar Alberni. our
71r. Appnrximatc rlrlurrrc ref *ass remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials used (cheek ill that Apply);
ID Neat Ccmcnl Groot
❑ Sand Cemwi Grout
❑ Concreir Grunt
❑ Spectaltr Gruui
C7 Bentonite Slurry
t BetiRinitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Conlon
❑ CrL e:l
❑ Other Iviplain under 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment promdlure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerfifkratloo:
Brian Ewing
1/27/2021
50rauirc Of C•eniiiitd WCII k cur ni r w 'ell Ouir Drys
ffy .aagnria Mu form, f frere&y certify dial the wer'ilsJ was (were? abandoned in
ouorxh:fc'ewith 25.4 ,1 '..LC' 2C.01O r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You slay also :itaL;lt:rdditional pages if IkCe ,a. '_
SUBMITTAL INSTRiUCTIONS
loa. For All WeEL'': Sub]mii ilia I`nxm within 3tl day of completion of well
abprJdnnmcry re the fgllmsing'
1}it'i sirs of Water Resrmrcrs, Information Processing Uaii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. Fear [ulettton Well[: To iddiliots in sending the forest to the address in l()a
above_ ubsi submit one naps of this form within'3tl days of completion of well
:ibardanurerd to the following:
DIyistnn of Wilier Resources, Underground Injection Cool oil Program.
1.636 Msi1 Senicc Center, Raleigh, NC Zit 99-163fr
1flc, For Water %Dr)1T & lalr:ctian Went: In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
completion of well abandonment In the court', Jralth depatinieiu of the cocisv
where cibtirrd4ricd.
Non hCarolina Depanineri efEnti iranincni and Nanurat Rtwinrees - Diti isms of Wars R,saurec Ito. nod Anyeun 20L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or multiple wells
1. WCn f'4atrAe'mr'Inrorrnation_
Brian Ewing
Wclt{ouiractar Flame [or incl.! Driller persoiwtl, abandaiurig,i.cll an handier propcny )
4240-B
NC Well Cbnhudor Carl irralian bromber
SAEDACCO Inc
Covian> blame
2. Weti Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r�.r. euurrrr. hr4Mr. 1 �r� pax. '. . Vkarorrr
3. W l t use (check well um):
Water Supply Well:
❑ Agricultural
❑ Geolbcmwt (Healing:Cooling Supply.'
❑ Industrial/Commercial
❑ II t ii(iois
❑ hlenni ipKlaPt]hIk
❑ Rcsidenti:il Water Supph' rsingle)
❑ Residenriat Waver S1rp JI ' tsbared
Non -Water Supply Well:
❑ 1rIu]UIonoe
❑ Rm.oven'
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige sold Recover
❑ Aquifer Teal
❑ Experimental TechemLoin
DCeothensa] {Closed Loops
L IGeothenital (Heating:Cooling Return),
❑ GnnuMdnarer Renlreiiisl]cs
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsidence Caniml
L]Tracer
L Othertc'plain under 7g}
4. Dam w'e11(r) abandoned: 1/13/21
54. Well locution:
Former Queen City BP
Fabc1!l, thsrrerNlnrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Addrem. Ci4, and Zip
Mecklenburg 12710204
C alal. Parcel Idcnlifrcadme ND. (PIN)
5b.Latitude and longttade in elegrecilminuteifsecnnds or decimal dettreeN
if wall r4141, eiw Litlwy i, ui1 i r4ii
35.210533
rq-80.801887 }}
(:O STR11{'7'r{1N DETAILS OF WELLS} BEING ABANDONED
.ramie vref1 cr'mvJrucJrare rrcnrst a jJ uvarra,k. 1 ixr malrr,x .rthole or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrdarrhleNr_ yet. man sxfurera o re ferrh
6a.. Vs'rll [OIl:B4
6h. Tout well depth: 20 (ft.)
6e, BO reside d lamctcr: 1. 5 (In.}
(lees, Water level hell% pound wring:: Ott)
frc. Outer casing length {if lawn n is fit. i
frl. lnncr casingltnlrint I wig h lif knerwn
6g.Screen i4nlHh IIf know o): fft.i
Fame GW-?'
For Internal Use ONLY:
WELL ABANDONMENT DFTA1L4
7a, Number of wells being abandoned: 1
F.,r ndufupir r.'!' icUr rJJ rhoxwter sirpla). math ONLY rrtNJ 1W same
cauroverranJ abandonment, :wire ixarAlberni. our
Appnrximatc rarlurrrc ref watts remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
lc. Type ref disinfectant used:
7d. Amount of disi nfm twit used:
7c. Sealing materials Used (cheek all that Apply):
ID Neat Cement Groot
❑ Sand Cemwi Gmut
❑ Concrelr Groui
❑ Specnaltr Gruui
C7 Bentonite Slurry
BerJtanitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutlios
❑ Grar'r1
❑ Other Iviplain under 7g)
7f. For each material selected abole, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description oldie abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50ranaw!:Of Ckniiitd WC11 4411 Orso*r Drys
ffy .sagnria Men form, f frere&y certify dial the wer'ilsJ was (were? abandoned are
occmioh['e with 1 5.4 ,1 '..LC 2C .01004...r 2C .i200 [Nods' cunstrric.iic'L 5t,m 4dr orz
and firm a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :itaralt:tdditioneal pages if IkCe 5a. '_
SUBMITTAL INSTRUCTIONS
loa. For all Wells: Submit 11]is 1bnm within 3tl day of completion of well
ahpr]dnnmcrll r0 thi f01lmsing'
Division of Water ResemrErs, Information Processing Uaii,
1617 Mail Smier {'enter, Raleigh, NC' 276994611
Bib. Feer [ulettton Well[: rut Addition to sending the forest to the address in lIa
above_ also submit one naps of this form within '3(l days ref uoinptetion of well
:ibardanurera to the following:
Division of WJitcr Resources, Underground Injection Cool oil Program.
1.636 Msi1 Scrticc Ccutrr, Raleigh, NC Zit 99-163fr
1flc, For Water %Dr)1t: & lalr:ctian Went: In addition to sending tale form to
the address;es) above_ also submit one copy of this foam within 3fl days of
comptctioo of well abandonment In the count', health de/minim of the'county
where qbqnclukcil.
Non h C'arDlJm Ucpanuers efEnti iranincni and Nanurat Rcsuluccs - Diti isms of Mawr Trolirecs eyed Anyeun 20 L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourraclar Flame (or sled or,. lief persoiwtl, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriat Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiialimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/13/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adttrcss. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can 1adure12 Wra ferire
61. Well [b#:A24
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauvofC•eniliitd WCII C,eur ter 4411 Owir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wilier RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this foot" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the comet', health depatimem of the comity
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This form can be used for siggk or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wcli{ouuacrar Flame (or %leiI or,. lief persoiwil, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (check well um):
Water Supply Well;
❑ Agriculttrral
❑ Geoibcmwt (ealingJCoobng Supply.'
❑ Inchistrialfirommercial
❑ IIrid:I[iois
❑ hletnicipal,Priblk
❑ Rcsidenri:il Water Supph. rsingle)
❑ Residlential. Waver Supply tsbaredl
Nne-Water 4eppty Well:
❑ 1rlumlornie
❑ Rm.oven.
Tnjection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Techemloex
DCeathenita] {Closed Loops
L IGeothenital (Heating:Cooling Return).
❑ Gntumdnarer Reuieiiistiom
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Suhasidence Coriml
L]Tracer
L Othertc'plain under 7g}
4. Dim wCIl{t~) abandnncd• 1/13/21
54. Well Medium;
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zio
Mecklenburg 12710204
C'ouots Parcel Idtnlifrcatlrnt No. MIN)
5h.Latitude and lungitnde in elegreeafminuteifseconds or decimal degrees:
{ifwell r4I51, itiw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
.CONSTR1I{"Tr{)N DETAILS OF WELLSS} BEING ABANDONED
!(Fmk ,veil cr'mvJratikN uvada,k. 1 ixr mulrr,x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAgrBhftlrflurrhleNr_ yet. man sxfurefr o re ferih
61. Well II11tldl:A26
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (Iu.).
firs, Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
lnncr'rasingltnlrinp knob lif knerwnl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTA1L4
7a, Number of wdla being abandoned: 1
F..ir ndidufl rJnikrYiurr FJJ' rdoN rnxrrer sir'JI.0 rrlh ONLY "rah 1W same
caurrnrcrrayJ abandonment, yr,rd rxarAlberni. our
71r. Appnrximatc rrllurrrc ref water remaining in wrIl(s)a
FOR WATER SUPPLY WELLS ONLY:
7c. Type ref disiufeetard used:
7d. Arturant of disinf4 twit used:
7c. Sealing materials used (cheek ill that Apply):
Q Neat Cement Grant
❑ Sand Cemera Grout
❑ Concrete Grout
❑ Specialty Gruui
C7 Bentonite Slurry
C1d Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracei
❑ Other 1plainunder 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerlifkviloo:
Brian Ewing
1/27/2021
5rgrrauuv of C•eniliitd WCII C,eur nee 4411 Chvir Drys
ffy .sagnria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well sire details or well
abaudr1nuternl details. You may also :itaelt:dditional pages if ttecessat _
SUBMITTAL INSTRUCTIONS
loft. For All Wefts: Submit this I` rni within 30 day$ of completion of well
abpfdnnmcry r0 tr1i i01lmsing.
1}it i mien of Wsitr RI:MI[1 - s, Information Processing Bait,
1617 Mail Smice {'enter, Raleigh, lit:' 276994617
Bib. Fear [aietllion Vric11 : rut Addition to sendiltg tare forrtt to the address in lIa
abtlt_ gat submit one naps of this form widrio'30 days ref euinpterion of well
:ibardanuteW to the following:
Division of Winer Resources, Uodergrou nd Injection Cool oil Program.
Ui36 Msi1 Scrticc Center, Raleigh, New 27t499-1634
10e, For Water Su anti: & la lr:ctian Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this foam within 30 days of
comptctino of wit] abandonment to the count', health de/minim of the county
w]icri gbtlndnncd.
Non h C'arolmo Depanincri ofEnti iranincni atsi Natural. Rcsuurccs - Diti isian of Waver R ourec Rex 'sod August 20 L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourraclar Flame (or sled or,. lief persoiwtl, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriat Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiialimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/13/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adttrcss. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can 1adure12 Wra ferire
61. Well [b#:A14
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauvofC•eniliitd WCII C,eur ter 4411 Owir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wilier RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this foot" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the comet', health depatimem of the comity
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourraclar Flame (or sled or,. lief persoiwtl, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriat Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiialimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/13/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adttrcss. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can 1adure12 Wra ferire
61. Well Ib#:Al2
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauvofC•eniliitd WCII C,eur ter 4411 Owir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wilier RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this foot" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the comet', health depatimem of the comity
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! calve persoiaLI, abandasing %tell an Freon propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtiblk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Waver S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
L]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/13/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegree:tfminuteifsecondsor docintril dcl;rres:
{ifwell r4151, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse ,veil cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well ID #:A3
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lain a): RIl
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
cavern wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Ouir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and JIrat a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ,lees'r: Submit this !bem within 3El day of completion of well
abpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the form to the address in lIa
above_ oho subsist one noes of ibis fon" within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccutrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 days of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - DIs Isms of Water Ireitrecs Rca wed Ayeusi 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! calve persoiaLI, abandasing %tell an Freon propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtiblk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Waver S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
L]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/13/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegree:tfminuteifsecondsor docintril dcl;rres:
{ifwell r4151, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse ,veil cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well Ib#:A21
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lain a): Rt.l
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
cavern wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Ouir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and JIrat a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ,lees'r: Submit this !bem within 3El day of completion of well
abpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the form to the address in lIa
above_ oho subsist one noes of ibis fon" within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccutrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 day of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - Dls Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wcli{ourractar Flame (or %leiI or,. lief persoiwil, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. rsingle)
❑ Residential. Waver Slip JI tsharndl
Nee -Water 4eppty Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenstal {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiiatimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsidence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/14/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in elegrecilminuluifseaonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'mvJratikN uvada,k. 1 ixr mulrr,x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAgrBhftlrflurrhleNr_ yet. can sxfurefr o re ferih
61. Well ID#:A2
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8I. lnacr'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DETAIL:
7a, Number oiwdla beim abandoned: 1
F,ir ndidufl rJnikrYiurr FJJ' rdoN rnxrrer sir'JI.0 rrlh ONLY "rah 1W same
caurrnrcrrayJ abandonment, yr,rd rxarAlberni. our
71r. Appnoximatc rrolurrrc ref water remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Grout
❑ Concrete Grout
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Graces
❑ Other 1phainunder 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauv of C•eniliitd WCII C,eur ter 4411 Chvir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loll. For All Wells: Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Winer RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Vella In addition to sendiltg the form to the address in lIa
above_ also submit one naps of this foots within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Winer Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
1fle, For Water Sunny & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] ablydomnent to the comet', health depatinreiu of the county
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wcli{ourraclar Flame (or %lei! or,. lief persoiwil, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. %It'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geolbcmwt (Healing/Cooling Supply.'
❑ InchistrisliCornmercia1
❑ IIri:I[iois
❑ hltnnicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriai Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlonnIe
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tnchnoloin
DGeothenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reureiiialiour
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/14/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
if well r4141, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELL(S) BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrfleoThWeNr_ yet. can 1adure12 Wra ferire
61. Well II}#:A8
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t inner casingltnlrint knob lif known I; (ft.l
6g.Screen length IIf known): fft.l
Four GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurrrc ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilaircofC•eniliitd WCII Ceur ier 4411 Owir Drys
ffy .sagnria Mu form, f frere&y certify dial the weiilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:tdditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this Ibrni within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wafer RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, ]w C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this fon" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the court', health depatimem of the cocisv
where abarrdnn il.
Non h C'aralmo Depanineri ofEnti iranincni and Natural. Rcsuurccs - Diti isLon of Wrass i f- .',irec Rex reed August 20 L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wcli{ourractar Flame (or %leiI or,. lief persoiwil, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. rsingle)
❑ Residential. Waver Supply tsharndl
Nee -Water 4eppty Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenstal {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiiatimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsidence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/14/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
C'ouut, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in elegrecilminuluifseaonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. 1 ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can sxfurefr Wra ferire
61. Well Ib#:A20
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwter sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Grout
❑ Concrete Grout
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Graces
❑ Other 1phainunder 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauv of C•eniliitd WCII C,eur ter 4411 Chvir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Winer RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Vella In addition to sendiltg the form to the address in lIa
above_ also submit one naps of this foots within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Winer Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
1fle, For Water Sunny & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] ablydomnent In the comet', health depatimem of the county
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourraclar Flame (or sled or,. lief persoiwtl, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriat Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiialimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/14/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adttrcss. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can 1adure12 Wra ferire
61. Well Ib#:A32
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauvofC•eniliitd WCII C,eur ter 4411 Owir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wilier RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this foot" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the comet', health depatimem of the comity
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This form can be used for siggk or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouiractar Flame (or „ct1 onn'r persoiaLI, abandaivaig,i.cll an ha Ire proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. %It'd 1 use (cheek well use):
Water Supply Well:
❑ Agriculttrral
❑ GCothemwt (Healing/Cooling Supply.'
❑ Industrial/Commercial
❑ II t ii(iois
❑ hlennicipal,Piblk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residential. Wader S1rp JI ' tsbared
Non -Waiter Supply Well:
❑ 1NumlonJte
❑ Rm.oven'
injection Well:
❑ Aquifer Recharge
❑ Aquifer Siang a and Recover
❑ Aquifer Teal
❑ ExporiuteN31 Tecliemloe
DCeothensa] (Closed Loop)
L IGeothenital fHearing:Cooliug Return),
❑ Oiuumdnarer ReIIieiiisliom
❑ Salmi{; Hamer
❑ Stour ater L ral:n ge
▪ Subsidence Catiml
:]Tracer
L Othertc'plain under 7g}
.1. Date neIL(s) abandoned: 1/14/21
54. Well lunation;
Former Queen City BP
Facilil, tlwnerNucor
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
Caron, Parcel Idered carlmrNo.IPIN)
5h.Latitude and longttsdc in elegy+ceafminuteifseconds or decimal dcl;rccs;
{ifwr:ll r4kl, iww Litludiy i, ui1 i rein}
35.210533
rq-80.801887 }}
(:c 1NSTR1I{"Tr{)N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .r rJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrdarrhleNr_ yet. clan 1adurerr o re ferih
61. Neill IOE : B8
6b. Tout well depth: 20 (ft.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(rii. Water level hClnwpound miring:: ;fr,)
(rc. Outer casing Icn 1b {if lawn a): Rt.l
id, lnncr'rasingltnbinp kn0h lif known
6g.Semen l4nuoHb IIf known): fft.l
Fame GW-?'
For inknnel Use ONLY:
WELL A BAN IM1N M ENT DFTAIL4
7a. Number niwdla being.al,andoued: 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns OW same
caurrnrcr,ion abandonment, :wire ixar Alberni. our
71r. Appnrximatc rlrlurrrc ref *ass remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials used (cheek ill that Apply);
ID Neat Ccmcnl Groot
❑ Sand Cemwi Grout
❑ Concreir Grunt
❑ Spectaltr Gruui
C7 Bentonite Slurry
t BetiRinitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Conlon
❑ Gomel
❑ Other Iviplain under 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment promdlure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerfifkratloo:
Brian Ewing
1/27/2021
50rauw!:Of C•eniiiitd WCII Cgmr ndrr well Ow it Drye
ffy .aagnria Mu form, f frere&y certify dial the wer'ilsJ was (were? abandoned in
ocxorxh:fc'ewith 25.4 ,1 '..LC' 2C.01O r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You slay also :itaL;lt:rdditional pages if IkCe ,a. '_
SUBMITTAL INSTRiUCTIONS
loa. For All Wells: Submit ilia I`nxm within 3tl day of completion of well
ahprJdnnmcry re the fgllmsing'
1}it'i sirs of Water Resrmrcrs, Information Processing Uaii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. Fear [ulettton Well[: To iddiliots in sending the forest to the address in lIa
above_ ubsi submit one naps of this form within'3tl days of completion of well
:ibardanurerd to the following:
DIyistnn of Wilier Resources, Underground Injection Cool dal Program.
1.636 Msi1 Senicc Center, Raleigh, NC Zit 99-163fr
1flc, For Water %Dr)1T & lalr:ctian Went: In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
completion of well abandonment In the court', Jralth depatinieiu of the cocisv
where cibtirrd4ricd.
Non hCarolina Depanineri efEnti iranincni and Nanurat Rtwinrees - Diti isms of Wars R,saurec Ito. nod Anyeun 20L:i

WELL ABANDONMENT RECORD
This form can be used for sigghe or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ourracrar Flame (or „ct1 onirr persoiaLI, abandmuaig,i.cll an ha Ire proper!, )
4240-B
NC Well Coulrudor Carl irralian Number
SAEDACCO Inc
Covian> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd 1 use (check well use):
Water Supply Well;
❑ Agricultktral
❑ GCoibcmwt [HCaiingCpoting Supply.'
❑ Industrial/Commercial
❑ IIri :I[ioil
❑ hlennicipal,Ptiblk
❑ Rcsidenti:il Water Suppi' r: ingle)
❑ ResidenriatWaverS pJI'tsbaredl
Non -Water Supply Well:
❑ 1Numlornis
❑ Rm.oven'
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Stahl a aid Recover
❑ Agrnifer Teal
❑ Experimental Tochemloo
DCeothensa] (Closed Loop)
L IGeoLhenital (Heating:Cooling Return),
❑ Gnaumdnarer ReIIieiiislion
❑ Salmi{; Hamer
❑ Stour ater L ral:n ge
▪ Subsidence Caniml
L]Tracer
L Othertc'plain under 7g}
4. Date neIL(s) abandoned: 1/14/21
54. Well locution;
Former Queen City BP
Facilil, tlwnerNucor
Fseilels 11711(irupplicablei
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
Caron, Parcel Idereikaidme No. MIN)
ih.Latitude and langttadein elegrecilminuteifsecondsordccimal dettree ;
{ifwell r4151, eiw Litluriy i, ui1 i rCii}
35.210533
Iq-80.801887 }}
CONSTRII{7r{1N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare rrcnrst a jJ uvada,k. ru malrr,x .r rJrur or non -wader supph.
we& ONLY well l ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. clan 1adurerr o re ferih
61. Neill IOdl: B16
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(rii. Water level helnw pound vprfAcc: 010
lrc. Outer casing length {if Mown a): ftt.l
8h. Inner casingitulrint knob lif known l; (fr.l
6g.Screen l4nlHb IIf known): fft.l
Fame GW-10
For Internal Use ONLY:
WELL ABANDONMENT DFTAIL4
7a. Number niwdla beim abandoned; 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns Ode same
caurrnrcr,ion abandonment, yr,rd ixar Alberni. our
71r. Appnrximatc rlrlurniz ref water remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7c, Sealing materials used (cheek all that Apply);
ID Neat Cement Grout
❑ Sand Cemwi Grout
❑ Concreir Groui
❑ Specialty Gruui
C7 Bentonite Slurry
t Betibinitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other Iviphainunder 7g)
717. For each material selected abos'a, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50ranaw!:Of C•eniiiitd WCII k cur ni r w ell Orsir Drye
ffy .aagnria Mu form, f frere&y certify dial the wer'ilsJ was (item? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.0100 r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/this record boa been provided ry are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also :itaL;lt:tdditional pages if IkCe 58r1'_
SUBMITTAL INSTRUCTIONS
loa. For All WeEL'': Sub]mii 1111S I`n rnn within 3tl day of completion of well
abprJdnnmcrll re the fgllmsing
Division of Wilier Resemrcrs, Information Processing Unnii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. For [aietllion Well[: rut ideliliotl to sending the ford[ to the address in lIa
above_ also submit one naps of this form within '3(l days ref completion of well
:ibardanurerd to the following:
Division of Water Resources, Underground Injection Cool col Program.
1636 14iai1 Smicc Coder, Raleigh, NC 2709-1634
1flc, For Water 5tlorrlT & in. edam We11t; In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
completion of well abandonment In lire count', health depatimeiu of the county
where abarrdnued.
Non hCarolina Depanineri efEnti iranincni and Nanurat Rtwinrees - Diti isms of Wars R,saurec Rcxecd An on 20L:i

WELL ABANDONMENT RECORD
This form can be used for siggk or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouiractar Flame (or „ct1 onn'r persoiaLI, abandaivaig,i.cll an ha Ire proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. %It'd 1 use (cheek well use):
Water Supply Well:
❑ Agriculttrral
❑ GCothemwt (Healing/Cooling Supply.'
❑ Industrial/Commercial
❑ II t ii(iois
❑ hlennicipal,Piblk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residential. Wader S1rp JI ' tsbared
Non -Waiter Supply Well:
❑ 1NumlonJte
❑ Rm.oven'
injection Well:
❑ Aquifer Recharge
❑ Aquifer Siang a and Recover
❑ Aquifer Teal
❑ ExporiuteN31 Tecliemloe
DCeothensa] (Closed Loop)
L IGeothenital fHearing:Cooliug Return),
❑ Oiuumdnarer ReIIieiiisliom
❑ Salmi{; Hamer
❑ Stour ater L ral:n ge
▪ Subsidence Catiml
:]Tracer
L Othertc'plain under 7g}
.1. Date neIL(s) abandoned: 1/14/21
54. Well lunation;
Former Queen City BP
Facilil, tlwnerNucor
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
Caron, Parcel Idered carlmrNo.IPIN)
5h.Latitude and longttsdc in elegy+ceafminuteifseconds or decimal dcl;rccs;
{ifwr:ll r4kl, iww Litludiy i, ui1 i rein}
35.210533
rq-80.801887 }}
(:c 1NSTR1I{"Tr{)N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .r rJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrdarrhleNr_ yet. clan 1adurerr o re ferih
61. Well [b#:B6
6b. Tout well depth: 20 (ft.)
6e, BO reside D lamctcr: 1. 5 (Iu.)
(rii. Water level hClnwpound miring:: ;fr,)
(rc. Outer casing Icn 1b {if lawn a): Rt.l
id, lnncr'rasingltnbinp kn0h lif known
6g.Semen l4nuoHb IIf known): fft.l
Fame GW-10
For inknnel Use ONLY:
WELL A BAN IM1N M ENT DFTAIL4
7a. Number niwdla being.al,andoued: 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns OW same
caurrnrcr,ion abandonment, :wire ixar Alberni. our
71r. Appnrximatc rlrlurrrc ref *ass remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of Disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials used (cheek ill that Apply);
ID Neat Ccmcnl Groot
❑ Sand Cemwi Grout
❑ Concreir Grunt
❑ Spectaltr Gruui
C7 Bentonite Slurry
t BetiRinitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Conlon
❑ Gomel
❑ Other Iviplain under 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment promdlure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerfifkratloo:
Brian Ewing
1/27/2021
50rauw!:Of C•eniiiitd WCII Cgmr ndrr well Ow it Drye
ffy .aagnria Mu form, f frere&y certify dial the wer'ilsJ was (were? abandoned in
ocxorxh:fc'ewith 25.4 ,1 '..LC' 2C.01O r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You slay also :itaL;lt:rdditional pages if IkCe ,a. '_
SUBMITTAL INSTRiUCTIONS
loa. For All Wells: Submit ilia I`nxm within 3tl day of completion of well
ahprJdnnmcry re the fgllmsing'
Dii'isitlu of Water Resrmrcrs, Information Processing Uaii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. Fear [ulettton Well[: To iddiliots in sending the forest to the address in lIa
above_ ubsi submit one naps of this form within'3tl days of completion of well
:ibardanurerd to the following:
DIyistnn of Wilier Resources, Underground Injection Cool dal Program.
1.636 Msi1 Senicc Center, Raleigh, NC Zit 99-163fr
1flc, For Water %Dr)1T & lalr:ctian Went: In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
completion of well abandonment In the court', Jralth depatinieiu of the cocisv
where cibtirrd4ricd.
Non hCarolina Depanineri efEnti iranincni and Nanurat Rtwinrees - Diti isms of Wars R,saurec Ito. nod Anyeun 20L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourraclar Flame (or sled or,. lief persoiwtl, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriat Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiialimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/14/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adttrcss. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can 1adure12 Wra ferire
61. Well Ib#:A28
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauvofC•eniliitd WCII C,eur ter 4411 Owir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wilier RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this foot" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the comet', health depatimem of the cods,
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This form can be used for sio.i k or rnu]lipte wells
For Inknmi Use ONLY:
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{'oryracrar Flame (or sled onlrr perviiwtl, abandmualg,i.cll an he Ire proper!, )
4240-B
NC Well Cbntru lur Cerl irirailian Flaunter
SAEDACCO Inc
Covian> [+tame
2. Weil Construction Permit 70002483 L__r WI0300399
J.JKr.:t l irl p?h Q4✓e• w,eiF permJrr r�.r. r.'uurrrr. hr4Mr. J '. . i1 k'rorrr
3. W l t use (check well use):
Water Supply We1I;
❑ Agricultitral
❑ GCotbcmwt (CalingJCoobng Supply.'
❑ Iridusiria3(C0mrrrerdla1
❑ Ihi:i[iois
❑ hltonicipal,Ptihlk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residential. Warn S1ipply'tsbaredi
Nno-Water Supply Well:
❑ JNumlonJrt:
❑Rn:oven
Tnjection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tm Jinoloe
DGeothenlia] {Closed Loops
L ICitoEheniial (Heating:Cooling Retanl)
EIGRMOdIrdier Reuie�iarioer
❑ Salini{3' Hamer
❑ Stomn3ater Drainage
▪ Subsidence Caiiml
L]Tracer
Maier under 7g}
4.Dam woo) ahanrinncd: 1/14/21
54. Well locution;
Former Queen City BP
Fabc1!l, thsrrerNlnrr
Facility 11711(if =DRlicabl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. CiR, aid Zlri
Mecklenburg 12710204
C'ouW, Parcel IderdiFieadmi No. IPIN)
5h.1-atitudeand longitude in degreeilminutesirsevondsordecimal dettnees;
{ifuell r4151, rwr4 Lit.lwy i, ui1314r4ii
35.210533
rq-80.801887 }}
(:c1r STRII{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.lrGuir ,veil LT) ward! dioN el. co jJ uvarra,k. x .rrJrur or non -wader supph.
we& ONLY w JrA rile earrme wir.,rrrre rAak autrflurrhleNr_ yet. man °donee wee firth
61.. Weil IniCA30
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5
firs, Water level helms. surface: 010
fie. Outer casing length Of town a): RIl
fit lnncr casing/tubing I wig h lif known lc
6g.Semen If horn al: fft.l
Fame GW-10
WELL A BAND 1N M ENT DFTAIL4
7a, Number ufwdla being abandoned: 1
t'ry ndufupie rJllkrY!or r FJJ' rrurJ hurer 315.JI.IJ rrlh ONLY "rah OW some
caurrrIwr,ton abandonment, :wire 2 ar.'w wrrr our j;,rrjl,
Appniximatc rrilurrrc of *am remaining in we11(s)a
FOR WATER SUPPLY WEL[S (N1.Y:
7c. Type of disinfectant used:
7d. Artuiant of disinfe twat used:
7e. Sealing materials used (cheek all that Apply);
ID Nod Cement Grout
❑ Sand Cenieni Gmut
❑ Concreir Groui
❑ Specialty Gruui
C7 Bentonite Slurry
l Bead finite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other he' plainunder 7g)
717. For each material selected abota, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the alianrlrinment proi.cdi re:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certihkatloo:
Brian Ewing
1/27/2021
5i moans: iif C.e MAW W.0II 4411 O,sir Drys
ffy .sagnria Mu form, f frere&y certify dial the wviipri was (were? abandoned in
ou orxhifc'e with 2 5.4 ,1 '..]C 2C .01004...r 2C .0200 [Nods' cunstrric.iic'L Sramk r orz
and lhar a copy o/Nris record boa been provided Iv are wen! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abaudonureril details. You may :also :itai;lt actinium' pages if tieceasa.Y_
SUIrn1ITTAL INSTRUCTIONS
IOa. For All Was: Submit this Poem within 30 day of completion of well
abpridnnmcry r0 the following'
Dii'isirla of Wirier Rrsrmreers, Information Processing Unit,
1617 Mail Sell -ice {'enter, Raleigh, NC 27679-1617
Bib. Fear [aietllion Well[: rut rddilion [a sending the form to the address in lIa
above_ also sussed one °oils of this former within '3(lidays ref completion of well
:Ibandanutei to the following:
Division of Winter Resources, Undergrou yid Injection tool oil Program.
1636 Mii1 Senicc Center, Raleigh, NC Zit 99-163fr
'Inc, For Water Su pr)1i' & la lertlan We11r. Ili addition to sending the form to
the address;es) above_ also submit one copy of this form within 30 day of
comptctioo of net] abandonment to the count}' health deparinieiu of the county
w]icri qbqnclukcil.
Non h C'araliro Depanincri ofEnw imminent and N,Irurat Rtsuarccs - DIw ISLon of Vr'arcr fi,56itr{tii Rex iscd Augusi 20 L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourraclar Flame (or sled or,. lief persoiwtl, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriat Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiialimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/14/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adttrcss. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can 1adure12 Wra ferire
61. Well Ib#:A18
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8t lnner'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-10
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauvofC•eniliitd WCII C,eur ter 4411 Owir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wilier RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this foot" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the comet', health depatimem of the cods,
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL ABANDONMENT RECORD
This form can be used for sigghe or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourracrar Flame (or 'act! on lief on hi der proper!, )
4240-B
NC Wc1I Cbntru lur Flrunber
SAEDACCO Inc
Colman [+tame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r,.r. ruurrrr. hr4Mr. 1 iri pax. '. . Vkarorrr
3. V4'd 1 use (cheek well use):
Water Supply Well;
❑ Agricultural
❑ GCorbcmwt (Healing:Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIriginiois
❑ hlennicipal,Ptiblk
❑ Rcsidenti:il Water Sapph' r: ingle)
❑ Residenriat Water S1ippl ' tshan':d i
Non -Water So Fay Well:
❑ 1Numlonare
❑ Rm.overr
['ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Agreifer Teal
❑ Experimental TechemLoin
DCn:oihensa] {Closed Loops
L IGeothenital (Heating:Cooling Return)
❑ Gnaumdnarer Reuieiiiation
❑ Salini{3' Hamer
❑ Stour ater Drainage
❑ Srlasidence Cariml
L]Tracer
L Othertc'plain under 7g}
i. Dam w'e11(r) abandnncd: 1/14/21
54. Well locution;
Former Queen City BP
F Rils tlwnerNlnrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
Colas Parcel IdcnliFieadmi No. MIN)
5h.Latitude and longitado in elegnceafminuteifseconds or decimal dcl;rccs;
{ifwell r4151, eiw Litlwy i ti i1 i rCiii}
35.210533
rq-80.801887 }}
CONSTRII{'7'r{1N DETAILS OF WELLS} BEING ABANDONED
.lrGuir vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .rbJrur or taus -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak BhftlrflurrhleNr_ yet. man sxfuiera o re ferih
61. Vs'rll IOdl: B13
6b. Tout well depth: 19 (h?.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(iii. Water level hell% pound airfAcc: 010
frc. Outer casing length {if Morn a): ftt.l
fih. Inner casing/tubing kno b lif known
6g.Semen b IIf known): fft.l
ATM GW-?'
FOT Inknnui Use ONLY:
WELL ABAN DMFNMENT DFTA1L4
7a, Number of wdla being abandoned: 1
F.x. ndufupir r.'!' icUr rJJ rrurJ xwter air'JI.0 rrlh ONLY "rah OW same
causrntcrrayJ abandonment, :wire ixar Alberni. our j;ir jl,
Appnrximatc arrlurrrc ref *ator remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinf4 twit used:
7e, Sealing materials wand (check all that apply);
ID Neat Cement Grunt
❑ Sand Ceniwi Grant
❑ Concreir Groat
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Coulon
❑ Gravel
❑ Other leNphainunder 7g)
717. For each material selected abot•a, provide arnortat of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description [lithe abandonment i roi.c lure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cm-dilleallow
Brian Ewing
1/27/2021
50'i:fla v of C•eilfiCd WCII Ceur ter well Owir Drye
ffy signing Mu form, f trite&: certify dial the nviilsJ was (were? abandoned are
ou orxh:fc'e with 1 5.4 ,1 '..LC 2C .01004...r 2C .i200 [Nods' cunstrric:.trun SraraJrds
and that a copy o/Nris record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14itiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :ilach.:dditional pages if ri cis a.1'_
SUBMITTAL INSTRUCTIONS
loa. For All WeEL'': Sub]ni1 this I`nrnn within 3tl day of completion of well
abpndnnmcry r0 tr1i f01lmsing'
Division of Water Resrmrcrs, Information Processing Uaii,
1617 Mail &amice {'enter, Raleigh, NC 276994611
Bib. Fear [aietllion Went: rut iddiliots to sending the form to the address in lIa
above_ also submit one naps of this font within '3(l days ref completion of well
:Ibardanuieni to the following:
Dunstan of Winter Resources, Underground Injection Cool oil Program.
1636 mail Scrticc Ccdtrr, Raleigh, NC 2709-1634
1flc, For Water %ar)1T & la'cram We11t; In addition to sending the form to
the address;es) above_ also submit one copy of this form within 30 days of
comptctioo of well abindlomnent in the count', health de/minim of the county
'where :41mtidnn f.
Non h I'arolJm Depaniucri ofEnw iranincni and Nan irat Rcsuluccs - DIw ISL41n of Miss %olLrees. Rex iscd Anon .201.2.

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! ettlrr persoiaLI, abandasing %tell an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/14/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifsecondsor docintril dcl;rres:
{ifwell r4kl, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse 11re11 cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well II}#:A5
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lawn a): RIl
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Orsir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ulnas: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis food! within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 days of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - DIs Isms of Water Ireitrecs Rca wed Ayeusi 20 L:i

WELL ABANDONMENT RECORD
This form can be used for sigghe or multiple wells
1 r WO f'4atrAe'm r information:
Brian Ewing
Wclt{ourractar Flame (or „ct1 onn'r persoiaLI, abarmiannig,i.cll an ha Ire proper!, )
4240-B
NC We11 Cbnhudor Number
SAEDACCO Inc
Coiii an> Ntame
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. V4'd t use (check well use):
Water Supply Well;
❑ Agriculttoral
❑ Geothemwl(-lcalingJCoolingSupply.'
❑ Industrial/Commercial
❑ II t ii[iois
❑ hlennicipal,Piblk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residenriat Wader S1ipply'tsbaredl
Non -Waiter Supply Well:
❑ 1Numlorion
❑ Rm.oven'
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Teal
❑ Experimental TechemLoin
DCeothensta] (Closed Loop)
L IGeothenital (Hearing:Cooliug Return),
❑ Gnaumdnarer Reuieiiistioo
❑ Salmi{; Hamer
❑ Stour ater L mirage
▪ Subsidence Catiml
:]Tracer
L Othortc'iplain under 7g}
4. Dam se11(r) abandoned: 1/14/21
54. Well location;
Former Queen City BP
Facilil, tlwnerNucor
Facility 11711(iEuFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. CM, and Zip
Mecklenburg 12710204
Caron!. Parcel idered eadmi No. MIN)
511- alitudeand longitodein elegy+eeafminuteifsecnndsordecimal dcl;rccs;
{ifwell r4kl, loom Litluiiy i 1 i rCiii}
35.210533
Jq-80.801887 }}
(:c 1NSTR11{'7'r{1N DETAILS OF WELLS} BEING ABANDONED
.lrGuir vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .rrJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrdarrhleNr_ yet. clan 1adurerr o re ferih
61. Vs'rll [Odl:B15
6b. Tolst well depth: 19 (h?.)
6e, BO reside J!minder: 1. 5 (In.}
(41. Water level hClnsr' pound arrfAcc: Olt)
(rc. Outer casing length {if 1, mm a): ftt.l
8t lnncr casingltnlrint knob lif known I;
6g.Semen l4nrHh IIf known): fft.l
Fame GW-?'
For Inknnel Use ONLY:
WELL ABAN DMFNMENT DFTA1L4
7a. Number niwdla beiugabandoued: 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY irrib OW same
caurrnrcr,ion abandonment, :wire ixar Alberni. our
71r. Appnrximatc alrlurniz ref *no remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
lc. Type of Jisiufeetaut used:
7d. Amount of 43isinf4mtait used:
7e, Sealing materials wand (check all that apply);
ID Neat Cement Grant
❑ Sand Ceniwi Grout
❑ Concreir Grunt
❑ Spectaltr Gruui
C7 Bentonite Slurry
Berrtanitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gr2rcel
❑ Other leNphainunder 7g)
7f. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cm -Mk -allow
Brian Ewing
1/27/2021
50rauuv Of C•en tote WCII Cgmr idrr well Ow it Drye
ffy .sagnrrag Mu farm, f frere&y certify dial the wer'ilsJ was (were? abandoned in
ocxorxh:fc'ewith 25.4 ,1 '..LC 2C.01O r 2C .i200 [Nods' cunstrric:.trun SraraJrds
and that a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJridrnuienl details. You may also :itaelt:dditional pages if IkCe 5811'_
SUWrn1 ITTAl. INSTRUCTIONS
10a. For All WeEL'': Sub]ni1 ilia 1bnm within 3tl day of completion of well
ahprJdnnmcry re the fgllmsing'
Dii'isiu of Water Resrmrcrs, Information Processing Unit,
1617 Mail &amice {'enter, Raleigh, NC 276!9-1617
Bib. Fear [aietllion Went: To Addition to sendiltg the forest to the address in Ina
above_ abu subsoil one naps of this form within'3tr days ref eumptetion of well
:ibardanuierd to the following:
DIyistun of Wilier Resources, Underground Injection Cool dal Program.
1636 mail Scrticc Coder, Raleigh, NC 21699-1634
[Er, For Water %Dr)1T & lalr:ctian We11t; In addition to sending the form to
the address;es) above_ also submit one copy of this foam within 30 days of
comptctioo of well abandonment Mille count', health depuiimeiu of the county
where gtagndnnCd.
Non h Carolina Dcpanineri efEnti iranincni and Nanurat Rcsuiuccs - Dolma of Warr It %eil.rces wed An on 20 L:i

WELL ABANDONMENT RECORD
This form can be used for sigghe or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourracrar Flame (or 'act! on lief on hi der proper!, )
4240-B
NC Wc1I Cbntru lur Flrunber
SAEDACCO Inc
Colman [+tame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r,.r. ruurrrr. hr4Mr. 1 iri pax. '. . Vkarorrr
3. V4'd 1 use (cheek well use):
Water Supply Well;
❑ Agricultural
❑ GCorbcmwt (Healing:Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIriginiois
❑ hlennicipal,Ptiblk
❑ Rcsidenti:il Water Sapph' r: ingle)
❑ Residenriat Water S1ippl ' tshan':d i
Non -Water So Fay Well:
❑ 1Numlonare
❑ Rm.overr
['ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Agreifer Teal
❑ Experimental TechemLoin
DCn:oihensa] {Closed Loops
L IGeothenital (Heating:Cooling Return)
❑ Gnaumdnarer Reuieiiiation
❑ Salini{3' Hamer
❑ Stour ater Drainage
❑ Srlasidence Cariml
L]Tracer
L Othertc'plain under 7g}
i. Dam w'e11(r) abandnncd: 1/15/21
54. Well locution;
Former Queen City BP
F Rils tlwnerNlnrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
Colas Parcel IdcnliFieadmi No. MIN)
5h.Latitude and longitado in elegnceafminuteifseconds or decimal dcl;rccs;
{ifwell r4151, eiw Litlwy i 1 i rCiii}
35.210533
rq-80.801887 }}
CONSTRII{'7'r{1N DETAILS OF WELLS} BEING ABANDONED
.lrGuir vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .rbJrur or taus -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak BhftlrflurrhleNr_ yet. man sxfuiera o re ferih
61. Well IOE: B17
6b. Tout well depth: 19 (h?.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(iii. Water level hell% pound airfAcc: 010
frc. Outer casing length {if Morn a): ftt.l
fih. Inner casing/tubing kno b lif known
6g.Semen b IIf known): fft.l
ATM GW-10
FOT Inknnui Use ONLY:
WELL ABAN DMFNMENT DFTA1L4
7a, Number of wdla being abandoned: 1
F.x. ndufupir r.'!' icUr rJJ rrurJ xwter air'JI.0 rrlh ONLY "rah OW same
causrntcrrayJ abandonment, :wire ixar Alberni. our j;ir jl,
Appnrximatc arrlurrrc ref *ator remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinf4 twit used:
7e, Sealing materials wand (check all that apply);
ID Neat Cement Grunt
❑ Sand Ceniwi Grant
❑ Concreir Groat
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Coulon
❑ Gravel
❑ Other leNphainunder 7g)
717. For each material selected abot•a, provide arnortat of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description [lithe abandonment i roi.c lure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cm-dilleallow
Brian Ewing
1/27/2021
50'i:fla v of C•eilfiCd WCII Ceur ter well Owir Drye
ffy signing Mu form, f trite&: certify dial the nviilsJ was (were? abandoned are
ou orxh:fc'e with 1 5.4 ,1 '..LC 2C .01004...r 2C .i200 [Nods' cunstrric:.trun SraraJrds
and that a copy o/Nris record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14itiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :ilach.:dditional pages if ri cis a.1'_
SUBMITTAL INSTRUCTIONS
loa. For All WeEL'': Sub]ni1 this I`nrnn within 3tl day of completion of well
abpndnnmcry r0 tr1i f01lmsing'
Division of Water Resrmrcrs, Information Processing Uaii,
1617 Mail &amice {'enter, Raleigh, NC 276994611
Bib. Fear [aietllion Went: rut iddiliots to sending the form to the address in lIa
above_ also submit one naps of this font within '3(l days ref completion of well
:Ibardanuieni to the following:
Dunstan of Winter Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Ccdtrr, Raleigh, NC Zit 99-163fr
1flc, For Water %ar)1T & la'cram We11t; In addition to sending the form to
the address;es) above_ also submit one copy of this form within 30 days of
comptctioo of well abindlomnent in the count', health de/minim of the county
'where :41mtidnn el -
Non h I'arolJm Depaniucri ofEnw iranincni and Nan irat Rcsuluccs - DIw ISL41n of Miss %olLrees. Rex iscd Anon .201.2.

WELL ABANDONMENT RECORD
This form can be used for siggk or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouiractar Flame (or „ct1 onn'r persoiaLI, abandaivaig,i.cll an ha Ire proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. %It'd 1 use (cheek well use):
Water Supply Well:
❑ Agriculttrral
❑ GCothemwt (Healing/Cooling Supply.'
❑ Industrial/Commercial
❑ II t ii(iois
❑ hlennicipal,Piblk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residential. Wader S1rp JI ' tsbared
Non -Waiter Supply Well:
❑ 1NumlonJte
❑ Rm.oven'
injection Well:
❑ Aquifer Recharge
❑ Aquifer Siang a and Recover
❑ Aquifer Teal
❑ ExporiuteN31 Tecliemloe
DCeothensa] (Closed Loop)
L IGeothenital fHearing:Cooliug Return),
❑ Oiuumdnarer ReIIieiiisliom
❑ Salmi{; Hamer
❑ Stour ater L ral:n ge
▪ Subsidence Catiml
:]Tracer
L Othertc'plain under 7g}
.1. Date neIL(s) abandoned: 1/15/21
54. Well lunation;
Former Queen City BP
Facilil, tlwnerNucor
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
Caron, Parcel Idered carlmrNo.IPIN)
5h.Latitude and longttsdc in elegy+ceafminuteifseconds or decimal dcl;rccs;
{ifwr:ll r4kl, iww Litludiy i, ui1 i rein}
35.210533
rq-80.801887 }}
(:c 1NSTR1I{"Tr{)N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .r rJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrdarrhleNr_ yet. clan 1adurerr o re ferih
61. Well [b#:B9
6b. Tout well depth: 19 (ft.)
6e, BO reside D lamctcr: 1. 5 (Iu.)
(rii. Water level hClnwpound miring:: ;fr,)
(rc. Outer casing Icn 1b {if lawn a): Rt.l
84. lnncr'rasingltnbinp kn0h lif known
6g.Semen l4nuoHb IIf known): fft.l
Fame GW-10
For inknnel Use ONLY:
WELL A BAN IM1N M ENT DFTAIL4
7a. Number niwdla being.al,andoued: 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns OW same
caurrnrcr,ion abandonment, :wire ixar Alberni. our
71r. Appnrximatc rlrlurrrc ref *ass remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of Disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials used (cheek ill that Apply);
ID Neat Ccmcnl Groot
❑ Sand Cemwi Grout
❑ Concreir Grunt
❑ Spectaltr Gruui
C7 Bentonite Slurry
t BetiRinitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Conlon
❑ Gomel
❑ Other Iviplain under 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment promdlure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerfifkratloo:
Brian Ewing
1/27/2021
50rauw!:Of C•eniiiitd WCII Cgmr ndrr well Ow it Drye
ffy .aagnria Mu form, f frere&y certify dial the wer'ilsJ was (were? abandoned in
ocxorxh:fc'ewith 25.4 ,1 '..LC' 2C.01O r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You slay also :itaL;lt:rdditional pages if IkCe ,a. '_
SUBMITTAL INSTRiUCTIONS
loa. For All Wells: Submit ilia I`nxm within 3tl day of completion of well
ahprJdnnmcry re the fgllmsing'
Dii'isitlu of Water Resrmrcrs, Information Processing Uaii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. Fear [ulettton Well[: To iddiliots in sending the forest to the address in lIa
above_ ubsi submit one naps of this form within'3tl days of completion of well
:ibardanurerd to the following:
DIyistnn of Wilier Resources, Underground Injection Cool dal Program.
1.636 Msi1 Senicc Center, Raleigh, NC Zit 99-163fr
1flc, For Water %Dr)1T & lalr:ctian Went: In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
completion of well abandonment In the court', Jralth depatinieiu of the cocisv
where cibtirrd4ricd.
Non hCarolina Depanineri efEnti iranincni and Nanurat Rtwinrees - Diti isms of Wars R,saurec Ito. nod Anyeun 20L:i

WELL ABANDONMENT RECORD
This form can be used for siggk or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouiractar Flame (or „ct1 onn'r persoiaLI, abandaivaig,i.cll an ha Ire proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. %It'd 1 use (cheek well use):
Water Supply Well:
❑ Agriculttrral
❑ GCothemwt (Healing/Cooling Supply.'
❑ Industrial/Commercial
❑ II t ii(iois
❑ hlennicipal,Piblk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residential. Wader S1rp JI ' tsbared
Non -Waiter Supply Well:
❑ 1NumlonJte
❑ Rm.oven'
injection Well:
❑ Aquifer Recharge
❑ Aquifer Siang a and Recover
❑ Aquifer Teal
❑ ExporiuteN31 Tecliemloe
DCeothensa] (Closed Loop)
L IGeothenital fHearing:Cooliug Return),
❑ Oiuumdnarer ReIIieiiisliom
❑ Salmi{; Hamer
❑ Stour ater L ral:n ge
▪ Subsidence Catiml
:]Tracer
L Othertc'plain under 7g}
.1. Date neIL(s) abandoned: 1/15/21
54. Well lunation;
Former Queen City BP
Facilil, tlwnerNucor
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
Caron, Parcel Idered carlmrNo.IPIN)
5h.Latitude and longttsdc in elegy+ceafminuteifseconds or decimal dcl;rccs;
{ifwr:ll r4kl, iww Litludiy i, ui1 i rein}
35.210533
rq-80.801887 }}
(:c 1NSTR1I{"Tr{)N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .r rJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrdarrhleNr_ yet. clan 1adurerr o re ferih
61. Neill IOE : B5
6b. Tout well depth: 19 (ft.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(rii. Water level hClnwpound miring:: ;fr,)
(rc. Outer casing Icn 1b {if lawn a): Rt.l
84. lnncr'rasingltnbinp kn0h lif known
6g.Semen l4nuoHb IIf known): fft.l
Fame GW-?'
For inknnel Use ONLY:
WELL A BAN IM1N M ENT DFTAIL4
7a. Number niwdla being.al,andoued: 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns OW same
caurrnrcr,ion abandonment, :wire ixar Alberni. our
71r. Appnrximatc rlrlurrrc ref *ass remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials used (cheek ill that Apply);
ID Neat Ccmcnl Groot
❑ Sand Cemwi Grout
❑ Concreir Grunt
❑ Spectaltr Gruui
C7 Bentonite Slurry
t BetiRinitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Conlon
❑ Gomel
❑ Other Iviplain under 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment promdlure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerfifkratloo:
Brian Ewing
1/27/2021
50rauw!:Of C•eniiiitd WCII Cgmr ndrr well Ow it Drye
ffy .aagnria Mu form, f frere&y certify dial the wer'ilsJ was (were? abandoned in
ocxorxh:fc'ewith 25.4 ,1 '..LC' 2C.01O r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You slay also :itaL;lt:rdditional pages if IkCe ,a. '_
SUBMITTAL INSTRiUCTIONS
loa. For All Wells: Submit ilia I`nxm within 3tl day of completion of well
ahprJdnnmcry re the fgllmsing'
1}it'i sirs of Water Resrmrcrs, Information Processing Uaii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. Fear [ulettton Well[: To iddiliots in sending the forest to the address in lIa
above_ ubsi submit one naps of this form within'3tl days of completion of well
:ibardanurerd to the following:
DIyistnn of Wilier Resources, Underground Injection Cool dal Program.
1.636 Msi1 Senicc Center, Raleigh, NC Zit 99-163fr
1flc, For Water %Dr)1T & lalr:ctian Went: In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
completion of well abandonment In the court', Jralth depatinieiu of the cocisv
where cibtirrd4ricd.
Non hCarolina Depanineri efEnti iranincni and Nanurat Rtwinrees - Diti isms of Wars R,saurec Ito. nod Anyeun 20L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuacrar Flame (or stet! atelier persoiaLI, abandasingocll an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (check well use):
Water Supply Well;
❑ Agricultkrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itisis
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1NuntIonnne
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Technoloin
DCneolherltal (Closed Loop)
L IGeoEllenirml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Caniml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 11711 EiruDRl+cablfir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifseconds or docintril dci res:
{ifwill r4kl, idiw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.ramie 11re11 cr'rzrJrucJrt're uvada,k. l ixr maitiplr x .rrJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak alatrileoThWeNr_ yet. man 1adure12 Wra ferire
61. Well IOE :A29
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(ill, Water level hCIrm prvrpnd lrrfAcc: 010
fro. Outer casing Icn11b 1i1 lawn a): Rt.l
inner casingltnlrinp knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For Internal Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlllurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemwi Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutlios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII O,sir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .0200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailr>. You slay also 11taelt:rdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
loa. For All WeE1'r: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isinlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis fonu within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fd
1flr, For Water 5uol)1T & latertian Went: Ili addition to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 days of
comptctino of well abandonment In the count}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'aralJtn Depanincri efEns imminent and Natural Remoras - DIs Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! ettlrr persoiaLI, abandasing %tell an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifsecondsor docintril dcl;rres:
{ifwell r4kl, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse 11re11 cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well Ib#:A31
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lawn a): Rt.l
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Orsir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ulnas: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis food! within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 day of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - Dls Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuacrar Flame (or stet! atelier persoiaLI, abandasingocll an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (check well use):
Water Supply Well;
❑ Agricultkrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itisis
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1NuntIonnne
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Technoloin
DCneolherltal (Closed Loop)
L IGeoEllenirml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Caniml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 11711 EiruDRl+cablfir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifseconds or docintril dci res:
{ifwill r4kl, idiw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.ramie 11re11 cr'rzrJrucJrt're uvada,k. l ixr maitiplr x .rrJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak alatrileoThWeNr_ yet. man 1adure12 Wra ferire
61. Well IOE :A19
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(ill, Water level hCIrm prvrpnd lrrfAcc: 010
fro. Outer casing Icn11b 1i1 lawn a): Rt.l
inner casingltnlrinp knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For Internal Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlllurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemwi Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutlios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII O,sir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .0200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailr>. You slay also 11taelt:rdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
loa. For All WeE1'r: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isinlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis fonu within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fd
1flr, For Water 5uol)1T & latertian Went: Ili addition to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 days of
comptctino of well abandonment In the count}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'aralJtn Depanincri efEns imminent and Natural Remoras - DIs Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! ettlrr persoiaLI, abandasing %tell an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifsecondsor docintril dcl;rres:
{ifwell r4kl, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse 11re11 cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well Ib#:A17
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lawn a): Rt.l
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Orsir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ulnas: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis food! within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 day of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - Dls Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! ettlrr persoiaLI, abandasing %tell an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifsecondsor docintril dcl;rres:
{ifwell r4kl, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse 11re11 cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well II}#:A9
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lawn a): RIl
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Orsir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ulnas: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis food! within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 days of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - DIs Isms of Water Ireitrecs Rca wed Ayeusi 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! ettlrr persoiaLI, abandasing %tell an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifsecondsor docintril dcl;rres:
{ifwell r4kl, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse 11re11 cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well IN:A13
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lawn a): Rt.l
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Orsir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ulnas: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis food! within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 day of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - Dls Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This form can be used for sigghe or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourracrar Flame (or 'act! on lief on hi der proper!, )
4240-B
NC Wc1I Cbntru lur Flrunber
SAEDACCO Inc
Colman [+tame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r,.r. ruurrrr. hr4Mr. 1 iri pax. '. . Vkarorrr
3. V4'd 1 use (cheek well use):
Water Supply Well;
❑ Agricultural
❑ GCorbcmwt (Healing:Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIriginiois
❑ hlennicipal,Ptiblk
❑ Rcsidenti:il Water Sapph' r: ingle)
❑ Residenriat Water S1ippl ' tshan':d i
Non -Water So Fay Well:
❑ 1Numlonare
❑ Rm.overr
['ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Agreifer Teal
❑ Experimental TechemLoin
DCn:oihensa] {Closed Loops
L IGeothenital (Heating:Cooling Return)
❑ Gnaumdnarer Reuieiiiation
❑ Salini{3' Hamer
❑ Stour ater Drainage
❑ Srlasidence Cariml
L]Tracer
L Othertc'plain under 7g}
i. Dam w'e11(r) abandnncd: 1/15/21
54. Well locution;
Former Queen City BP
F Rils tlwnerNlnrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
Colas Parcel IdcnliFieadmi No. MIN)
5h.Latitude and longitado in elegnceafminuteifseconds or decimal dcl;rccs;
{ifwell r4151, eiw Litlwy i ti i1 i rCiii}
35.210533
rq-80.801887 }}
CONSTRII{'7'r{1N DETAILS OF WELLS} BEING ABANDONED
.lrGuir vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .rbJrur or taus -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak BhftlrflurrhleNr_ yet. man sxfuiera o re ferih
61. Well IOE: B11
6b. Tout well depth: 19 (h?.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(iii. Water level hell% pound airfAcc: 010
frc. Outer casing length {if Morn a): ftt.l
fih. Inner casing/tubing kno b lif known
6g.Semen b IIf known): fft.l
ATM GW-10
FOT Inknnui Use ONLY:
WELL ABAN DMFNMENT DFTA1L4
7a, Number of wdla being abandoned: 1
F.x. ndufupir r.'!' icUr rJJ rrurJ xwter air'JI.0 rrlh ONLY "rah OW same
causrntcrrayJ abandonment, :wire ixar Alberni. our j;ir jl,
Appnrximatc arrlurrrc ref *ator remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinf4 twit used:
7e, Sealing materials wand (check all that apply);
ID Neat Cement Grunt
❑ Sand Ceniwi Grant
❑ Concreir Groat
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Coulon
❑ Gravel
❑ Other leNphainunder 7g)
717. For each material selected abot•a, provide arnortat of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description [lithe abandonment i roi.c lure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cm-dilleallow
Brian Ewing
1/27/2021
50'i:fla v of C•eilfiCd WCII Ceur ter well Owir Drye
ffy signing Mu form, f trite&: certify dial the nviilsJ was (were? abandoned are
ou orxh:fc'e with 1 5.4 ,1 '..LC 2C .01004...r 2C .i200 [Nods' cunstrric:.trun SraraJrds
and that a copy o/Nris record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14itiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :ilach.:dditional pages if ri cis a.1'_
SUBMITTAL INSTRUCTIONS
loa. For All WeEL'': Sub]ni1 this I`nrnn within 3tl day of completion of well
abpndnnmcry r0 tr1i f01lmsing'
Division of Water Resrmrcrs, Information Processing Uaii,
1617 Mail &amice {'enter, Raleigh, NC 276994611
Bib. Fear [aietllion Went: rut iddiliots to sending the form to the address in lIa
above_ also submit one naps of this font within '3(l days ref completion of well
:Ibardanuieni to the following:
Dunstan of Winter Resources, Underground Injection Cool oil Program.
1636 mail Scrticc Ccdtrr, Raleigh, NC 2709-1634
1flc, For Water %ar)1T & la'cram We11t; In addition to sending the form to
the address;es) above_ also submit one copy of this form within 30 days of
comptctioo of well abindlomnent in the count', health de/minim of the county
'where :41mtidnn el -
Non h I'arolJm Depaniucri ofEnw iranincni and Nan irat Rcsuluccs - DIw ISL41n of Miss %olLrees. Rex iscd Anon .201.2.

WELL ABANDONMENT RECORD
This form can be used for sigghe or mu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourracrar Flame (or 'act! on lief on hi der proper!, )
4240-B
NC Wc1I Cbntru lur Flrunber
SAEDACCO Inc
Colman [+tame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r,.r. ruurrrr. hr4Mr. 1 iri pax. '. . Vkarorrr
3. V4'd 1 use (cheek well use):
Water Supply Well;
❑ Agricultural
❑ GCorbcmwt (Healing:Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIriginiois
❑ hlennicipal,Ptiblk
❑ Rcsidenti:il Water Sapph' r: ingle)
❑ Residenriat Water S1ippl ' tshan':d i
Non -Water So Fay Well:
❑ 1Numlonare
❑ Rm.overr
['ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Agreifer Teal
❑ Experimental TechemLoin
DCn:oihensa] {Closed Loops
L IGeothenital (Heating:Cooling Return)
❑ Gnaumdnarer Reuieiiiation
❑ Salini{3' Hamer
❑ Stour ater Drainage
❑ Srlasidence Cariml
L]Tracer
L Othertc'plain under 7g}
i. Dam w'e11(r) abandnncd: 1/15/21
54. Well locution;
Former Queen City BP
F Rils tlwnerNlnrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie!, and Zip
Mecklenburg 12710204
Colas Parcel IdcnliFieadmi No. MIN)
5h.Latitude and longitado in elegnceafminuteifseconds or decimal dcl;rccs;
{ifwell r4151, eiw Litlwy i ti i1 i rCiii}
35.210533
rq-80.801887 }}
CONSTRII{'7'r{1N DETAILS OF WELLS} BEING ABANDONED
.lrGuir vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .rbJrur or taus -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak BhftlrflurrhleNr_ yet. man sxfuiera o re ferih
61. Vs'rll IOE: B1
6b. Tout well depth: 19 (h?.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(iii. Water level hell% pound airfAcc: 010
frc. Outer casing length {if Morn a): ftt.l
fih. Inner casing/tubing kno b lif known
6g.Semen b IIf known): fft.l
ATM GW-?'
FOT Inknnui Use ONLY:
WELL ABAN DMFNMENT DFTA1L4
7a, Number of wdla being abandoned: 1
F.x. ndufupir r.'!' icUr rJJ rrurJ xwter air'JI.0 rrlh ONLY "rah OW same
causrntcrrayJ abandonment, :wire ixar Alberni. our j;ir jl,
Appnrximatc arrlurrrc ref *ator remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinf4 twit used:
7e, Sealing materials wand (check all that apply);
ID Neat Cement Grunt
❑ Sand Ceniwi Grant
❑ Concreir Groat
❑ Specialty Gruui
C7 Bentonite Slurry
5t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Coulon
❑ Gravel
❑ Other leNphainunder 7g)
717. For each material selected abot•a, provide arnortat of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description [lithe abandonment i roi.c lure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cm-dilleallow
Brian Ewing
1/27/2021
50'i:fla v of C•eilfiCd WCII Ceur ter well Owir Drye
ffy signing Mu form, f trite&: certify dial the nviilsJ was (were? abandoned are
ou orxh:fc'e with 1 5.4 ,1 '..LC 2C .01004...r 2C .i200 [Nods' cunstrric:.trun SraraJrds
and that a copy o/Nris record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14itiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :ilach.:dditional pages if ri cis a.1'_
SUBMITTAL INSTRUCTIONS
loa. For All WeEL'': Sub]ni1 this I`nrnn within 3tl day of completion of well
abpndnnmcry r0 tr1i f01lmsing'
Division of Water Resrmrcrs, Information Processing Uaii,
1617 Mail &amice {'enter, Raleigh, NC 276994611
Bib. Fear [aietllion Went: rut iddiliots to sending the form to the address in lIa
above_ also submit one naps of this font within '3(l days ref completion of well
:Ibardanuieni to the following:
Dunstan of Winter Resources, Underground Injection Cool oil Program.
1636 mail Scrticc Ccdtrr, Raleigh, NC 2709-1634
1flc, For Water %ar)1T & la'cram We11t; In addition to sending the form to
the address;es) above_ also submit one copy of this form within 30 days of
comptctioo of well abindlomnent in the count', health de/minim of the county
'where :41mtidnn el -
Non h I'arolJm Depaniucri ofEnw iranincni and Nan irat Rcsuluccs - DIw ISL41n of Miss %olLrees. Rex iscd Anon .201.2.

WELL ABANDONMENT RECORD
This form can be used for siggk or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouiractar Flame (or „ct1 onn'r persoiaLI, abandaivaig,i.cll an ha Ire proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. %It'd 1 use (cheek well use):
Water Supply Well:
❑ Agriculttrral
❑ GCothemwt (Healing/Cooling Supply.'
❑ Industrial/Commercial
❑ II t ii(iois
❑ hlennicipal,Piblk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residential. Wader S1rp JI ' tsbared
Non -Waiter Supply Well:
❑ 1NumlonJte
❑ Rm.oven'
injection Well:
❑ Aquifer Recharge
❑ Aquifer Siang a and Recover
❑ Aquifer Teal
❑ ExporiuteN31 Tecliemloe
DCeothensa] (Closed Loop)
L IGeothenital fHearing:Cooliug Return),
❑ Oiuumdnarer ReIIieiiisliom
❑ Salmi{; Hamer
❑ Stour ater L ral:n ge
▪ Subsidence Catiml
:]Tracer
L Othertc'plain under 7g}
.1. Date neIL(s) abandoned: 1/15/21
54. Well lunation;
Former Queen City BP
Facilil, tlwnerNucor
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. Cie, and Zip
Mecklenburg 12710204
Caron, Parcel Idered carlmrNo.IPIN)
5h.Latitude and longttsdc in elegy+ceafminuteifseconds or decimal dcl;rccs;
{ifwr:ll r4kl, iww Litludiy i, ui1 i rein}
35.210533
rq-80.801887 }}
(:c 1NSTR1I{"Tr{)N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .r rJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak autrdarrhleNr_ yet. clan 1adurerr o re ferih
61. Neill IOE : B3
6b. Tout well depth: 19 (ft.)
6e, BO reside d lamctcr: 1. 5 (Iu.)
(rii. Water level hClnwpound miring:: ;fr,)
(rc. Outer casing Icn 1b {if lawn a): Rt.l
84. lnncr'rasingltnbinp kn0h lif known
6g.Semen l4nuoHb IIf known): fft.l
Fame GW-?'
For inknnel Use ONLY:
WELL A BAN IM1N M ENT DFTAIL4
7a. Number niwdla being.al,andoued: 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns OW same
caurrnrcr,ion abandonment, :wire ixar Alberni. our
71r. Appnrximatc rlrlurrrc ref *ass remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials used (cheek ill that Apply);
ID Neat Ccmcnl Groot
❑ Sand Cemwi Grout
❑ Concreir Grunt
❑ Spectaltr Gruui
C7 Bentonite Slurry
t BetiRinitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Conlon
❑ Gomel
❑ Other Iviplain under 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment promdlure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerfifkratloo:
Brian Ewing
1/27/2021
50rauw!:Of C•eniiiitd WCII Cgmr ndrr well Ow it Drye
ffy .aagnria Mu form, f frere&y certify dial the wer'ilsJ was (were? abandoned in
ocxorxh:fc'ewith 25.4 ,1 '..LC' 2C.01O r 2C .i200 [Nods'cisslrriclion SraraJrds
and That a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You slay also :itaL;lt:rdditional pages if IkCe ,a. '_
SUBMITTAL INSTRiUCTIONS
loa. For All Wells: Submit ilia I`nxm within 3tl day of completion of well
ahprJdnnmcry re the fgllmsing'
1}it'i sirs of Water Resrmrcrs, Information Processing Uaii,
1617 Mail Smite {'enter, Raleigh, NC 276994611
Bib. Fear [ulettton Well[: To iddiliots in sending the forest to the address in lIa
above_ ubsi submit one naps of this form within'3tl days of completion of well
:ibardanurerd to the following:
DIyistnn of Wilier Resources, Underground Injection Cool dal Program.
1.636 Msi1 Senicc Center, Raleigh, NC Zit 99-163fr
1flc, For Water %Dr)1T & lalr:ctian Went: In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
completion of well abandonment In the court', Jralth depatinieiu of the cocisv
where cibtirrd4ricd.
Non hCarolina Depanineri efEnti iranincni and Nanurat Rtwinrees - Diti isms of Wars R,saurec Ito. nod Anyeun 20L:i

WELL ABANDONMENT RECORD
This form can be used for siggk or multiple wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouiractar Flame (or „ct1 onn'r persoiaLI, abandaivaig,i.cll an ha Ire proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Ntame
2. Weil Construction Permit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. {'uarrii. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. V4'd 1 use (check well use):
Water Supply Well:
❑ Agricultural
❑ GCoibcmwt (HCatingCpoting Supply.'
❑ Industrial/Commercial
❑ hlennicipal,Piblk
❑ Rcsidenti:il Water Supph' r: ingle)
❑ Residenriat warn S1rp JI ' tsbared
Non -Waiter Supply Well:
❑ 1NumlonJte
❑ Rm.oven'
injection Well:
❑ Aquifer Recharge
❑ Aquifer Siang a and Recover
❑ Aquifer Teal
❑ ExporiuteN31 TechemLoin
DCeothensa] (Closed Loop)
L IGeothenital (Heating:Cooling Return),
❑ GnnuMdnarer Reureiiiation
❑ Salina{; Hamer
❑ Stour ater L rairwge
▪ Subsidence Catiml
:]Tracer
L Othertc'plain under 7g}
4. Date neIL(s) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Facilil, tlwnerNucor
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Address. CM, and Zip
Mecklenburg 12710204
Caron, Parcel Idered carlmrNo.IPIN)
5h.Latitude and longitude in elegy,eeafminuteifseconds or decimal dcl;reeN
{ifwr:ll r4kl, iww Litludiy i, ui1 i rein}
35.210533
rq-80.801887 }}
(:c 1NSTR1I{'7'r{1N DETAILS OF WELLS} BEING ABANDONED
. ramie vrf1 cr'mvJrucJrare uvarra,k. 1 ixr malrr,x .r rJrur or non -wader supph.
we& ONLY well r1Jr aaisa wic,rrro_rAak BhftlrdarrhleNr_ yet. clan 1adurerr o re ferih
61. Vs'rll IOE : B7
6b. Tout well depth: 19 (ft.)
6e, Bp relate d lamctcr: 1. 5 (Iu.)
(rii. Water level hClnwground surface: ;fr,)
(rc. Outer casing length {if lawn el: III
84. lnncr'rasingltnbinp kn0h lif laniwnI;
6g.Semen l4nuoHb IIf known): fft.l
Fame GW-?'
For Inknnel Use ONLY:
WELL ABANDONMENT DFTAIL4
7a. Number niwdla beim abandoned: 1
FN. ndufupir r.'!' icUr rJJ rrurJ xwter airArkr rrlh ONLY erns OW same
caurrnrcr,ion abandonment, :wire ixar Alberni. our
71r. Appnrximatc rlrlurniz ref ater remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfe toot used:
7e. Sealing materials used (cheek ill that Apply);
Q Ncai Cement Grout
❑ Sand Cemwi Grout
❑ Concreir Grunt
❑ Spectaltr Gruui
C7 Bentonite Slurry
t Beritanitc Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gravel
❑ Other Iviplain under 7g)
717. For each material selected abase, provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description rif the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Cerfifkratloo:
Brian Ewing
1/27/2021
50rauw!:Of C•eniiiitd WCII Cgmr ndrr well Ow it Drye
ffy signing Mu form, f frere&y certify dial the wer'ilsJ was (were? abandoned in
ocxorxh:fc'ewith 25.4 ,1 '..LC 2C.01O r 2C .i200 [Nods' cunstrric:.trun SraraJrds
and That a copy o/this record boa been provided 1v are wee'! owner.
9. Site diagram or 2,14ltiorlut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also :itaL;lt:tdditional pages if IkCe 5811'_
SUBMITTAL INSTRUCTIONS
loft. For All Wefts: Sub]ni1 ilia Ibnm within 3tl day of completion of well
ahprJdnnmcry re the fgllmsing'
Division of Water Resrmrcrs, Information Processing Unit,
1617 Mail Smite (eater, Raleigh, NC 276994611
Bib. Fear [ulettton Well[: rut iddiliotl to sending the forest to the address in lIa
above_ also submit one naps of this form within'3(l days ref completion of well
:ibardanurerd to the following:
Division of Wilier Resources, Underground Injection Cool dal Program.
1636 mail Senicc [venter, Raleigh, NC 2709-1634
1flc, For Water %Dr)1T & lalectian Went: In addition to sending the form to
the addresses) above_ also submit one copy of this foam within 30 days of
comptctioo of well abandonment In the count', Jralth deputinieiu of the cocisv
where cibtirrdnn f.
Non hCarolina Depanineri efEnti iranincni and Nanurat Resources - Diti isms of Wars R,saurec Ito. nod An on 20L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! ettlrr persoiaLI, abandasing %tell an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifsecondsor docintril dcl;rres:
{ifwell r4kl, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse 11re11 cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well IN:A25
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lawn a): Rt.l
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Orsir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ulnas: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis food! within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 days of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - DIs Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This form can be used for niggle or rnu]lipte wells
1. WCn f'4atrAe'mr information:
Brian Ewing
Wclt{ouuaclar Flame (or stet! ettlrr persoiaLI, abandasing %tell an Meade propcny )
4240-B
NC Well Cbnhudor Number
SAEDACCO Inc
Conway turn
2. Weil Construction Pandit 70002483 L__r WI0300399
1.Jxr<r♦i irl p?hQ4Ir w,riFprrmJrr r,.r. e•tturrrr. h'r4Mr. 1 iri pax. '. . Vk'rorrr
3. W It use (cheek well use):
Water Supply Well;
❑ Agriculttrral
❑ GCoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ IIri:Itiois
❑ hlttnicipalrPtihlk
❑ Rcsidenri:il Water Supph' rsingle)
❑ Residenriat Wader S1rpJly'tsbaredi
Nos -Water Su platy Well:
❑ 1rluntIonaE
❑ Rm.oven'
Ttje Lion Welt:
❑ Aquifer Recharge
❑ Aquifer Stou rge aid Recover
❑ Aquifer Teal
❑ ExpoaiuteN31 Tn Jinolosy
DCneolherltal (Closed Loop)
L IGeoElleniiml (Healing:Cooling Return)
❑ GnnuMdnaier ReIlieiiisl]cs
❑ Salini{3' Hamer
❑ Stomiwu!er t7rainage
❑ Subsidence Catiml
:]Tracer
L OthorteNplain under 7g}
4. Date weU{r) abandoned: 1/15/21
54. Well locution;
Former Queen City BP
Fabcilil, r(hsrrerNlnrr
Facility 117r1 Eir uFpI ;abl fir
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adtimm. Ci . sod Zio
Mecklenburg 12710204
( iiiL l Parcel Idcnliksdmr Na. {PIHj
5b-1alitude and longitude in elegy+eeafminuteifsecondsor docintril dcl;rres:
{ifwell r4kl, iriw Lit.lwy i, 11 i rCii}
35.210533
rq-80.801887 }}
(:c1NSTR1I{'rr{)N DETAILS OF WELLS} BEING ABANDONED
.!louse 11re11 cr'rzrJrucJrt're uvada,k. l ru maitiplr x .rrJrur or non -wader supph.
we& ONLY well r ea7.tlrt wir..drro_rAak alatrfleoThWeNr_ yet. man 1adure12 Wra ferire
61. Well IN:A23
6h. Tout well depth: 19 (h?.)
6e, BO rebule diameter: 1. 5 (Iu.)
(rid, Water level hCIrm prvrpnd irrfAcc: 010
fro. Outer casing Icn1Fb 1i1 lawn a): Rt.l
inner casing/whim:, knob lif known I;
6g.Semen l4ngHh lIf hnivan): fft.l
Fame GW-10
For InknJui Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number of wdla being abandoned; 1
nrufupie rJ!+rrYitOr FJJ' rrurJ hover airArkr rrlh ONLY wNJ OW same
careen wrron abandonment, yr,rr ixar AlbeJrrr our j;ir jl,
71r. Appnrximatc rlrlurniz ref stir remaining in wrll(s)a
FOR WATER SUPPLY WELLS ON1.Y:
7c. Type of disiufeetaat used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
Q Neat Cement Grout
❑ Sand Cemera Gmut
❑ Concrete Grunt
❑ Spec:141[y Gruui
C7 Bentonite Slurry
5f Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutiios
❑ Grar'r1
❑ Other 1plainunder 7g)
717. For each material selected about provide amount of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief deseripticm of the abandonment i roi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
50rauircofC•eniiiitd WCII Ceur ter w 'eII Orsir Drys
fly .sagnria Men form, f frere&y certify dial the nviilsJ was (were? abandoned in
ou orxhuac'e with 2 5.4 ,1 '..LC 2C .01004...r 2C .02200 Fell cunstrric-rrun 5t,mdjdrds
and firm a copy o/this record boa been provided fa are wed! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abJrldrnutenl detailrs. You slay Also ,nraelt:tdditionlal pages if uecessa. _
SUBMITTAL. INSTRUCTIONS
11aa. For All ulnas: Submit this !bem within 3El day of completion of well
ahpfdnnmcry re the f01lmsing'
Dii'isitlu of Water RI:MI[1MM, Information Processing Uaii,
1617 Mail Smite Center, Raleigh, NC 276994611
Bib. Farr IPlethton Vrircll : To iddiliotl to sending the fordo to the address in lIa
above_ oho subsist one noes of ibis food! within'30 days ref eumptetion of well
:Ibardanuteia to the following:
Nils/Ain of Wilier Resources, Underground Injection Control Program.
1636 Flail Scrticc Ccotrr, Raleigh, New Zit 99-163fr
1flr, For Water 5uol)1T & latertian Went: Ili addiliotr to sending the form to
the address;es) above_ also subutiii one copy of this foam within 30 days of
comptctino of well abandonment In the court}' health deparimeiu of the county
w]icri ibCindnnCd.
Non h C'arolJro Depanincri efEns imminent and Natural Remoras - DIs Isms of Water Ireitrecs Rca wed Ayeusr 20 L:i

WELL ABANDONMENT RECORD
This faun can be used for sigghe or rntu]lipte wells
1. WCn f'4atrAe'mr lnrorrn4tion_
Brian Ewing
Wclt{ourraclar Flame (or sled or,. lief persoiwtl, proper!, )
4240-B
NC Well Cbnhudor Carl irralian Number
SAEDACCO Inc
Coiii an> Name
2. Weil Construction Pantie 70002483 L__r WI0300399
1.Jxr<r♦i Offp?hQ4Ir w,riFprrmJrr r�.r. euurrrr... t%.. 1.iriiaax.• '. . Vk'rorrr
3. V4'd t use (cheek well use):
Water Supply Well;
❑ Agrinaltttral
❑ Geoibcmwt (Healing/Cooling Supply.'
❑ IIsiii lria3(C0mrr1Crdla1
❑ Ihi ii[iois
❑ hltoeicipal,Ptiblk
❑ Rcsidenri:il Water Supph. r: ingle)
❑ Residenriat Waver Supply tsharndl
Nee -Water Supply Well:
❑ 1rlumlornie
❑ Rm.oven.
"'ejection Well:
❑ Aquifer Recharge
❑ Aquifer Sionige and Recover
❑ Aquifer Peal
❑ Experimental Tn JinoLoin
DC othenital {Closed Loops
L]Geothenital (Heating:Cooling Return),
❑ Gnaumdnarer Reuieiiialimi
❑ Salmi{; Hamer
❑ Stour ater Drainage
❑ Subsictence Catiml
L]Tracer
L Othertc'plain under 7g}
4. Dim 'BOO) abandoned: 1/15/21
54. Well locution:
Former Queen City BP
F Rils tlwnerNinrr
Facility 11711(iruFRl+cabIo
2650 Shenandoah Ave Charlotte, NC 28205
Physical Adttrcss. Cie!, and Zip
Mecklenburg 12710204
C'ouui, Parcel IdcnliFrcarlrnr No. MIN)
5h.Latitude and longttsdc in degreesfurinulusirsevonds or decimal degrees:
{ifwell r4I51, iriw Litlwy i, ui1 i rCii}
35.210533
rq-80.801887 }}
iCONSTRII{'rr()N DETAILS OF WELLS} BEING ABANDONED
. lfrrMir ,veil cr'rzrJradiore uvada,k. l ixr maitiplr x .r boa or non -wader supph.
we& ONLY well r1Jr aaisa wir..drro_rAak alatrileoThWeNr_ yet. can 1adure12 Wra ferire
61. Vs'rll II11tldl:A16
6b. Tout well depth: 20 (h?.)
6e, BO reside d lamctcr: 1. 5 (In.)
(41. Water level helnw arkund lrefiiec: ;l{,)
ire. Outer casing length Of Form a): RIl
8I. lnacr'rasingltnlrinp knob lif knownl:
6g.Screen length IIf known): fft.l
Fomi GW-?'
For IntermA Use ONLY:
WELL ABANDONMENT DFTAIL4
7a, Number oiwdla beim abandoned: 1
ndufupie rJnikrYiurr FJJ' rrurJ xwrer sir'JI.0 rrlh ONLY "rah OW same
caurrnrcrrayJ abandonment, yr,rd ixarAlberni. our
71r. Appnoximatc rlolurniz ref atcr remaining in wrll(s)a
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfe toot used:
7c. Sealing materials used (cheek all that Apply):
ID Neat Cement Grout
❑ Sand Cenrere Gmut
❑ Concreir Grout
❑ Specialty Gruui
C7 Bentonite Slurry
t Bentonite Chips 0-Pellets
❑ Dry Clay
❑ Drill Cutliogs
❑ Gracel
❑ Other 1phainunder 7g)
717. For each material selected abase, provide arnoiiot of materials used:
Bentonite.:501b ,Wtr:gal.
7g. Provide a brief description of the abandonment proi.cdure:
Removed DPT tooling, once injections completed and
backfilled with hydrated bentonite chips
S. Certification:
Brian Ewing
1/27/2021
5rgnilauvofC•eniliitd WCII C,eur ter 4411 Owir Drys
ffy tignria Mu form, f frere&y certify dial the nviilsJ was (were? abandoned in
ouorxh:frewith 25.4 ,1 '..LC 2C.01O r 2C .i200 FNada'cisslrriclion SraraJrds
and that a copy o/Nris record boa been provided fa are wee'! owner.
9. Site diagram or 2,14itiortut well details:
You may use the back of this page t0 provide additional well site details or well
abandonment details. You may Also :rttaelt:dditional pages if.i ces a. '_
SUSn1ITTAl. INSTRUCTIONS
loa. For All Wes': Submit this I`nxm within 3tl day$ of completion of well
ahpfdnnmcry r0 thi f01lmsing.
Division of Wilier RI:MI[1 - s, Information Processing Unit,
1617 Mail Seller {'enter, Raleigh, lw C' 276994617
Bib. Fear [aietllion Wellt: In addition to sendiltg the form to the address in lIa
above_ ubsi submit one naps of this foot" within'30 days ref eumptetion of well
abardanuteril to the following:
Division of Wilier Resources, Underground Injection Cool oil Program.
1636 14iai1 Scrticc Center, Raleigh, NC Zit 99-163fr
ifle, For Water Suorrlr & in. ctlan Went: In addition to sending the form to
the address;es) abase_ also submit one copy of this form within 30 days of
comptctioo of wet] abaldomnent In the comet', health depatimem of the cods,
where abandoned.
Non hC'arolmo Dcpanineri ofEnti iranincni and Natural. Remoras - Doti isLon of WaverB ourns Rex iced August 20L2.

WELL CONSTRUCUON RECORD
Thy fonii• ne be rlsfld fur stlu;}c'I1 I!nlallid: ,s girls
1. Welt Cuirtrricti.r Il,rrurnirrliont
1F'ar frOcroil" USe DN1.V
Brian Ewing
W gilt {tulip l ur Nara
4240-B
NC Well Coulr,Icior Carl iiimLiun M1ii rti
SAEDACCO Inc
W'e1I #aostr,e iun Perna*, wi0300399; 70002483
liurd21pvliruhirkrlrPrrmir4lr-r.. yriIL11rY SLtlr_Y'yridlLr 1.9fert'Or#.h-.�
3. Well Use tehcidc mil M
Water Supply Vied:
flt r'clrltLlral
UCreolli nwI literaiog'Coaling 5upp]}i
I' 1lndusi,ia fCantrrli:rcial
❑ IImpILhnn
LlhJirlrir.lpctllrhlic
r1FktsfdennmlR1airFSunk! aSiRfJcl
I-lRcsidentrml Water Supply is]'Iared
NOP-Water Supply Well:
❑hioniloriuc ❑lea}> '
nji:I/alrll V- IL,
r1Ad111ifir Rectiarr
pArinircr 9tora8c iid Ttecr131er,r
❑ Agpircr 7�61
❑ EN rimcrilR1 TgC1rn6Lw3 '
❑ Ci ulhermal iCluted Ltnlpt
❑ Gradicftlial iFIciiiii Cnsslim Rutuilll
DSRIini13 13arncr
❑ ya0rrowii er Erryio.2gg
❑tiilhwdei cc Cailm1
❑ '1l-aorr
®O1lier iucpluiil uilirt /21 Renlutks)
. D:rti.• Welllxl Crinilllarnil; 1/12/21 1t'e11 JJ iAl
i.L. %fell lalrathln:
Remediation Management Service Company
I. . .1 I i 1 ' [if rrepli:irblei
2650 Shenandoah Ave., Charlotte, NC, 28205
r'IM Icpt rlifdrea City_ ;md Zip
Mecklenburg 12710204
VwmJ1 Prldecl fde,uiflciuolr Nn fP1N?
ih. T:irlillliriiid Ltingttmhr In lP12-prxra11nhimrteeilccnnrls nr drt•imol kt rrra;
rifutli Add Int' LIUIativ lT,tl<Jur
35.210533 (-80.801887 '
9. l3 lmre) Ihr!11 rIII i ❑Permanral Li Tol 'moron'
7, is r xir thin a rrpair iu itm iodiowrit: 011ie or MIND
+
{rrlrri rr Ir rriNllr.•i l ii F 0.4,11.0 i1 lflcorlJ.7rllllfCo'ri rlrllJ'TJJ'rIJIJJI iIN'i I'irlrrlrJ' rAI' rllrrNrr IIr r(Ir
rr,4drrulaLN 1i rrei rich Y[e•Jrna 1Jr All [Im hack rrr Mrs form!.
S. Number of well tnirlrnieeed: 1 _
F it uwdrote rreMArilmll W rime-Irxwr.1ONLY ll'.rh rrlr WNW cMrrrnreri,Nr
...WwIlrr RAC fiJnu.
9. TOW wdl depth helm land surface 19
for I'NIHri[(I' nli r+rl thifiVirect (e'Jr{rrrtrdre- 7 ' aril 7 ;IVO
11F0. Siik wrtr;r Ie►rt iicluwp oir1f cuiiu1
i+ IV/NH kiri 9 Mom.. L iri; a.r' ".
1. llar#2114110 iIIjnicltr. 1. 5"
tJrul �,.IN
12. Well i`uniilnpCtipii itwilimul: DRIVEN
fri,t
(r1.t
c Le. airgcr, rninr►, i-0hlc, dlleci IL erc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa Yield !Wm!! 1144.111041 oftr•sr!
I313. fiFisinferitiira ripe: 4muuot:
14 WM= 2.01,11s
Iraviw l 11;
R!_tir'HIP IJl1',
rt.
t5. {MJT R CASFNC {nrr Iriu141-aieil nab) OR L FfER (it amaRcahkh
FROM 11-0 PR ITTFR TPPI('P FM4
0 11' j 11' O.
I 2fir LN}1R cot:SINc Iln'r_l)91niirlrivr.r4rir[I�[rarup_.
k FROM TO DLk411ESFR TDICI:r§ESS MALE JAL
to
n,
1.5" Jo.
is
NA
pr.l lTrrl' R J li l,ir-L lrs.
19' II- 1.5"
I.
NA
NATIENTAI
Steel
THitlistSi
NA
w.krllkril,
Steel
IL
rt.
le
7111. tiROrT
I rr
Nn[Eltlii. F.#trL1C Mk4TllMInomLaAMOt1NT
ft.
n,
rt,
r4
rr.
IL
19. 5.3.4.1414CRAVPL PAC. I+r dyllicibk}
room
R.
T[r
p,
,JI FL HLII.
girEl_1( I'%Ir*r1' ul_ejlgn
{
(I.
111, DRILLING LOG I nlfach iddllionxl 4botii if rre •'aalrr I
FROM
0 fl,
rt.
TO
19' fi.
IL
DP.W-REPT1(J Ni IFuhr, ,'iron+, Rllµ'nK k i5 Rr• a'Iii 4r, OK. I
rt.
14
IL
tL
if -
FL.
Ira
R-
IL,
21. BItMA.104
Temporary injection point through DPT tooling
2/_ (crir1-leafiom
Brian Ewing
Sieshourg a Fecal red W c8 Couurbrar Nee
AT MT*111. 4 drhr frrFml. I rrrr.+b' eirr7II' Mull rNAY ivrd{ 14rd a 1.m J twrurrireirra Ire ve.ervmmune
II'JtA l •bl riCAC OSC .0frrr ro. ?rl rvt',1CL�i� 2(V8 C,t1 W Y I I)Jrrrrerrnor Stalrida,i mist i e
rT .11 orals rm. and ,Jii &Mu prrrl'Id.WI IrM AL. 4I1r+J1 rrlwwr.
1/27/2021
23. Site diiiy;l'slni or iiddtti'Jirmit well delimit?.
Ycnr r11a1 ose ate Lack of drla "rage to provide addilicinul gh.ell site ddA's or we] L
r8rtslru ;LIuli rlelaiEr. Yoti Hul% also Arlr11;x1dilr4ftlur twb'es rL in.
;iu uRtrf7•Ai. CNs1 tJcl f{xN5
lda. lhlr All Wrik Suhaoi ilia Farm wires 31J dais of courplerloo of slrt
cousrluctipn to the rblkomrl .
kb:61lia ill WsIcrrkriuurce5, Int11rmmiluu Poi rsxiog Gull,
1617 MAI Sersire Ctmier, Raleigh, NC 27699-1617
241. For daitiim WedIA ONLY: Iri addition to aeladitlg Elie rofnl to Ilia :1ddr> S Pik
a�eabo4'e. a1s.i suhlii1 a copy of tills. try uiiLlui 10 dirks of ca111pletii ii of Wu!!
ca st Uct.ruri Irk (he IaL]Ohviu .
Tlh iairm rif Water Resources.lrndergtllund 1njim irrif Control Program,
1636 Halt Senile Center. Raleigh, NC 276994634
2 iL Fur Witrr.54RpI} 1r Inl11tilpe 'WOW
Also submit sire cop). of !hi . ru4n1 u Itlliu ;8 liars of conlpieriorl uF
tircll cnogrnrrttnn co tL1e cnllut} hIm ilrll lleporluxen1 or air churl 141lcm
conilmcicd
rarin trii -I
wFn n h .In' II Inv L[.t mtr ii ilr III bp, II1r,0IIIII 111
alrl LIILuim1 rtesasects- 171krs 1011 nl' V4aicr IlmuLF
Reh'L9Cd Aug= hrl;I

WELL CONSITRUC CON RECORD
Thy fonrl+nu tic eked cog 511u;k,K ergs) rk,serl5
1. Wel I' Cuntrrieti.r Il,irurrriirliont
1F. r fnicMill Li Se DN1.V
Brian Ewing
▪ cILCra..tm rurHarare
4240-B
❑ C Well Coui{,icior C'crllfrkLiun Piratic/
SAEDACCO Inc
V41I 4raostnictiun Pernik O; 11i0300399; 70002483
liuuli oglilruhlr wv/t vemil4lr-r.. G iltnty SLtlr_Y'iridlLr 1r 9rtfori. r.1
3. Will Use tehcidc well MO
Water Supply Well:
r'cllltural
UCreollk'rnwl literaingiCooling
I' Ilndusiria fCantrnercial
❑ Irt nn
Olvitliriripal/Pulrlic
17 fkrsfde11n1I1 Wdier Sunk! 1€i RLl.Icl
I-lRcsidentl,11 Water Supply .s]'Iaredt
NOP-Water S+upp1}' Well:
❑I4ioi iIorine 1=11 a}> '
I L1j4`ri9iii V- Ik
r1Ad111ifCr Reciiktrim
iAuprircr 9tormc ald Ttecrrr5er,r
❑ AgpiFFr 7�61
❑ EwcrimCluR1 TgClrn€rG.3e}'
❑ i uihermal iCluerd Ltnlpr
❑ Geoheitrial illes,uii Cnssliug Rutuilll
4. Dine Welllxt Crjrlgrlel€tl; 1/12/21
{+a_ %fell l.ilrathrn:
L0 7renoadwaler p.umlimit:r!
DSalin11% $ irnc r
❑ A' orrn5rrrler Ertuo.2ge
❑ 'abwideicc Carlml
❑ '1l-aorr
®O1ller iucpiuiil biller 121 Remarks)
Well flrmrA7
Remediation Management Service Company
l•.' I I i I' of rrepli:rltrle6
2650 Shenandoah Ave., Charlotte, NC, 28205
PInmal I Addrea City_ ;md Zip
Mecklenburg 12710204
Cgruu) } ieecl ldeiuifleiuol, Nn fP1Nl
ih. T:inmIlrirind langltmhr In nr der'imol rkt rxr4.;
idt rli field Int' LIVIativ strnekmr
35.210533 N-80.801887 '
9. l3 lure) the 11 rIII i ❑Ierni9nred ur 211 'moron'
7. Is thin a rrpair iu an rhriodieg wait: 1t'rs or El Nip
ifillr; Ii Ir lriNllr•,f+Nrii F rTNrIIW Ir'1'flcoroJ.7'IFIITro'rl ilrlJ'TlJ flJlkl iiri I'SrlrflrJ' rIII' lI l Nrl' Ile ri1r
rr,4drr uldifef 1 Frei rlt5 set.li a ur r41 der hack cd Mrs forJu.
S. Wini#et of well ronairueeed: 1 _
f r IlwirljVte ln..65' uilwl ve rime-Irxwr l ONLY ir.r11 rllr WNW eMrrrnreri,Nr
_5dI�5'Ilrr RAC fiJnu.
9. 7'urial wan depth beim lama surface 19
for I'0.10ll' tf ifi iroit(e'Jr{rrrtrdre- 7f ND' aril 7 ;IVl
11F0. SUSTIE water' level iicluw nip of culiul1
i+ IV/NH k''.ri it Mom.. L iri; a.r' "*
11. llar#2114110 illjnrrlt r. 1. 5"
12. Well Lr ndllnlctiao Inetlia(I: DRIVEN
rf.I,
(fl.I
cLe. Airger. Iwl4nr►, i-0hlc, dllrci Itierc.r
FOIl WATER sUPPJ.YWELLS ONLY;
I.la. Vivid Igpinr of
I313. bi lnf'c[ ua rapt: 4muuot:
14 WM= Molls
Iravil l ,n
ri!_tii'HIP rJl1',
It.
It.
t5. {MJT R CASITiC «llr Ir1u141-swig nab) OR L FfER (it amaRcahkh
FROM I TO 1110.1 rFTFR TIIICKNFM4
0 it. j 11' fi,
I hr LN}1R cot:SINc Iln'r_t)91niirivr.r4rir[I�[rarup_.
k FROM TO DLk41ESFR TDICKl§ESS MALE JAL
61.
n,
1.5" Jo.
NA
T1} pr.# )Trent J $ I fire L:Ils.
19' II- 1.5"
I.
NA
11..kPEN TAI
Steel
THIr lk!rPv4
NA
m.#Tllkril,
Steel
IL
It.
iN, GROW
RAOi1
Nn[EItl1[. F.#TrL1C Mk4TNILnomLaAMOUNT
ft.
n,
i4
Ir.
IL
24, ! WI;RAVPL PA€:k► I+r dyrlicibk}
rpil�r
R.
T[r
I(,
IJI FL
Lrirl'i_1( r'%IF*r1' ui=me11.4n
{
(I.
11, DRILLING LOG I cinch iddllionxl' both if neemary I
FROM
0 fl,
TO
19' fi.
IL
DP.Wr lt!PT:it Ni I suhr. 1, irdh ,., RIIµ'r K k r1 Rr cril.n 4r, Of[.
R.
14
IL
IL
Ic.
14
Ira
R-
IL,
21. altra..100
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg aFecal God Wc8Comm:tor Nee
AT MTItlINI fir frMrl, I rrrr.'bI' erMfr7I' rllw rNAY 1A-1 Y'l 14rd JI l J tyietwlreirtL err ileervmmune
u'JtA l •bl rirCAC OTC .Ofrrfl nJ. i TA rvt'r1CL�(�L'C A.041 %'W Y I)JrrrrNi rmur Sioridanic Wend i o
vim orals rm.and Am beau perlelfl.Wl FFF JllW 4I1r+J1 iiI wr.
1/27/2021
23. Site diagr'slni or ad dtli'Jiimil well delimit?.
Ycn1 rlla, 1k Ile Lack of digs "rage to provide addilicsnUh gh.ell site details ur we] L
r8Ii Inu;Llali glelails. You Hul4 ulso Ara;E[1diirfuur twb'es rl 1'I«:CSSHr1 .
;iu BRICf I•Ai. LNb7 tJc f{xN5
Zia. "hir All Wrik Suhaoi ilus Farm within 3U dale of courplermoo of swat
cousrructtpn to the fblkomrl4.
i h NFra ufWafer Remo rce5, Intlrrmmiluu Procrss.iog Grill,
1617 Mail Semler Ctmier, Raleigh, NC 27699-1617
241. Fier [uiiectinu Wedl9 ONLY: In addition Ie aeladitlg Ilie rofnl to Ills :Idd aces Pik
a�e�bo4'e. als.i suhl/di a copy of tills. fury uiiLlui iLl dlks of COmpluticith of vcc ll
co str uKLluu Irk (he FeLlt+Veiu .
I"h imam of Water Resources, lfnderg nand 1njr:riIoiu Control Program,
1636 Halt Service Center. RialeIgh, NC 2 7iWcr-I(I36
2.3L Fur Wit ...54ppl} Irijei ioe 'WOW
Also submit sire cop). of Ali& rulu, u Itllru ;8 lays of colrr1lerion uF
tire)) cnoglrpettnn co tLre cnlrut} 1101101 rleportiricn1 or air court 'whim
coral rucrcd
rarin tali -1
wFnn t .Jrc'IIIna L'rurrii ilr nI EFIImiIwI 111
mid Lmuck1 JtC&]IQctfi - DPE10I1f1.1% aicr ilG'{JLF
t#[I'L9Cd Aug= ILI I:I

WELL CONSITRUC CON RECORD
Thy fonrl+nu be rlscii cog 511u;k ,K I!l Ir11 trk hw ell5
1. W.11 Curltrnctur iInfor>wixfime
1F'ar FrOcmill 4ic D141.V
Brian Ewing
▪ �CtL CF P ri 4LT Nara
4240-B
NC Well Coulr,Icior cr1IfrJLiun Nitro
SAEDACCO Inc
? . V4'e14 4raristr,e iun Pernik O; w10300399; 70002483
liudin opvilruhlr wv/tovemil4lr-r.. G iltnty SLtlr_Y'yridlL Pea -Um 1.11-.0
Weil Isar trim& well tithe
Water Supply Weil:
ciiltLlral
1:10eorhermal lifealiogiCoaling Stipp]}�
I' 1ledusitia fCantmerciai
❑ hntpIsnn
L1hinnicipaliPllhlic
CJRtsfdennlil Water Sunk! aSinfJcl
I-1Rcsidenlr,Il Water Supply ts]'Iarodl
NIrP-Water S1upp1}' Wtll:
❑hioi iIoiiuc 1=11 a}> '
Eiji:I/arr1I V- IL,
r1Ad111ifir Recitarr
pArinirer 9tormc and RecillM ,r
❑ AgpiFFr 7�61
❑ EN rimCiuR1 Ttclin log
❑ Ci ulhermal iClustif Loopr
❑ Geotheitiial tilentiir JC'nolirig Rutuitil
L0 7ronodwatcr pk'l1iCS{1JYa4r7
DSalinits 13arncr
❑ p' orrn5rlrler ErRig2ga
❑tii11WcieilCC C'ahyr{ll
❑ '1l-aorr
®011ler iipiuru wider 121 Remarks)
. D:rti' WeIICst Completed; 1/12/21 Well JJ i All
5a_ %fell Larrathln:
Remediation Management Service Company
I. • [if rrr'pli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;tied Zip
Mecklenburg 12710204
CVrmJll t3ieecl Ideiuif eiuol, Nn fP1N?
ih. l:imI iiid 1Jngttnti In +icplreailmim4leel!cecnnds nr derimil d•egrrra;
idt rli field Int' LIUIativ strnekiur
35.210533 (-80.801887 '
fr. is lari) Ihi ur 211'moron'
7. Is this a rrpair iu an rsiodir iowelt: �11'rs or El Nip
+
{fillet Ii Ir lriNllr.•i l ii F r:FlrrIIW IW'flcor•'J. fou.Trr'rl llrllJ'TlJ'flJlkl iiri I'SrlrrlrJ' rIII' llllrNrr Ire rilr
rr,4drr uIdL.i'!1i r ei rk set.li a LW All der hack rtr Mrs forJu.
S. Plumber of well consrrueeed: 1 _
i r crddro Vre lreMAI40.11 W rire-Irxrrr .1•11Atift ONLY lI' r11 rllr WNW ivarrnreri,Nr
_5dI�5'Ilrr RAC fiJnu.
9.1'001 wall drpp' helm lima surface 19
for hNllirp1l' thi i erect 1 .terrrtldre- T*:017' aAIr17 ;IVO
11F0. Siitkk water' level below nip ref 4:uliu1
i+ IV/NH k'.ri 9 arl'rlua' L ire; a.r' "*
1. Ilai i4lk Ilijnleltr 1. 5"
tJrul �,.IN
12. Well i`riiditntvtipii iiwililul: DRIVEN
iri.
(fl.I
cI.¢, rorger, roam:. i-0hlr, dITrci elkEILerc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa Yield Igparir test:
111�, LM.9ilarttua ripe: Amuuut:
1 . WATICIL 7CO lls
RCN 11n
R!_tii'HIP rJl1',
R.
Its
t5. {MJT R CASiliC «llr rrru14I-F ieil nab) OR L FfER (rT appJRcahkh
FIiO11 1111 PR ITTFR TiiiCKNFM4
0 IL. j 11' fi,
I 3firIFTli 0 cot:SINc on Tt)91fr1iivilrl!rirlraIll�rll.li 1p_.
k FROM TO DtiAlESFR TDICKl§ESS MATE111.9i
to
n,
1.5" Jo,
19' II- 1.5"
Ir.
NA
NA
THIr 1,1
NA
11.iTIENTAI
Steel
Steel
IL
It.
711, (iRl}IT
RAOi1
1st
Nn [Eltlii. ! F. trLI. Mk4Tlllr.nomL a AMOUNT
It.
n,
rr.
iL
24, S)l1,4W4;RAVPL PAC), I+r dywlicibk}
R.
Tr3
1JI FL HLII.
1{ilr'1.1( r wnr *r i' u1-e 11.gn
{
(I.
11, DR1I+LING LOG I notch iddllionxl rbotifl if memory I
FROM
0 II.
TO
19' ft.
IL
DP.W-REPllil Ni I suhr. NA ., R µ'r K k hh Fr• a'In wir, OK. I
R.
IL
IL
It..
Ic
It.
IR-
arriLlk.04
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a f chcni red W c8 Conic• rur Nee
AT ST41111.4 drhr frMrl, I rrrr.'bi' erM0r7I' Mull ri+Y 11rd0l 14rd JI l J t41usrrlrelea elf.0.ra'rvmmlr
u'JtA 1 •isl rfCAC OTC .Of IV nJ. i TA Y rvc',1CL�u�.TC,(V8f11'44• I non'RH'rrior Sta rida,ds Wend NMI o
rT .11 orals rm. and lll:h b,rrrJ plrlr'Id.W1lrFJIIW 4I1r+J1 iIwwr.
1/27/2021
23. Site diiK;r'slni or additi'Jirul well delimit?.
Ycn1 rl1Hr 1k O Ile L1;icL uI drla pow to provide addilicsl,iih site ddails or well
construction Retails. You nun ulso Milo 11;xldilirftlnt twb'es rL r,cwnsirk .
;iu BRlrf7 AI. LNb1'tJcL7oNS.
lda. Len( All Wr,ik Sohaoi dos Form wiles 3U dale of c+amplerloo of writ
construction to the fblkomrl4.
1Fl►isFia ill' Warr Resources, InIrlrsoatIrli Pni rs log Gull,
1.817 blab Sersire CeLlcr, Raleigh, NC 27691P-1617
241.. For [uiiectillu Wedl9 ONLY: io addiliou to aeladitlg the form to are :Idd resa ni
aye �bo4's . ales+ suhlrril a copy of tills. fonii u iiLlui 10 dates of Llampluticith of well
construction ILl the faLlowiu .
IL'h imam of Water Resources, lrndcrgrnund 1njrelimu Control Program,
1.8.16 Halt Senile Center. Raleigh, NC 27fi'f4•.1836
2 iL Farr Veiti.rSippI} 4Ir IDj1FEt pi WOW
Also submit owe cop). of this furs, u Itluu ;8 slays of contp•1eIiopF uF
tircll cnoglrlrrttnn co tLle cnliim 1101101 IleppinimN1l or air county whim
coral-n[ ice
rarin trii -1
-rims t an' II Ina L'Imtr ii JIL III LI I11F0IIJI !"
mid muckl ILcs0lucts- DPE10I11 nl' Warr 11C{JLF
t#[h'L9Cd Aug= 11.1I;I

WELL CONSTRUCUON RECORD
Thy fonrl+nn be rlsi3d fur siug}c "1 I!lIlJI rk ,s ergs
1. WV I Curltr'rietr.r ILnroririAtiont
1F'ar FrOcroil) USe DN1.V
Brian Ewing
W elt {tulip l ur NarnC
4240-B
NC Well Coin{,Icior Carl iihmLiun M1ii rti
SAEDACCO Inc
W'e1I #aoatrswctiun Perna*, mI0300399; 70002483
J'irrull opvllruhir 0.YirPrrmil4 lr-r.. ( IILIIeY SLtlr_ Y'yridlLr 1.9Jfr'A }
W'rdl Use trim& will M
Water Supply Well:
flt r'catltural
UCreolli nwI IiieariogrCoaling 5upp]}l
I' 1lndusi,ia fCantrnercial
▪ Irniplirni
L1M iicipal/Plrhlic
r1 fklrsfdellnitl Wti1CF Sunk! l Si RL:1Icl
I-lRcsidentrml Water Supply is]varerl
NOP-Water Supply Well:
❑kloniloriuc ❑lea}> '
Eijl'r111r1I V- Ik
r1Ad111ifir 1 ecti51r re
pArinircr 9tormc mid Ttecr131er,r
❑ AgpirFr 7�6I
❑ EN rimcrilR1 TgClrn€rG.3e}'
❑ Ci ulhermal iCluted Linlpt
❑ Geodreiiiial illaringfenoliq Rutuiihl
DSalini1% 13arncr
❑ A' orrn5rlrler Erryig2r4
DNillwdeicc Caalrtll
❑ '1l-aorr
11IO1lrer iucpiuiil uilllrr /21 Mere/irks)
. D:rti.• WeII» Crjilrlrlel€tl; 1/12/21 1t'ea1JJ i A15
5a_ %fell l.11rLthln:
Remediation Management Service Company
I. . .1 I i 1 ' [if rrr'pli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Aifdrea City_ ;urd Zip
Mecklenburg 12710204
VwmJ1 t3ieecll[feiu9rleiuol4 Nn fP1N?
ih. T:Initl irold 1aangltntir In lP12-prxrarinhimrtelilccnnrls nr drtimol kt rrra;
utli Add Int' LiVIativ wIfITJCJ<Jur
35.210533 (-80.801887 '
9. l3 lure) Ihr!11 rIII i ❑Permanral Li Tog 'moron'
7. Is thin a rrpair iu an r xiodioil wail: 011ie or MIND
+
{rillri Ii Ir lriNllr.•i l ii F 0.4,11.0 i1 lflcoroJ.7rlallfCo'ri llrllJ'NLrIJIJJI mod I'SrlrflrJ' rAI' llllrnirr IIr rJlr
rr,4drr ulaLl+r 11 rrh.I&rlth set.li a ur All [Im hack rtr Mrs fr'rJu.
S. PluuLbet of welly ronmirueeed: 1 _
F it Tully Vote oreMArllal W Nretl-lr.VPrr .141104 ire'tO ONLY lI'.rh rllr WNWenlrarnrethilr
sdtwilrro )'iJnu.
9. TOW wdl depth helm lima surface 19
for I'0.10p1I' thifiVirect 16JGfr' ijdre- 7* ' aril 7 ;IVO
11l4. SiSTIE wrter' Ie►rl iicluwp oirrf culiu1
if IV/NH k'[ri it Mom.. L iri,; a.I' ".
11. l'koiIok illjnrcicr: 1. 5"
tJrul �,.IN
12. Well i iiidrinrctipii itwilirul: DRIVEN
(ri, t
(fl.t
c Le. Airger, rninr►, i-0hlc, dlleci IL erc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa Yield IRpamt of
I313. 11(.4MA:c dlie ripe: 4muuut:
14 WM= Molls
Iravil l 11;
R!_tir'HIP IJl1',
ri.
t5. {MJT R CASFNC {nrr Ir1u111-aieiI nab) OR L FfER (it amaRcahkh
FROM 11-0 PR ITTFR TPPICKNFM4
0 it. j 11' O.
I 2fir LN}1R cot:SINc Iln'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO DLk41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" Jo.
NA
lli PrArrrr'Illt J $ifirrL:lls.
19' II- 1.5"
I.
NA
11.iTIENTAI
Steel
THIClis ;v4
NA
m. rl[krm.
Steel
IL
rt.
7111. (TROUT
FAOi1
I r7
Nn [EItl1[. F.#TFL1i> M 4T lliL nomL & AMOUNT
ft.
n,
rt+
r4
rr.
IL
24, ! WfiRAVPL PAC. I+r dy1licibk}
room
T[r
p,
,JI FE HLII.
gsrl'i _1( r' %IF *r 1' ul_e 11.4n
{
(I.
111, DRILLING LOG I nliach iddllionxl 4botii if rreemalr3' I
FROM
0 fl,
ri.
TO
19' fi.
IL
DPW-REPT1(J N k hh Fr a'Iii
rt.
14
IL
IrL
it..
if -
FL.
Ira
R-
IL,
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a Fecal God W cit Comm:tor Nee
AT MT*111. 4 drhr frrFml, I rrrr.+b' eM0r7II' Mull rNrr ived{ Ilyd JI4l J tyiet rlreiraa Ulf.0Iee'rima[Ir
u'JtA l •bl riCAC OSC .Okay) ru. i ?r1 rvt',1CL�i� 2(V8 C,t1 W Y I rwrrrrNi rmur Siorida,i mist that e
rT .11 orals rm. and ,Jm:h b[rrN plrlVlfl.Wl llrJllW 4IlLJ1 rllwwr.
1/27/2021
23. Site ditioslni or ad dtii'Jlull well delimit?.
Ycn1 rllal ose ate L ac6 of digs "rage to provide addilicsnul ,rcll site details or we] L
cordrvl LLau [klails. Yoti nun ulso Mill 11;e[JdilHrimt twb'es rl r,ewcssan .
.till uRlrf7•AI, LNb7 tJc f{xNS
lda. Iriir All Wrik Suhaoi This Farm wires 31J dais of courplerloo of welt
cousrlucttpn to the Foltor41t1,4,
kb:611la ulWeerkrluurce5, Intlrrmrsiluu Poi rss.iog Gall,
1A17 MAO Sersire CeLlcr, Raleigh, NC 27699-1617
241. Firr [uieciiim WedIA ONLY: In addition Ie aeladitlg Ilie rofnl to Ills iKldnzs Pik
aye abo4'e. mils.i suhlii1 a copy of tills. try u iiLlui iLl dlks of I:amplrtii it of Wu!!
ca struruuu Irk (he Ia b.Yriu .
Tlh ialrwl of Water Resources.lrndcrgniund 1njim irrif Control Program,
1.836 Halt Senile Center. Raleigh, NC 27fi'f4..1839
2 Tr_ For Wif ...54ppl} IDJra7ilps WOW
Also submit oire cop). of !hi . rule, u iF[ ;8 hays of conif+ieliopF uF
tircll cnoglnirttnn co tLle cn,rut} 1101101 llep rluxe rl or air court whit=:
coral rni icd
rarin trii -I
e' fl n t .In' II II:r Lmiarcii iiE III LI I%mi iIJIICIII
and LII[ul ml ILcs0lucts- 1714r5 1011 nl' Wager 11.m.m.rem
Kehr Aug= hrI:1

WELL CONSTRUCUON RECORD
Thy fonrl+nn bc,wad roc sIiig}c+lr iiiiJI l'I „eFIS
1. Vid I Cunir'ricti.r Il,irurnidrliont
1F'ar Fnic'Mill Li Se D1,11.V
Brian Ewing
CF P ri 4L.THirn
4240-B
NC Well Coal{,Icior C'cr[IfkkLium M1iinbcr
SAEDACCO Inc
V41I 4raoatrl,ctiun Pernik O; wi0300399; 70002483
liaird2opvllruhlrwv/tovrmil41r-r.. ( IILIIeY SLtlr_Y.yd+ILr 1.9Jfar. oe#.o-.l
3. Wr I Use tehcidc wall MO
Water Supply VieIL-
ClAgrielrltnral
UCreolli nwI Iiteraiog'Coaling 5upp]}l
I' 1lndusi,ia fCantrnerciak
❑ Irt nn
L1M iicipal/Plrhlic
r1 fk4sfdellnlrl Vridizir Sunk! l Si RL:1Icl
I-lRcsidentrml Water Supply .s]'laredl
NOP-Water Supply Well:
❑hiaioloriuc ❑lea}>'
Eiji:ri9iii V- IL,
r1Ad111iCi r R4'Ct1Nrire
pAtinircr 9tormc aid Recnilcr,r
❑ AgpirFr 7�61
❑ EN rimCllR1
❑ Ci ulhermal iCluted LrnlpF
❑ Geoheitrial illes,uii Cosslim Rutuiihl
10 7recRodwalcr p,k'rnCtlimi9r!
DSalini1% 13arncr
❑ A' orrn5,lrler Ertuo.2r4
❑tiillwdeicc caalrtll
❑ *soar
11IO1lier iiipiuiil Hillier /21 Remarks)
4.D:Nt V4'ekICxlCrjnilpitIcd; 1/12/21 )ye11JJiA4
5a_ %fell 1.Ilrathrn:
Remediation Management Service Company
l•.' 1 I i 1! rif rrepli:rlble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;md Zip
Mecklenburg 12710204
CVwmJ1 } ii 1ldeiu9Eleiuol4 Nn fP1N?
ih.1:1L1itd�r'Ad IJngltnnh' In flriaxraElnhimrteiizccnnrls nr decimal etc rrra;
diw 1i Add Ink' LiOntiv strnekiiiE
35.210533 (-80.801887 '
9. l3 lure) Ibh!11 rIPI i ❑Iermanral Li 211 'moron'
�11 7. Is thin a rrpair iu an rhriodlr iowalk: 'rs or ®hlo
+
{rill ri Ii Ir lriNllr. •i rrii F �TNrIIW wen r4rrJ.7ril11 f rail d lrrl J'TrJrrIJlkl mod I'irlrratJr rA 1' llll' rr IIr rllr
rr,4drrulaLN 1i rrei rlth Y[e•Jrna ur All [Ime hack nr Mrs form.
S. Plunibbet of well rniillrrueeed: 1 _
l r IlwlrljVte lr06u40.11 W rire-Irxwr.1ONLY lr.rll rllr knNWcirrrarnreri,r+r
sdo'llrr RAC fiJnu.
9.1'01r l well depth helm lama surface 20
ror I'0.1rp1i' N'i'iJt 11r,r irri rillq r+r7 thifi Arect 16.terrrtidlr` 7*ND' arI l 7 ;IVO
1♦4. Stitkc water level iicluw nip at cuiiu1
fI I141+I'1. k''.m 9 Mom.. Luiri; a.r' •'
11. Flai 4ik rlijnicUt 1. 5"
12. Well {l rA-Inretipli itwilim41: DRIVEN
ifi.
ff1.I
cl.¢, Airger. rninrl, cAble. dlirdl Itierc.r
FOIl WATER SUPPJ.YWELLS ONLY;
k 1a Vivid IRpamt of
I313, bi.Jnfac ua ripe: 4muuot:
14 WM= Molls
RCN l 1n
DEld'HIP IJl1'
rt.
t5. {MJT R CASFNC {nrr Iriu141-swig ii Ni) OR L rfER (it amaRcahkh
FROM I TD PR IrFTFR TPPICKNFM,.
0 11' j 12' 9,
I 2fir LN}1R cot:1INc Iln'r_t)91niiirlrivr.r4rir[I�[rarup .
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
n,
1.5" Jo,
NA
TO PlArlar1'R J $InTLWi
20' ri. 1.5"
..
NA
1rAPENTAI
Steel
THIr lk!rPv4
NA
m. rl[krm.
Steel
II.
rt.
Ili
7$1. CIRI}LT
RAOi1
I h7
RnTE1tPM. F.#TFL1i> IF1kwTlllr.nI(IJJ & AMOUNT
tr.
n.
rt+
r4
rr.
IL
24, ! WC.RAVPL PA€:k► I,r dyrlicibk}
room
T[r
rl ,
1JI FE HLll.
I[irEH _1( r %Ir *c 1' ulm a 11•gn
{
II,
31, DRILLING LOG Inlrach iddllionxl4botii it nmaan.I
FROM
0 kl,
ri.
TO
20' ff.
IL
nP.Wrl[!PT1rJ Ni I,Rhr,1,irdh ,., RII 'nK k hh Rr a'Iii 4r, Cf[.I
rt.
14
rL
IL
rt
Ic.
1L,
It.
Ft-
BIEFILIOW
Temporary injection point through DPT tooling
21. Certification..
Brian Ewing
Sieshourg a fecal God W cat CouurL'rur
AT MTQVI1.I4 Au'frMrl• I rrrr.'bl' corr7I algal rl+r 1A-10.1 14rd aI l J tY.O.V.trirelea Ire.0.ra'rvmmune
u'JtA l •Il riCAC r7SC .Ofrrrl ry ?r1 rvt',1CL�i� 2C,(V8I1 l44'W Y I)Jrrrrrrrrnur SihINe♦ar., rlrld riLU o
rTrf.l orals rm. and Ambrrr J plrlr'Ifl.Wl ha' Au 4I1:1J1 iiI wr.
1/27/2021
23. Site dikar'slni or ad rl[ti'Jlimil well delimit?.
Ycn1 rlla, ,ise Ilse Lack of digs "rage to provide addilicsl,iih gh.ell site details ur we][
r8rtslru ;hall Iklails. You Hul4 ulso Ara;E[1diirmiut twb'cs d ock:nsor1 .
.till BRIT. f7•Al. LNb7 tJc IONS
2da. I i it All Wrik Suhaml tins Form wires 3U dale of courpkdmoo of welt
couslnicttpn to the rblkohrltl
hind.Fra ill Wsrirrkriuurce5, Inr.irmmiluu Poi rss.iog Gull,
1A17 MAO Sersire CeLIcr, Raleigh, NC 27699-1617
241. For [dectiirll WelI9 ONLY; In addition Ie aeladitlg the rofnl to the :Iddress ui
a�e�bo4e. �1s.i suhllri1 a copy of tildk try uiiLlui 10 dirks of r:ampletioti of )Aril
c n tructfuii ILl [he IaUOhvaai .
IT.ialrm of Water Resources.,lrndcrgrnuird 1njr:riIoiu Control Program,
1.836 Halt Service Center. Raleigh, NC 27i 94-1839
24r For Veilr ...5oppI} Indrisips 'WOW
Also submit acre copx1• of this- fain, u IFLuil ;8 days of con) 1eIion uF
tircll cnoglrlietinn co tLle criiiim UJ*1iltil lleppininenl or air comity whit=
coral Tllircd
rarin tali -I
e'fnh arc' II II:r Lmiarcii iiE III LIII lhrlwrcui
auks Natural iteraluctfi - DPE1611 n1' Wager 11.muLF
Kelaged Aug= 11.11;I

WELL CONSITRUC CON RECORD
Thy fonrl+nu be ascii Goa SIiiirk +11' mull lrk hw ell5
1. W.11 Contractor Information:
1F. r fnicmill sic D14121.''
Brian Ewing
ed1 Cn1Jr;14Ir.r H irn
4240-B
N C Well Coulr,lcior CarllfrmLiun Numi i
SAEDACCO Inc
? . V4'e14 (wistnictiun Pernik O; RI0300399; 70002483
liudin opv1J'ruhlr 0.YirPrrmil4lr-r.. G iltnty SLtlr_Y'yri+lLr frofortfori. h-.1
Wrdl Isar trine& well M
Water Supply Weil:
IJCreolli nwI lifealiogiCoaling 5upphl•
I' lledusitia fCanunercial
❑ Imgairnn
L1M iicipal/Plrhlic
rlR sidr:llnlll Water. Sunk! aSinfJcl
I-1Rcsidenu,ll Water Supply ts]'Iar'd
NIPA-Wawa S+upp1}' Well:
❑hionilorine 1=11 a;ar]'
I1iji:I/aIr11 '114.1.)krIk
r1Ad111ifCr Rectiarr
pArinircr 9tormc ald Ttecrrr5er,'
❑ AgpirFr 7�61
❑ EN rimCluR1 Ttclin log
❑ Ci uihermal iClused Loopt
❑ Geotlicltrial iFIciiiirl'JC•nolirl Retuiil}
I SRlinii3 13arncr'
❑ A' orrnytirrler ErRia.2ga
❑5i9bRickilCC coil nil
❑ Traor'r
®O11ier i ucplluu Mullet /21 Remarks)
. ll:lti' Welikst CrjilhIPItOrtl; 1/12/21 Well Mt A22
5:1_ %idi f.Ilrathrl:
Remediation Management Service Company
I.• Ii'![ifrllpli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIiv .cIiI Addrea City_ ;md Zip
Mecklenburg 12710204
Cnuntl Prldec1 ILi iuifle.iuui1 Nn (P1N1
ih. T.411ba ie lr d laangltntle In IIe`plreailmimtte1Isacermrls nr der'imil rkt rers;
i d s rli Add Ink' LiSnativJs strlltl<Jn r
35.210533 N-80.801887 '
fr. Is l mri) Ibi 1+ rIII i OPerillginred u r 211'moron'
7. Is this a rrpair ill an rhriodiriir trait: D't'rs or MIND
{f ill ri Ii Ir lriNllr.•i bier i1 lfl coromfll1 f ?pm l lrll J'TrJ,rIJi JJ1 newel 1' i w lrratJ, 111...11.049r r Ire NIr
rr,4drr uldifef r11 rrei rlt5 set.li a ur r41 der hack rtw Mrs forJu.
S. Plumber of welly cniisrrueeed: 1 _
F it craiti V,rc .1r06.140.11 W rime-Irxwr 111Ati ' LIMA aI r11 rllr WNW ivarrnrethilr
_5d1�5'Ilrr RAC fiJnu.
9.1'001 well depth below land surface 20
f.ir uNlliw�rfl' N'fi�r �rlwiwwi d1'LJrlor tfeArect 1 .terMtrdre- 7* ' ar,1r+ 2cir P.Crl
110. Stitic water' level below nip of cusiu1
+FI14NI'r k'r•r•i 14 awl Ii)F Lwri; a.1' "*
11. Ilur iiik IIIjnicltr 1. 5"
12. Well i`uestintctiart twetliiul: DRIVEN
117341
rt.I,
(fLI
c1.¢, rorger, roam i-0hlr, din: 0 Itierc.r
FOIl WATER sUPPJ.YWELLS ONLY;
1.1a. Yield Want 1144.111041 of t er:
1.113, fiiisiorecitiuu ripe: 4muuut:
1.4Wft =V.0115
IRID4 11rr
ri!_tir HIP 1'Jl1'
rt.
ft.
t5, OUTHR CASFNC {tllr rnu111-sail nab) OR um ER (it apOlcahkh
FROM I TD PR IrFTFR TIIICKNFM,.
0 i j 12' t1,
I 2fir LN}1R cot:SINc Los'r_ 91niirivr.r4rirr rrarup_.
k FROM TO IMA241ESFR TDICKl§ESS MATE.III.9i
to
n,
1.5" Jo,
NA
Ter RiAraFI1?R J $I,tF Wi
20' r1. 1.5"
..
NA
NA TIEN TA I
Steel
THILIk!rty4
NA
m.#rllkrsl,
Steel
IL
rt.
iN, GROW
FROM.
1st
NnTeltPM. ! EMPLI.VEMI.NTlllr.nI€ILJkAMOtINT
tr.
n,
l4
ir.
IL
24, 55.4.1'4111CRAVPL PA(:. I+r dyllicibk}
rpir�l
R.
Trr
II,
1JI FL HLl1.
gsrEl _1( F %Ir *r 1''dome1.1•111.1
{
rI ,
11, DRILLING LOG Iconch iddllionxl rlredi if mermanI
FROM
0 f1,
TO
20' ft.
IL
DPW-RIF :0J'i 1Buhr.iirdhyr+ 411'n1ckhh Rr• a'In 4r, ef[.I
r1.
14
IL
tL
It
Ic
14
It.
R-
I1.
21. BI rgiAM
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
SiErinurg a fecal God W cit Couurb'rur Decc
AT MT41111.II Au'frMrr• 1 rrer.'bi' cor.r0I rMu1 rNJY i1'ed1181 11frY JI l J t41ustrlrJ IrtI err.0.rt'rimmrlr
u'JtA l•bl rirCACOTC.Of140nJ. ?rt rvc',1CL�i�2(V8 C,t11'44'IY1>+rrIrirrrmurShINe♦ari nandriLUo
r' n oralsr+rr'nnd ilr:h beau plrlr'Id.W1 lrFJIIW 4I1r+J1 iIwwr.
1/27/2021
23. Site dat:r'slni or additi'Jiimit well delimit?.
You r11Hs 1k Ilse fxicL .uf d11a false to provide addilicsnul ,yell site details or well
construction details. You ours also Milo 11;xldilr4ftwt isnLxs d h1«CS#an .
$L' IIRiCf7 AI, LNb11.1C IONS
2da. lhl( All Wr,ik Suhaml this Form within 3U da2s of courplelloo of swell
construction Lathe Following.
1Fh NFla ul'Wafer Resources, Infrrrmrr.iluri Pt -Hemming Grill,
1617 Malt Sersire CeLIcr, Raleigh, NC 27699-1617
241. For ['discern. Wells ONLY: In addition to aeladitlg the rofnl to floe :Iddr> s ni
a�eab34'e. alsar suhiiii1 a copy of tills. form uiiLlui i0 dates of L:onmliftraso of well
construction action ILl the Iallowiu .
IT.ialrm of Water Resources, lrndcrgniund 1njr:elIalr Control Programs,
1.8.16 Halt Service Center. Raleigh, NC 27694•.1639
2.3L Farr Water54ppl). 4Y Iril1Etipi Wells!
Also sulrllrii acre cop). of Ali& furs, sy 1CLuil ;8 flays of COrltpieliopF uF
swell cnoglrprtinn co IL1e crrliit} hIm iItii slepplrtirxnl or air county Is liii
coraanucrcd
rarin tell -1
e' fl n t arc' II Ina Lmiarsii iiE III LI II1r5r men
a lei 1+I;ILW�11 itesoluctfi - 17rkr5 1011 f1.1% Warr 11.m.i.nrcm
Rcucd. 11.1 I:I

WELL CONSTRUCUON RECORD
Thyfonrl+nutic asciicog 5Iii k.'imI111Eilkhsofl5
1. Wel I' Curltr'rrcti.r Iiiruririlrliont
1F'ar fnicrnill USe D1,11.V
Brian Ewing
▪ CFP rl4lr'rNarrnC
4240-B
N C Well Co ui{,Icior Carl iihmtiun tkiinhci
SAEDACCO Inc
? . V4'e14 traoatrswctiun Pernik O; wi0300399; 70002483
liuid2 opvlll..Jhlr 0.YirPrrmil4 lr-r.. ( IILIIeY Slap_ Y.yd+ILr Peal.-Uoe#
3. Wr I Isar tehcidc wall M
Water Supply Vied:
flt r'cllltural
UCJeortrrmal Iiiaariog'Coaling 5upp]}l
I' Ilndusiria fCanunercial
❑ knipirni
L1M iicipal/Plrhlic
r1 fk4sfdellnlll "Wdr r Sunk! l Si RL1.Icl
I-lRcsidentrml Water Supply .s]'Iaredl
NIPP-Water S+upp1}' Well:
❑hianiloriuc 1=11 a}> '
Eiji:I/mall V- Ik
r1Ad111ifCr Rect1Nrire
pArinirer 9tormc mid Ttecrrrler,r
❑ Agpilcr 7�61
❑ EN rlmcruRl TgClrn€rG.3e}'
❑ Ci uthermal iCluted LinlpF
EIGeotheiroal illea111i1+Cnssllm Rutuiihl
L0 7r41901dwal :r p,k7 mlimit:r!
DSalini1% 13arncr
❑ A' orrn5rrrler Ertuo.2r4
❑SilbRidkiICC carllrtli
❑ Traorr
11IO11kr 11 4 Eiuiil milllrr 121 Reretoks]
4. NNW Weplrxl Crlrrilrlrlcd; 1/13/21 We.11 Mgr A6
{+a_ %fell I.ilrathln:
Remediation Management Service Company
l•.' 1 I i 1! rif rrepli:Iltrle6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea Cirt_ ;urd Zip
Mecklenburg 12710204
CVwmJ1 Prieecl ldeiu9Eleiuol4 Nn fP1N?
ih.I:Initd�rind Iaingltnrhr In rlcpncearinlirrµte1Ili4 nnrls nr dr,r'imil rktrxr4.;
taliA'Id Ink' Li'lojJsstr,MtkiuE
35.210533 (-80.801887 '
9. l3 lure) Ibh!11 rIII i ❑eim oral ur 211 'moron
7. Is thin a rrpair iu an rhriodll iowait: 1t'rs or El Nip
+
{rillri Ii Ir l.» ilr.•i l.00r r:FlrriIY.l I1'J'flr4rrJ.7ril1 i'rl llrllJ'TrJrflJlkl iiri I'SrlrratJr rlll' llll'Nrr IIr rJlr
rr,4drr urdL.i'!1i r ei rk Yr eJrari LW All llrr hack rtr Mrs form!.
S. Plufiible -of well ronmrrueeed: 1 _
F .r iirddr Vote lr06u40l1 W Nre-Irxrrr.1!WM' ONLY lr.r11 rllr WNW rnlrarnreri,r+r
...romlrr RAC fiJnu.
9. Tuts) wen depth helm lama surface 20
r,rr thifi erect 16.terrrtrdre- *.:1;10' aril 7 ;IVO
10. SiSTIE water level iicluw nit] of culiu1
▪ I141+I'1. k''.ri9arom..Luiri; ll.r' •'
11. Fiat 4110 ilijnielcr 1. 5"
12. Well {1 rA-Inrctipli itwilir411 DRIVEN
(fl.I
cI.c Airger. roan . i-0hIr, dIlecipush_ erc.r
FOIl WATER sUPPJ.YWELLS ONLY;
11a Vivid !Wm!! of tr•sr!
I313, fiFisinferitilia ripe: 4muuot:
1.4 WM= Molls
RCN 11n
DElif'HIP IJl1'
Ii.
Its
t5. {MJT R CASFNC {nrr Iriu11I-F ieil nab) OR L FfER (ir amaRcahkh
FROM 11-0 PR IrFTFR TPPICKNFM,.
0 it. j 12' tr.
I ri. rN}10 cot:gm on 7T_a91niirlrivr.r4rirr rrarup_.
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
9-
n,
1.5" Jo,
NA
Trr' PrArrrrI1?ir J Jiifirrsra
20' ft. 1.5"
..
NA
NA
IIATI •IITAI
Steel
m. rlekrsl.
Steel
IL
It.
Ii
rlt, tiROrT
RAOi1
I h7
RnTE1tPM. ! F.#TrL1C Mk4TliMT.nomLJkAMOUNT
ti.
n.
rt+
r4
rr.
IL
24, S)lNWC.RAVPL PA€:k► I+r dyrlicibk}
7E3
rI ,
1JI FE HLII.
1[irr'i_1( rwnr*cl' ulme11•gn
{
(I.
Z 1, DRILLING LOG I nliich iddllionxl 4botii if nm as n. I
FROM
0 fl,
Ii.
TO
20' ff.
IL
nP.WrhrlPllilN ...ahr,i,irdhn...tI'nKkh5 Rr cri.n ,OK.I
It.
14
IL
tL
Ic.
Ir,
Ira
R-
IL,
21.BItri4104
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a Fecal God W cit CouurL'rur Dtec
AT MT41111. 4 Au'frMrl• I rrrr.'b1' erM0r7I rllw rliz 1A-10.1 14rd JI l J tClusrrlrelrtI Ire.0.ra'rvmmune
u'JtA l •Il rifCAC OTC .Okra) ry ?r1 f'c'r1CL�u.'C,(V8I1 W Y I I)Jrrrrirrnur Sh tiellari nand dint
rT .11 orals rm. and ill:h br,r J plrlr'Id.WI IrFJIIW ,I,r+J1 iIwwr.
1/27/2021
23. Site dikarslni or ad dtti'Jiima,I well delimit?.
Ycn1 rlla, ose ate Ll ick of digs "rage to provide addilicsnul ,rcll site details ur we] L
cordril;Llati Iklails. Yoti Hul% ulso Ara;Eddiirmiut twb'es rl h,ewcssan .
.till BRICf I•Ai. LNs1 .1C"rfoNS.
2da. Ihl( All Wrik Suhaml this Form within 3U dale of courplermoo of swat
cousrluctipn to the folkomrl
1Fl►isFra ill Wsrrrrkr!Iuurce1, Intlrrmmiluu Poi rss.iog Gull,
1A17 MAO Sersire CeLIcr, Raleigh, NC 27699-1617
241. Fier [uieciiir7l WedIA ONLY: Ire addition to aeladitlg the rofnl to the iKldnzs Pik
a�e�bo4e. alsar Stith llrll a copy of tildk try uiiLlui 10 dirks of Campletii it of vcc ll
co struKLluu bale IaU]Ohviu .
I"h.ialen of Water Resources.lrndcrgrnutrd 1njr:riIair Control Program,
16.36 Halt Senile Center. Raleigh, NC 27iW4-1839
24r For Wirgi° S4ppl} ! Inlln7ion 'WOW
Also submit otte cop). of llii . rulu, u IFLuil ;o days of colirf+ieliOir uF
tircll cnoglrlrrttnn co ILre crmiim lim iltil llepplrtirienl or air criu*i 1h'liii
conlminrcicd
Fargo trii -I
wFn n h art' a Ina L'Ictr ii in nI EFII rhr IwYC ul
a lei ni.unl itesoluctfi - l rvGlaunl'1'.11er 11.m.c.nrcm
Kelaged ALVA 11.11;I

WELL CONSTRUCUON RECORD
Thy fonrl+nn bc,Isi3d roc sIiig}c.Ir mlilllid: „ergs
1. Welt Cuiltriicti.r Ilrirrirnidtlirm:
1F'ar rnicrnill USe D1,11.V
Brian Ewing
▪ CF P ri 4L.TNarn
4240-B
NC Well Courr,Icior C'crllfrkLiun M1iinbcr
SAEDACCO Inc
? . V4'e14 traristnictiun Pernik O; 1110300399; 70002483
liutin opvllruhlr wv/tovrmil4lr-r.. G iltnty SLtlr_Y'yridlL 1.9ferteriri. h-.1
3. Well Isar tehcidc well M
Water Supply Well:
Atirt,clllttlril
UCreolli nwI Iiiaatiog'Coaling 5upp]}i
I' Ilndusiiia fCantrnerciak
❑ Irt nn
L1M iicipal/Plrhlic
rl R sidr:Ilnul "Wilier Sunk! a €i n fJcl
I-lRcsidentiol Water Supply i.s]'Iar'd
NIP: -Wake S+upp1}' Well:
❑hionllcrrirrc ❑lea}>Pry
Eiji:ri9iii Wi.rl
rlAdllriCi r Rectik1ri[e
pArinircr 9tormc ald Recrnlcr,r
❑ AgpirFr 7�61
❑ EN rlmcrlRl TgC1rn6Lw3 '
❑ CIauiherm;rl iCluerd Ltnlpi
❑ Geotheitrial iFlesiuirgfenolinn Rrtuiihl
I SRlinii3 l arncr
❑ p' orrowsfier Erolig2r4
❑5i9bRickiCC Carlmi
❑ 'soar
®Oilier t Ia iiuiu biller /21 Remarks)
. D:rti• Welkst Crjrlrlrlel€tl; 1/13/21 Well JJ i A10
5.t. %fell Lalrathrn:
Remediation Management Service Company
I' . of lrepli:.nble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI rlifdrea Cir.. ;ar4 Zip
Mecklenburg 12710204
CVwmi1 Prii 1 Irieiuoleiuuii Nn (P1N1
ih.I:initd�riiid Iaangltnrhr In flrirrxrarinrimrteiizccnnrls nr decimal etc rrra;
dttli Add Ink' Llrlloj 1J strfrekm
35.210533 N-80.801887 '
9. l3 lure) Ini 11 rIPIji. ❑errrianral ur 211rInporon'
7. Is thin a rrpair iu an rxiodioil writ: 1t'rs or MIND
+
{rigid II Ir IriNIIr. •i rrii F �TNrIIW I4i'Ir rYNA7fll1 fll'rl ilrrll'TlI+rIJIA'I liNri I'Sr lrrldJr rill' III)' rr Ir+ rjlr
rr,4drr uldL.i'!1i reu&rk set.li a LW All der hack ri? Mrs form.
S. Winiitiet of well rnirlrnieeed: 1 _
F .r Dakota Ir06u40.11 W rime-Irxrrr l• ONLY lr+r11 rllr WNW cMrrrnrethilr
_...gtII2r RACfrl All.
9.1'01,1 wen depth beim lama surface 20
For hrai 'p1i' N'i'1Ji 11hr ir+1 fii'yr1l, thifi erect 16JGf Mtrdre- 7f ND' arr17 ;IVO
1♦0. SUSTIE water level iicluw nip of c,rliolr~
fI I141+I'1. k''.m 9 Mom.. Luiri; a.r' •'
1. LSar itik ilijnreler. 1. 5"
t1r.1 +.SIN
12. Well iui jnrctirru Inetlinil: DRIVEN
fl, I
(ILI
cI.c Forger. roinr►. t hlc, dlleclprEIL.M.F
FOIl WATER sUPPJ.YWELLS ONLY;
k.lA Yield ligpinI of ter:
lib, 11(.lnrartime'leper. 4muuut:
14 WAI= Molls
Iravil 11n
R!_tirltIP IJl1'
ft.
ft.
t5. OLITeR CASFNC «llr Ir1u11I-F ieil nab) OR um ER fit amaRcahkh
FI O rl I TO PR IrFTFR TPPI(P FM,.
0 it. j 12' tr.
I 2Er LN}iRS cot:SINc Lls'r_l)91niirivr.r4rirr rrarup_.
k FROM TO DtiAlESFR TDICI:r§ESS MALE JAL
km_
9-
n,
1.5" Jo,
NA
Tri PrArrrrI1?ir J Ji I:or sr i
20' r1. 1.5"
..
NA
11.iTIENTAI
Steel
THILIk!gPv4
NA
m. rlekrsl.
Steel
IL
rt.
it GROUT
RAOi1
I r7
RnTeltPM. F.#TrLI. Mk4TlllLnl€rl/ & AMOUNT
tt.
n.
ri.
r4
rr.
IL
24. S)lNWC.RAVPL PA€ k. I+r dyrlicibk}
R.
Trr
rI ,
IJI FE HLII.
rrirEH _1( r %IF 1' ulm eh.4n
{
(I.
11, DRILLING LOG I nliach iddllionxl 44Ked1 it nm aarr3 I
FROM
0 kl,
TO
20' fi.
IL
DP.WrItlPllilNlF r,l,Mrdhx+,.tI'nlcki5 cril.n ,OK.I
rt.
14
IL
tL
rt
if-
Ft-
arriLlar.b4
Temporary injection point through DPT tooling
21. Certification..
Brian Ewing
Sieshourg a fetal God W c8I Comm rue Nee
PT MT41lI1.I4 Au'frMrr• I rrerobr rl+r ivrd{ u rY JI l J tY.O.V.trirelea ur.0.ra'rvmmlr
u'lrA 1 •Il rirCAC OTC .Okra) ry ?rl f't'r1CL�(J�.:C, V8ti %'W Y I71rrIIrrlrrrwr Shlrkllari rrrld riLU o
rT .11 orals rm. and Am&Mu plrlr'Ifl.Wl r� AL. nI1:1J1 iiI wr.
1/27/2021
23. Site diagrslni or ad dtlilnuil well delimit?.
Yun Fluky ose ate Lack .ul digs "Page to provide addilionul gh.ell site Mails ur we] L
cordrur LLali Iklails. You nun ulso Ara 1i ;i 1 ilr mint twb'es rl r,ewcsSan .
;iU BRlrf7 AI. LN.S11.1["riONS.
2da. L+Iir All Wrik Suhami ilus Farm wires 3U dal of courpkdloo of welt
cougnlctipn to the rblkomrl4.
iFh NFla ul'Water Remo rce5, Inform:rluu Pni rss.iog Golf,
1617 hill) Sersire CeLIcr, Raleigh, NC 27699-1617
2.I . Fier [uitale_ We319 ONLY: hi addition to aeladitlg Ilie rofnl to the :Idd ress ui
a�eab04•s:. a1s.i suhlull a copy of tills. try uiiLlui iLl dlks of COmpluticith of vcc ll
c n IJ'I ruuri Iv the FeUe.Yriu .
IT.ihlrm of Ware Resources, lrnderg nand 1njr:rlIan Control Program,
16.36 Malt Service Center. RaleIgh, NC 27i cr-1(136
2.3L Fur WiI °.54ppl} Iojri hoe 'WOW
Also snbIMit oite cop). of Ali . rule, u Ithiil ;o days of coniileiion uF
tircll cnoglrlrrttnn co IL1e criiiim him i1ril llepplrtmenl or air county irliii
coniminlcicd
rarin trii -I
e' fl n t an' II Ina Lmiarciitllr III tilt lase IIIIIcu1
sail Nminal JrC 0Iuctfi - DPE10I1 nl' W.nicr Rinut.rcL
KeirLSCA1 Aug= 11.1I;I

WELL CONSTRUCUON RECORD
Thyfonrl+nutic !mil cog SIiik.'im1111r'I hsefl5
1. Wel I' Cuntr'ricti.r Il,iruririlrliont
1F'ar fnicrnill USe DN1.V
Brian Ewing
ed1 Crrotrl44LT NarrnC
4240-B
❑ C Well Coulr,Icior CcrliihmLiun tkiilbci
SAEDACCO Inc
V41I 1raoatnictiun Perna*, 1110300399; 70002483
liuul2 opvllruhlr 0.YirPrrmil4lr-r.. G iltnty SLtlr_Y'yridlL 1r 9rtfor#. h-.1
3. Will Use tehcidc well iIi
Water Supply Well:
Agr1'clllttlril
UCreorli nwI Iiieariog'Coaling 5upp]}l•
I' llndusiiia fCanunercial
❑ hnipi nn
L1M iicipal/Plrhlic
0 R{SfdCllnlll Vridier Sunk! 1€i RL1.Icl
I-lRcsidentiol Water Supply i.s]'laredl
NOP-Water S+upp1}' Well:
❑I4ioi iIoriuc ❑lea}> '
Eiji:I/alrll '114.1.)krIk
�IAdilltifCr RCCIiktrim
robrittircr 9tonr.gc iid Ttecr,35er,r
❑ AgpirFr 7�61
❑ EN rimCluR1 TgClrn€rG.3e}'
❑ Ci ulhermal iCluted Ltnlpt
❑ Geoheitrial illes,uii Cnssliii Rrtuiih}
DSalini1% 13arncr
❑ A'orrowiler Ertuo
❑ 'abwidei cc CaalmI
❑ '*soar
11IO1lier rucpiuiil wader 1/21 Remarks)
4. NNW V4'eIllsl Crjlrlrlel€nl; 1/13/21 We11 Mgr B14
i.L. %fell lalrathrn:
Remediation Management Service Company
I' . of rrepli:iiL'I 6
2650 Shenandoah Ave., Charlotte, NC, 28205
t'IM IcIiI Addrea City_ ;end Zip
Mecklenburg 12710204
CVwmJ1 Prieecl ldeiuifleiuol, Nn fP1N?
ih. *:hol g ird laangltnrhr In nr derimil kt rrra;
taliA'Id Ink' LIr21[ isstr,Mtkiui
35.210533 N-80.801887 '
9. is lure) the rIII i ❑�elYri9nral ur 211'moron'
7. Is thin a rrpair iu an rhriodll iowait: 1t'rs or El Nip
+
{reggae Ii Ir lriNllr.•i l ii F �TNrIIW IW'flcorlJ.7rirllfCori llrllJ'TJJrrIJIJJI liNri I'irlrrltJr 111.. llll'Nrr IIr r(1r
rr,4drr uldL.i'!1i r ei rk Y[eJrari LW All der hack rtr Mrs form.
S. Plutlrl let of well rolrlrniceed: 1 _
F it Ilw2rote lr06u40.11 W rime-Irxwr l411tgr' ONLY ir.r11 rllr WNW enlrarnreri,r+r
_5dlra'II2r RAC fiJnu.
9. 7Yurial wen depth helm lama surface 20
r,rr diq r+17 thifi Arect 16.terrrtrdre- *.:1;10' aril 7 ;IVO
11F4. Siik water' level iicluw oip Irkc,rliolC
i+ IV/NH k''.ri 9 Mom.. Luiri; ll.r' •'
11. Flag lik iIIjnrcltr 1. 5"
tJrul �,.IN
12. Well tutflkimPtipi rnetlirul: DRIVEN
ff, I
(fl.I
c1.c Airgcr. roinr►. i-0hlc, dlTecl Itielc.r
FOIl WATER sUPPJ.YWELLS ONLY;
Oa Vivid !Wm!! oftr•sr:
1.111, fiFisinferitima rapt: 4muuut:
1.4 Wfti= 2.01,11s
Iravil l ,n
ri!_tir'HIP rJl1'
rt.
t5. OF THR CASFNC Orr prou141-ronoil ii Ni) OR L N ER fir amaRcahkh
FROM I TD PR IrFTFR TIIIICKNFM,.
0 11' j 12' t1,
I 2Er LN}1R cot:SINc Ils'r_t)91niilrlrivr.r4rir[r�[rarup_.
k FROM TO Drk'41ESFR TDICKl§ESS MALE JAL
to
9-
n,
1.5" Jo,
NA
Trr' PlArkTFI1?R J JiI,trTSWi
20' ri. 1.5"
..
NA
NA
11.iTIENTAI
Steel
„rArltkrsl.
Steel
IL
rt.
it GROUT
RAOii
Nn[Eltlii. ! F.#TrL1C Mk4TllMT.nomLJkAMOtINT
tt.
n,
rt+
r4
rr.
IL
24, 55.4.14W4:RAVPL PA€ k. I,r dyllicibk}
Firer:
T[r
rr ,
,JI FL HLl1.
girlH_1(r'%IF uMj1•gn
{
(I.
31, DRILLING LOG lnirich iddllionxl rlredi it neeaarr3I
FROM
0 fl,
F.
TO
20' fi.
IL
DP.W-REPT:OJ N k hh Fr. ctIn 4r, OK.I
rt.
IL
tL
rt
if -
FL.
Ira
Ft-
arriLlatb4
Temporary injection point through DPT tooling
21. Certification..
Brian Ewing
Sieshourt a retal God W cat Comm:tor Nee
AT ST41111.4 drhr frrFnll, I rrrr.'bi' erM0r7I rllw rNJY 1A-10.1 14rd aI l J t41ustrlrelrtI Ire .0.rrrimmlll e
u'JtA l •bl rirCAC OSC .Weer" ry ?r1 rvt',1CL�G�.TC,(V8f1 WI Y I)Jrrrrirrnur Sratie♦ari rlrld that e
r' n orals lis rand Am beau plrlr'Id.WI FFF JllW 4I1:1J1 iiI wr.
1/27/2021
23. Site diagrslni or ad dtli'Jiimil well delimit?.
Ycn1 rlla, ,kSJ: Ile Lack of digs "rage to provide addilionul gh.ell site details ur we] L
r8rtslru ;hate Iklails. You Hun ulso i li 1i ;i 1 ilrLsuut twb'cs d ock:CSSan .
;iu' BRICf I•Ai. LNb7 tJc f{xN5
2da. I iir All Wr,ik Suhami this Form wires 3U dal of courplermoo of welt
cousrnlctipn to the rblkomrl4.
kb:61lla if'Wafer Remo rce1, Intlrrmmiluu Poi rss.iog Grill,
1617 Mail Sersire CeLIcr, Raleigh, NC 27699-1617
241. For [deciie YWIA ONLY: In addition to aeladitlg flue rofnl to Ilia :gddresa ui
a�eab04•e. als.i suhl/di a copy of tills. try uiiLlui 10 dlks of Lamplrtrati of 11c11
LEn I uct.ruri Irk the raL]Ohviu .
TT.ialrm of Water Resources.,lrndetgrnund Injr:riIan Control Program,
16.36 Halt Service Center. RialeIgh, NC 27i 94-1839
24r For Veirgi° S4ppl). ! Irijlri hoe 'WOW
Also submit sire cop). of phi& rulu, u IFhiil ;o lays of conif+ieIiopF uF
tircll cnoglrlrrttnn co ILle crniut} 11mi101 rleporline11 or air c iu*i whit=;
corairrucicd
Fargo trii -I
wFnnt arc' IIIIFLmktnii i¢itil LII51r5�IIJII111
aul LnLurll itesaiirctfi - J7lkrs 1011 a Wake RinuLrc
KeirLuCd Aug= ILI I;I

WELL CONSITRUC CON RECORD
Thy lana i:4n be 11sfld roc sll gk +Iw mI111 Elrk hw e115
1. Welt Curltroct[.r Information:
1F'ar Fnic'Mill Li Se D1,11.V
Brian Ewing
Wd1 Cn1Jr;144LT H ir!nC
4240-B
❑ C Well Cool{,icior Carliihmtiun Nitro
SAEDACCO Inc
WLI t aristnictiun Pernik 1:; F10300399; 70002483
liuul2 opvllruhlr 0.YirPrrmir4lr-r.. G iltnty SLtlr_Y'aridlLr 1rofortrar#. h-.1
3. Weil Irse trim& well bale
Water Supply Weil:
ClAgricultural
LICreolli nwI lifeariog''Coaling 5upphl•
I' 1lndusiria fCantrnercial
❑ Imgalrnn
EffsloinicipaliPublic
rlR sidr:llnlll Water Sunk' aSinfJcl
I-lRcsidentr,ll Water Supply ts]'Iarodl
NIPP-Wake Supply Well:
❑ Woo !mine 1=11 a}> '
Eij4`ri9iii V- IL,
r1Ad11rifCr Reciikt ire
pAtinirer 9tormc mid Ttecr135er,r
❑ Agpircr TJ:6I
❑ EN rimCruR1 Ttchnolo
❑ Ci uthermal iClused Luo i
❑ Geodlcitiial tilenirri JC'noliEl Retuiii
0Cfrolaoddwater 1{um-1u111wt
I SRlinii313arricr
❑ p' orrowsiler ErRig2ga
❑ti11r3GhdC11CC C'ailmi
❑ Tratier
®O11Eer wlJrt /21 Renludc,c]
. D:Iri• Welikst Crjrlrlrlered; 1/13/21 Well Mt B12
5a_ %idI Lalrathrn:
Remediation Management Service Company
I. • I i 1 ! [if rrepli:irbleP
2650 Shenandoah Ave., Charlotte, NC, 28205
PIiv.cII Addrea City_ ;urd Zip
Mecklenburg 12710204
CVwmJ1 t31eec1lrll'Iuifle.iu511Nn rR1N1
ih. T:mildJirand laa.gttnrhr In nr derimil d•egrrra;
d tali field Ink' LIVIativJs +JIrIUCkiu
35.210533 N-80.801887 '
9. Is lure) IOi ll rIPIji. ❑Permanrnl Li 211 'moron'
7. Is this a rrpair iu an r sioding wait: D't'rs or El Nip
+
{rrlrri rr Ir l.» ilr..fig Jr r?N+II1J I4J'irr4rA'.1r+Hifr1'r1 rlrrlJ'T+Jlfl+lkl+IN'i I'11llrf+tJ1 UJI' lI l'Nrr Ire r(Ir
rr,4rlrr ulaLN 2r11 rrei r2t5 Y[ eJran 1Jr r41 der hack rtr Mrs form!.
S. Number of welbt consrruceed: 1 _
F it credo Vte rr06u40.11 ret1 - I r.VPd, r .141Atift Ire'ra ONLY lI'.rh rrlr WNW enrrarnreri,r+r
_5d1�5'Ilrr RAC fiJnu.
9.1'001 wan depth helm lane surface 20
for I'NIHrprl' rilaxhil thititdrect16Jrrrrrtrdic` 7 ' aAIr17 ;IVO
1♦0. SUStIE water level below nip of cuiiu1
fI I141+I'1. k ir.I 9 Mom.. Luiri; a.r' •'
1. LSar silk ili�reli r 1. 5"
12. Well i`uretinrctipii inietlirlal: DRIVEN
ire.
(fl.I
c 1.C, forger. roinn . i-0hlc, dlTeclelkEIL .CPC.
FOIl WATER SUPPJ.YWELLS ONLY;
I.la. Yield %rpanl elf t er:
I.113, LM.9ilartiva raper 4muuut:
14 WAIIk 2.01ills
RCN 11n
R!_SI'HIP IJl1'
It.
It.
t5. OLITeR CASiliC «llr Inu11I-F ieil nab) OR L 7PiRR (rT amaRcahkh
FROM I TD P 1IrFTFR TPPICKNFM,.
0 IL. i 12' It.
I 2Er IN}iR4 L'rLSINC Iln'r_t)91niirivr.r4rir[I�[rarup_.
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" Jo,
NA
TD PlAraFI1?R J JiInTSra
20' I1. 1.5"
I.
NA
NATIENTAI
Steel
THIClistSi
NA
>tl. rltars1,
Steel
IL
It.
Ii
it tiROIT
RAOi1
I it
RnTE1tPM. F.I.trLH:'EMk4TlIIT.nomLaAMOUNT
tr.
n,
t4
ir.
IL
19. S+►NWfiRAVPL PA€:1. I+r dyrlicibk}
Caere:
T[r
II,
1JI FE Hd II.
I[i1EH _1( r %Ir *c 1' u1=me 11•gn
{
II.
11, DRILLING LOG I Which iddllionxl' robe if nmaan.I
FROM
0 f1,
TO
20' ft.
IL
DP.Wrrt!PT1rJNi I[uhr.1'irdh ,.,.SII'nKkhh Rr a' tr, Cf[.I
rt.
14
IL
ft.
it
if -
FL.
It.
R-
IL,
21. BerglAM
Temporary injection point through DPT tooling
2/_ Cer irrrL'ationf
Brian Ewing
SiErinurg aFecal red Wc8Coumb:rur Dtec
AT MTQ411.+1 drhr )Fran•) rrcr.+b' ei0105' rMw rliz 1A-10.1 u rY aI l J twrl5rrireirra Ire ve.erimavire
II'JtA 1 •bl rirCAC 07C .Offer nJ. ?rt f't'+1CL�i�LTC,(i18f2 l44 I Y I>+rrrrirrrtur Sh tiellari rrrldf riLU o
rT .11 orals rm. and ,Jii &Mu prrrr'Ifi.Wl rya' Au 4I1r+i1 rrrwwr.
1/27/2021
23. Site dr ram or aiddtti'Jirul well delimit?.
Ycn1 rl1Hs use die hick of drla pow to provide addilicsl,ul gh.ell site ddiils or well
construction derails. You nun also Mind ai1dilrfunt Iwb'c rL rxwcsSan .
;iu BMirf7 Al. LNb11.1CTIoNS.
Lb. lhl( All Wr,ik Suhaoi this torn with 3U dale of z uiplerroo of welt
construction to the following.
hind.%Fra ul'ViarerRemairces, Information Procrss.iog Gull,
1A17 hlblt Sersire Ceuticr, Raleigh, NC 27699-1617
24h.. For lutecium Wedl9 ONLY: hi addition to aeladitlg the ro€nl to the :Idd resa Pik
a�eab04•e. areal suhlui1 a copy of tilde form uiiLlui 10 dates of CaanIpluticith of well
construction to (he fa t+Veiu .
Division of Water Resources, lrndctgrnund 1njr:elIalr Control Program,
1.8.I6 Halt Service Ceulrr. Raleigh, NC 27t cr..1(13(r
2.3L For Wire:F.54RPl} Ioj1Et1)i Wile.
Also submit afire cop). of ibis ruin, u 1FLuil ;o flays of comF+ietiopF uF
tircll cnoglnrrttnn co IL1e [What} him iltil Ileport11xn1 or air cpiu*i white,:
coral -lured
rarin trii -I
'win n Ian' II Ina L'Ictr ii sir nl bp, II 1r5r IIJIICIII
alai NaLurnl itesaiactfi - DPE1011. n1%Warr 1lG'{JLF
KeirLSCA1 Aug= 11.11:I

WELL CONSTRUCUON RECORD
Thy fonrl+nn bc,Isi3d roc sIiig}c.Ii inlal rk „ergs
1. Welt Cuiltriicti.r Ilrirrirnidtlirm:
1F'ar rnicrnill USe D1,11.V
Brian Ewing
▪ CF P ri 4L.TNarn
4240-B
NC Well Cour{,icior C'crllfrkLiun M1iinhci
SAEDACCO Inc
? . V4'e14 traristnictiun Pernik O; 1110300399; 70002483
liutin opvllruhlr wv/tovrmil4lr-r.. G iltnty SLtlr_Y'yridlL 1.9ferteriri. h-.1
3. Well Isar tehcidc well M
Water Supply Well:
Atirt,clllttlril
UCreolli nwI Iiiaatiog'Coaling 5upp]}i
I' Ilndusiiia fCantrnerciak
❑ Irt nn
L1M iicipal/Plrhlic
rl R sidr:Ilnul "Wilier Sunk! a €i n fJcl
I-lRcsidentiol Water Supply i.s]'Iar'd
NIP: -Wake S+upp1}' Well:
❑I4ioi iIorine ❑lea}>Pry
Eiji:ri9iii Wi.rl
rlAdllriCi r Rectik1ri[e
pArinircr 9tormc ald Ttecr,3ler,r
❑ AgpirFr 7�61
❑ EN rlmcrlRl TgC1rn6Lw3 '
❑ CIaulhermal iCluerd Ltnlpi
❑ Geotheitrial iFlesiuirgfenolinn Rrtuiih}
I SRlinii3 l arncr
❑ p' orrowsfier Erolig2r4
❑5i9bRickiCC Carlmi
❑ 'soar
®Oilier t Ia iiuiu biller /21 Remarks)
. D:rti• Welkst Crjrlrlrlel€tl; 1/13/21 Well JJ i B10
5.t. %fell Lalrathrn:
Remediation Management Service Company
I' . of lrepli:.nble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI rlifdrea Cir.. ;ar4 Zip
Mecklenburg 12710204
CVwmi1 Prii 1 Ideiuoleiuuii Nn (P1N1
ih.I:initd�riiid Iaangltnrhr In flrirrxrarinrimrteiizccnnrls nr rterimnl rkgrevs;
r d s rli Add Ink' LlVIativ s str ekm
35.210533 N-80.801887 '
9. l3 lore) Ihi 11 rIPIji. ❑errrianral ur 211rInporon'
7. Is thin a rrpair iu an rxiodioil writ: 1t'rs or MIND
+
{riligi II Ir IriNIIr. •i rrii F �TNrIIW I4i'Ir rYNA7fll1 fll'rl ilall'TlI+rIJIA'I liNri I'Sr lrrldJr rill' IIIl' rr Ir+ rjlr
rr,4drr uldL.i'!1i reu&rk set.li a LW All der hack ri? Mrs form.
S. Winiitiet of well rnirlrnieeed: 1 _
F .r Dakota Ir06u40.11 W rime-Irxrrr l• ONLY lr+r11 rllr WNW cMrrrnrethilr
_...gtII2ro )'iJAll.
9.1'01,1 wen depth beim lane surface 20
For hrai 'p1i' N'i'1Ji 11hr ir+1 fii'yr1l, thifi erect 16JGf Mtrdre- 7f ND' arr17 ;IVO
1♦0. SUSTIE water level iicluw nip of c,rliolr~
fI I141+I'1. k''.m 9 Mom.. Luiri; a.r' •'
1. LSar itik ilijnreler. 1. 5"
t1r.1 +.SIN
12. Well iui jnrctirru Inetlinil: DRIVEN
fl, I
(ILI
cI.c Forger. roinr►. t hlc, dlleclprEIL.M.F
FOIl WATER sUPPJ.YWELLS ONLY;
k.lA Yield ligpinl It•sr:
lib, 11(.lnrartime'riper. 4muuut:
14 WAI= Molls
Iravil 11n
R!_tirltIP IJl1'
ft.
ft.
t5. OLITeR CASFNC «llr Ir1u11I-F ieil nab) OR um ER fit amaRcahkh
FI O rl I TO PR IrFTFR TPPI(P FM,.
0 it. j 12' tr.
I 2Er LN}iRS cot:SINc Lls'r_l)91niirivr.r4rirr rrarup_.
k FROM TO DtiAlESFR TDICI:r§ESS MALE JAL
km_
9-
n,
1.5" Jo,
NA
Tri PrArrrrI1?ir J Ji I:or sr i
20' r1. 1.5"
..
NA
11.iTIENTAI
Steel
THILIk!gPv4
NA
m. rlekrsl.
Steel
IL
rt.
it GROUT
RAOi1
I r7
RnTeltPM. F.#TrLI. Mk4TlllLnl€rlraAMOUNT
tt.
n.
ri.
r4
rr.
IL
24. S)lNWC.RAVPL PA€ k. I+r dyrlicibk}
R.
Trr
rI ,
IJI FE HLII.
rrirEH _1( r %IF 1' ulm eh.4n
{
(I.
11, DRILLING LOG I nliach iddllionxl 44Ked1 it nm aarr3 I
FROM
0 kl,
TO
20' fi.
IL
DP.WrItlPllilNlF r,l,Mrdhx+,.tI'nlcki5 cril.n ,OK.I
rt.
14
IL
tL
rt
if-
Ft-
arriLlar.b4
Temporary injection point through DPT tooling
21. Certification..
Brian Ewing
Sieshourg a fetal God W c8I Comm rue Nee
PT MT41lI1.I4 Au'frMrr• I rrerobr rl+r ivrd{ u rY JI l J tY.O.V.trirelea ur.0.ra'rvmmlr
u'lrA 1 •Il rirCAC OTC .Ofrrrl ry ?rl f'r.'r1CL�(J�.:C, V8ti %'W Y I71rrIIrrlrrnur Shlrkllari rrrld riLU o
r' n orals rm. and Am&Mu plrlr'Ifl.Wl r� AL. nI1:1J1 iiI wr.
1/27/2021
23. Site diagrslni or ad dtlilnuil well delimit?.
Yuu Fluky ose ate Lack .ul digs "Page to provide addilionul gh.ell site Mails ur we] L
cordrur LLali Iklails. You nun ulso Ara 1i ;i 1 ilr mint twb'es rl r,ewcsSan .
;iU BRlrf7 AI. LN.S11.1["riONS.
2da. Ihlr All Wr,ik Suhami ilus Farm wires 3U dale of courpkdloo of welt
cougnlctipn to the rblkomrl4.
iFh NFla ul'Waterkrluurce5, Inform:rluu Pni rss.iog Golf,
1617 Mall Sersire CeLIcr, Raleigh, NC 27699-1617
2.I . Fier [uitale_ We319 ONLY: hi addition to aeladitlg Ilie rofnl to the :Idd aces ui
a�eab04•e. also+ suhluli a copy of t1Nk try uiiLlui iLl dlks of COmpluticith of vcc ll
c n IJ'I ruuri Iv the FeUe.Yriu .
IT.ialrm of Ware Resources, lrnderg nand 1njr:rlIan Control Program,
16.36 Malt Service Center. RaleIgh, NC 27i cr-1(136
2.3L Fur WiI °.54ppl} Iojri hoe 'WOW
Also submit oi,e cop). of Ali . rule, u Ithiil ;o days of coniileiion uF
tircll cnoglrlrrttnn co ILle cairn} him i1ril llepplrtmenl or air county irliin
coniminlcicd
rarin trii -I
wFnnt arc'ulnFLmktnii iiEIII LIIt1r5�IIJIYCIIr
sail Nminal JrC 0Iuctfi - DPE10I1 nl' W.nicr Rinut.rcL
KeirLSCA1 Aug= 11.1I;I

WELL CONSTRUCUON RECORD
Thy lanai:4n tic rwad fur 5I1gk.'i cola" rk,serl5
1. %V t Cufltr'ricti.r Iiiruriridrliont
1F'ar fnicrnill USe DN1.V
Brian Ewing
eNlt CFP rl4lur NarnnC
4240-B
N C Well Couir,Icior Carliihmtiun tkiinhci
SAEDACCO Inc
? . V4'e14 traoatnictiun Perna*, 1110300399; 70002483
liuul2 opvllruhlr 0.v/f ovimir4 lr-r.. G iltnty SLtlr_ Y'yri+lLr 1.9f9rtrar#
3. Well Isar tehcidc wall M
Water Supply Well:
r'cilltural
UCreolli nwI Iiiaaliog'Coaling 5upp]}l
I' 1lndusiiia fCantrnercial
❑ hnipi nn
L1M iicipal/Plrhlic
r1I'I{Sfde11n111 Vridier Sunk! i Si RL1.Icl
I-lRcsidentrml Water Supply i.sltaredt
NIPP-WaIcr S+upp1}' Well:
❑hioi iIoiine 1=11 a}> '
Eiji:I/arr11 '114.1.)krIk
r1Ad111ifCr Rect1Nrire
pArinircr 9tora8c iid Ttecr+35er,r
❑ AgpirFr 7�61
❑ EN rimCNR1 TgC1rn6Iw3 '
❑ Ci ulhermal iCluted Ltnlpr
❑ Gradieriiial illt!Juii Cnsslim Rutuiihl
❑ 7reffadwaler p,Crmlimi9r!
DSalini1% 13arncr
❑ 0rrn5rlrler Erryio.2ge
❑ti'abwidkllcc CaalmI
❑ '1l-aorr
®O11ier 1ucpiuiil Mkt 1/21 Remarks)
4. "late` Well» Crjililrlel€nl; 1/13/21 We.11 Mgr B2
5a_ %fell lalrathln:
Remediation Management Service Company
I'.tifrrepli:,11t71e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Aifdrea City_ ;urd Zip
Mecklenburg 12710204
CVwmJ1 Prieecl ldeiuoleiuol, Nn fP1N?
ih. T:4m1l iiid Iaangltnrhr In nr der'imil rkt rxr4.;
d t ale Add Ink' Li '1oj Js strf,tl<Ju
35.210533 (-80.801887 '
9. is lure) the rIII i ❑IeiYri9nral ur 1planporon
7. Is thin a rrpair iu an r siodioil w tlb 011ie or El blip
+
Ornate rr Ir rriNllr.•i l+N+r r+IIIW war cor.'J.7ril1I frr'rI rlri1J'TJJIrIJIJJI iiri I'ir lrrjtJl pJI' rllrmlr r I ra r(1r
rr,4rlrr uld6'r 2r1f remark.. Y[ eJrarr LW All [Irr hack rtr Mrs form.
S. Pluti le -of well ioliainieied: 1 _
F it uwrrljVte .1r0 m4a1 W rrrn'J-Irxwr lulrjift ONLY lr.r11 rlIr WNW enrrarnreri,r+r
_5d1�5'Ilrr RAC fiJnu.
9. Tuts" well depth helm lama surface 20
ror FNllirlrfl' thifi erect 16xerrrtrdle- 7 ' aAIr17 ;IVO
1♦4. SiStIE water level iicluw tut Irk cuiiu1
i IV/NH k'o-r•i 9 Mom.. Luiri; rr.r' •'
11. Flai lik iIIjnrCIer: 1. 5"
tJrul �,.IN
12. Well tutdirntvtipii Irw111md DRIVEN
fri,I
(fl.f
c1.c Airger. roinn. i-0hlc, dlleclprEIL.M.F
FOIl WATER sUPPJ.YWELLS ONLY;
Oa Yield IRpamr of t er:
1.313. bi lnfac ua riper. 4muuut:
1.4 WftiIk tO L
Iraviw l 11r;
R!_tir'HIP rJl1'+
ri.
t5. {MJT R CASFNC Orr r11u111-aleil arNi) OR um ER (it amaRcahkh
FROM I TD PR IrFTFR TPPI(P F5t4
0 11' j 12' t1,
I 2fir 0.1142 L'JISINC as 7T_a91niirlrivr.r4rir[r�[rarup_.
k FROM TO Dt AlESFR TDICI:r§ESS MALE JAL
61.
n,
1.5" Jo,
NA
Trr' PrAnarl- IR J $1:or sr i
20' 11. 1.5"
..
NA
NA
NATIENTAI
Steel
m. rl[krs1.
Steel
IL
rt.
Ii
it GROUT
RAOii
Nn [Eltlii. ! F.#TrL1C Mk4TllMT.nomL & AMOUNT
tt.
n,
rt+
r4
rr.
IL
19. S)lNWI;RAVPL PAC. I+r d FJ1I4cibk}
Firer:
R.
T[r
rl ,
IJI FL HLl1.
girrH_1(r'%IF 'dlmehgr1
{
(I.
31, DRILLING LOG Inirich iddllionxl itmerii it neeaarr3I
FROM
0 fl,
F.
TO
20' fi.
IL
DP.WrltEPT:O Ni IFuhr, imnir ....tI 'nK k hh Fr. aYIn 4r, OK.I
rt.
14
IL
tL
rt
rc.
Ir,
Ira
R-
IL
24 arri lath ,
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourt a Fecal red W cal Couurb'rur Dtec
AT ST41111.4 dllyr frrJ'nr, f rrrr.+b' ei0105' rrlw rNJY 1A-10.1 u rY iI l J t41r15trirelrtI Ire ve.erimavire
11'JtA 1 •Il rifCAC OSC .0frrr ry ?r1 rvt','CL�G�.TC,tV8f11.Vrif Y rwrrrrNi rmur Srdlridari rrrld riLU
rTrf.1 orals rm. and ,Jii &Mu prrrvld.wl rFF JIIW 4I1:1J1 iiI wr.
1/27/2021
23. Site diagrslni or ad dtii'Jiimil well delimit?.
Ycn1 r11Hs ose ate Lack of fills "rage to provide addiliol,ul i ell site Mails ur we] L
cordnim;Llati Iklails. Yoti Hul% also Ara;E[1diirmiat twb'es rl ock:nsirk .
;iu' BRICf I•Ai. LNb7 tJc f{xN5
2da I iir All Wr,ik Suhami nips Form wires 3U dale of courplerloo of swat
consrmuctipn to the rblkohri[l4.
kb:61lia if'Wafer Remo rce5, Intlrrmriiluu Poi rss.iog Gull,
1617 hlblr SersirJe CeLIcr, Raleigh, NC 27699-1617
2.I . For daitirm We319 ONLY: Iti addition to aeladitlg flee rofnl to the :Idd Tess Pik
a�ea11,04•e. alsar Stith llrll a copy of tildk try uiiLlui 101 dads of Llampluticith of vccII
c n tructfurf Iv the faLlrrhviu .
IT.ialrm of Ware Resources, lrndcrgrnund Injr:riIalr Control Program,
16.36 Halt Seance Center. RialeIgh, NC 27iW4-1836
24r For Wirgi, Srrppl} ! Iojri hoe 'WOW
Also submit sire cop). of Ali . turn, u ltliiu ;o days of com leliopF uF
tircll cnoglnrrttnn co IL1e criltut} him iIri1 ileporline11 or air cpiu*i irllcm
coniIncicd
rarin trii -I
e' f n t .f n' 111nr L' iarciitiiE n1 bp, I11r5r IIJIIC111
au1 LIILui ml itesaiactfi - 171krs 1011 r1.1% Warr klim LF
KeirLuCd Aug= ILII:1

WELL CONSTRUCUON RECORD
Thy fonrl+nn bc,wad rei sIIIg}c.'i IrII111EIrk „erl5
1. Welt Cuiltr'rictr.r ILnrrEi'IriAliunt
1F'ar rnicrnill 4x D1,11.V
Brian Ewing
W of t Crolnio ur Narn
4240-B
❑ C Well Cool{,icior C'crllfrkLiun M1iinbcr
SAEDACCO Inc
V41I 1raoatrirctiun Pernik O; 1110300399; 70002483
liu ul2 opyllruhlr 0.v/t Perm?$ l r-r.. - it th SLtlr_ Y'yridlL keert'Or#
3. Wdl Isar tehcidc well M
Water Supply Well:
r'citlturld
1:10eortrtrool Iiiaaiiog'Coaling 5upp]}i
I' Ilndusi,ia fCantrrli:rm:iak
❑ Irt nn
L1M iicipal/Plrhlic
r1 fk4sfdellnlll "Wtier Sunk! k t Si RLl..Icl
1:1Resitientml Water Supply i.shared
NIP: -Wake S+upp1}' Well:
❑hionilorine ❑lea}> '
Eiji:I/arr1I Wi.rlk
rlAdjll!Ci r Recti51rire
pArinircr 9torc mid Tt ecr,3ler,r
❑ AgpirFr 7�61
❑ ENKri icrlRl TgC1rn6Lw3 '
❑ Ci ulhermal iCluted LCnlpF
❑ Gtotheiiiial illea111ii+CooIi i Rrtuitil
I SRlinii3 13arncr
❑ 0rrowsfier Urolig2r4
❑5i9bRickiCC Carlmi
❑ Traorr
11IO11kr Iii p11iiii biller /21 Remarks)
. Di.itt•WellINI Cutlgrltletl; 1/13/21 1t'e11J10iB4
5a_ %Veil lalrathrn:
Remediation Management Service Company
I' . .1 I i 1 ! rif rrepli:,Ilblei
2650 Shenandoah Ave., Charlotte, NC, 28205
PIn Icpl . ddrea Cirt_ ;m d Zip
Mecklenburg 12710204
CVwmil Prii 1 IrletuiELciuoli Nn (P1N1
ih. I:initu rind Iaangltnrhr In flrirrxraElnlimrteiilccnnrls nr derimol clot rrra;
r d t rli field Ink' LIVIativJs strf,tl<JU E
35.210533 N-80.801887 '
9. l3 lure) IOill rIPIji. ❑eim oral ur 211rInporon'
7. Is thin a rrpair iu an rxiodioll trait: 1t'rs or ®NE.
+
{rillri II Ir IriNIIr.•i l ii F �TNrIIW I1'J'flr4rlJ.7riHI1.6'rI IIrl1J'TIJrrIJIJJI liNri I'irlrrlrJr rA1' III?' rr Ire rJlr
rr,4drr uldL.i'! .i r ei rk set.li a LW All der hack air Mrs form!.
S. Jlrunible.I of well ronarrueied: 1 _
F .r Dakota Ir06u40l1 W Nre-Irxlwr .141Atift I11.4r ONLY ir.r11 rllr WNW cMrrrnrethilr
.*Ilrr RAC fiJnu.
9.1W wen depth helm lama surface 20
For I'NlHrir(I' Frei/i 11hr1W fii'Lr117 tf ifi irect16.terrrtrdre- 7f ND' arr17 ;IVO
1♦4. Nolte water level iicluw nip of c lodalI~
fI I141+I'1. k''.m 9 Mom.. Luiri; a.r' •'
1. Isar 1rlllk ilijnreltr. 1. 5"
tJrul �,.IN
12. Well {1lnlitnretipii IPw111 411 DRIVEN
fl, I
(fl.t
cl.c,rgct•, rn>nr1, i-0hlc, dllectItierc.r
FOIl WATER sUPPJ.YWELLS ONLY;
Oa Yield !Wm!! ref t er'
lib. 11(.9il clime raper. 4muuut;
14 WM= Molls
Iravit 11n
R!_tirltIP IJl1'
rt.
t5. OUTER CASFNC «llr Inu11I-F ieil web) OR L FfER (it aprOlcahkh
FROM 11-0 PR IrFTFR TP01(1 F5t4
0 it. j 12' tr.
I 2Er LN}iRS cot:SINc Lllt'r_l)91niirivr.r4rirr rrarup_.
k FROM TO DLk'41ESFR TDICl:r4ESS MALE JAL
km_
9-
n,
1.5" Jo,
NA
Tri PrAniFI1'R J Ji I:or sr i
20' ft. 1.5"
..
NA
VATIENTAI
Steel
THILIk!rPv4
NA
m. rlekrsl.
Steel
IL
rt.
I.
it tiROrT
RAOi1
I r7
RnTE1tPM. F.#trLI. Mk4Tlllr.nomLaAMOtINT
tt.
n.
rt+
r4
rr.
IL
24, ! WI;RAVPL PA€ k. I+r dyrlicibk}
R.
7E3
rI ,
1JI FE HLII.
r[irEH _1( r %Ir *c 1' ulm a 11.4n
{
(I,
31, DRILLING LOG I ntrach iddllionxl 44Ked1 it iceman.
FROM
0 kl,
TO
20' fr.
IL
DPW-REPT141Ni I,yhr,imninv.,., R'Iµ'r'Hkr1 Rr a'Iii 4r, OK.I
rt.
14
IL
tL
rt,
rc.
Ir,
Ira
R-
IL,
24 al ri klatA
Temporary injection point through DPT tooling
21. Certification..
Brian Ewing
Sieshourg a recal God W cli Cauuserur Dote
AT MT41lI1.I4 drhr faro??, I rrerob' cori.0I rllw ri+Y ivrd{ 14rd JI l J tY.O.V.trirelea err.0.rrrimavir:'
u'JtA 1 •Il rifCAC 07C .Wrier ry ?r1 rvt','CL�(� 2C,(V8t1 % Y I I>,rrrrrlrrnor Sihlrkllar., Wend r♦i,U o
r' n orals rm. and llii &Mu plrlr'Irl.Wl IrM AL. 4I1r+J1 iiI wr.
1/27/2021
23. Site diagrslni or umidtli'Jlimil well delimit?;
Yo i Fluky iLie ate Lack of digs "rage to provide addilionUh ,Fell site details ur we] L
cordr il;llati Iklails. Yoti nun ulso Ara actiilrsfuur twb'es rL r,ewcsSan .
;iU BRIT. I"1•AI. LNb711["f IONS
2da. I+Iir All Wrik Selmer this Form wires 31J dais of courpkdmoo of welt
cousrructipn to the rblkomrl4.
i h NFla if Wafer Remo rce5, Inform:iluu Poi rss.iog Golf,
1A17 Mlle Sersire Ctmier, Raleigh, NC 27699-1617
2.I . For [uitale_ We319 ONLY: hi addition Ie aeladitlg the rofnl to the iKldnzs Pik
2-i. .'4. mi1s.i suhluli a copy of tildk try uiiLlui 10 dirks of Lliampluticith of 1t•cII
;symb l:Lluri ILl (he itido. riu .
IT.ialrm of Ware Resources.lrndilgrnund 1njeriIalr Control Program,
1.836 Halt Service Center. Rial Igh, NC 27iW4-1839
2.3L For Wiwi...54ppl} Iojrtt1)e WOW
Also subIMit sire cop). of Ali . ILA Ill ?h iFhiii ;o days of coniileriOir uF
seem? cnoglrlrrttnn co tLle criiiim him iIiil rlepplr turn) or air commit' 1r'lICi1:
corail mica
rarin trii -I
wFnni ari'ulnFLmktnii iiEIII LIII1r5�IIJIYCIIr
mid LIILWckliteraluctfi- DPE10I1nl' W.nicr Rinut.rcL
Kelaged ALVA 11.1I;I

WELL CONSITRUC CON RECORD
Thy farlrl+nu be ascii cog 51.iiirk .'i mIi11 Irk hs eFlS
1. Welt Curttr'rrcti.r Information:
1F'ar Fnic'Mill Li Se D1,11.V
Brian Ewing
eN11. {n1Jr;14ALT NarinC
4240-B
❑ C Well Coulr,Icior Carliihmtiul1 Nii rbcr
SAEDACCO Inc
WLI 1romatrl,ccian Penile O; w10300399; 70002483
liuul2 opvllruhlr 0.YilPrrmil4lLt. G iltnty SLtlr_Y'aridlLr 1r 9rt'Or#. h-.1
3. Well Ilse trim& well iI�
Water Supply Weil:
UCeorha nwI lifeariogJ'Coaling 5upphl•
I' 1lndusi,ia fCantreercial
❑ ImgaIinn
Lffsloi riripaliPublic
rlR sidr:llnlll Water Sunk' aSinfJcl
I-1Rcsidentral Water Supply ts]'Iarodp
NIPP-Wake Supply Well:
❑ Mon' lotion 1=11 a;Ct]_
nji:I/atm11 V- Ik
r1Ad111ifir ReC.1151ire
pAtinircr 9tor18c ald Ttecr,35er,r
❑ AgpirFr T�6I
❑ EN rimCNR1 Ttclrnt}Lk3p'
❑ Ci uihermal iClused Luo F
❑ Georher ial illt!Juii Cnsslim Retutii
Qttrolaodwaret Rum-1.4111mi
DSalini1% 13arncr
❑ p' orrn5rlller ErRig2ga
❑511hGhdC11CC C'ahyr{ll
❑ Tracer
®011rerriipiuiuliimkt/21 Remarks)
4. NNW WeII» CW1411Ir1A11; 1/13/21 We.11 Mgr A24
i.L. %Veil Location:
Remediation Management Service Company
I. • I i 1 ! [if rq'pli:irbleP
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM Icpt Addrea City_ ;urd Zip
Mecklenburg 12710204
CVAm ll Pit 1 1l'iuifle.iuuia Nn fP1N?
ih.1.411 risielr d laa.gttmhr In nr dreimol rkt rers;
d t ali Add Ink' Li'loj Js str ekm
35.210533 N-80.801887 '
9. Is Imrei the 11rIII i ❑I'ermanrnl Li 1planporon'
7. is this a rrpairiu an r w(ll
iowrit: 1t'rs or El Nip
+
{rill ri la Ir lriNllr. •i rrii F �TNr11W 11'a'flr4rrJ.7r44I1.6'r1 dlrll J'TrJrrIl1JJ1 ilri 1'11llrrlrJr rA 1' 111l' rr Ire r(Ir
rr,4drr uldifef 1 rrei rlt5 Y[ eJ nFi ur Ali der hack rtr Mrs form!.
S. Number of well cnitdrirueeed: 1 _
F it uwlionte lr06u40l1 ret1 - I r.VPd, r .141Atift Ireta ONLY ir.r11 rllr WNW ivarrnreri,Nr
_5dI�5'IIrr RAC fiJnu.
9.7001 wan depth helm lewd surface 20
ror FN11ir1rfl' thifiVirect 16. ere'trdle- 7 ' aA1r17 ;IVO
1♦0. SUStIE water level below nip of l'41siu1
fI I141+I'1. k''.m 9 Mom.. Luiri; a.r' •'
1. llur IAlk ilijnreltr 1. 5"
tJrul �,.IN
12. Well curetinrctipii iniellimd DRIVEN
iri.
(fl.t
c 1.c Auger. roinn. i-0hlc, d1TeclelkEILelc.F
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield %rpaml nftrerr
I.113, Lliilnfad ua raper 4muuut;
DEld'HIP IJl1'
R.
t5. OLITUR CASiliC «llr r1ru141-aswl nab) OR L rfER (rT amaRcahkh
FRO rl I TO PR IrFTFR TIII€'KNFM,•
0 it. j 12' tr.
I 2Er IN}iR4 L'l1SINC as 7T)91ftici itrerirrrarr F11.l1rlp_.
k FROM TO DtiAlESFR TnlrlifiESS MALE JAL
to
n,
1.5" Jo,
NA
TD Pr.oTFI1'R J Jiifirrstirs'
20' ft. 1.5"
i,
NA
Steel
THIClistSi
NA
�rl Tllkril,
Steel
IL
rt.
Ii
it GROUT
'FROM.
I At
RnTeltPM. EMPLI.VEMK.NTlllLnI(ILaAMOUNT
tt.
n,
I4-
rt.
IL
24.! W1:RAVPLPA( .I+rdyllicibk}
R.
Tri
II,
1JI FE Hd ll.
1[irEH_1( r %Ir*c1' ulmejign
{
rI .
11, DRILLING LOG A nliich iddIAionxl 4botifl if memory I
FROM
0 f1,
ri.
TO
20' fr.
IL
DP.W-REPllil Ni 1 Buhr, i,irdhn...tI 'nK k hh Fr. a'Iii 4r, OK.I
rt.
IL
tL
it
Ic
Ir,
rt.
R-
24 BCMAtSRb A
Temporary injection point through DPT tooling
2/_ Cer rirrL'ationf
Brian Ewing
Sieshourg a Fecal red W cit Courrib'rrlr Dtec
AT ST*111.4 dlhr frrr'n11, I rrer.+b' erM0r7I rllul r2+Y 1A-10.1 14rd aI l J tvusrrirelrtI err ve.ervmmlr
u'JIA 1 •bl rirCAC OTC .Ofrrrl ry i ?rt rvc','CL�u�.TC,rV8I1 WI Comm -emu rmur Shlrkllari rrrld dint
rT .11 orals rm. and lll:h bPr*J T rlr'1d.W1lrFJIIW 4I5:41 iiI wr.
1/27/2021
23. Site dat:rslni or aiddlli'Jiuil well delimit?.
Ycn1 1I1Hs use Ilse hick .ul drla page to provide addilicsl,ul ,h.ell site details or well
construction derails. You nun also Milo 1i aildiromiat Iwb'c d hxwcsSan .
;iu1 uRlrf7 Ai. LNb11.1CTIoNS.
2da. Len( All Wells. Siihaol this Form with 3U dal' of z uipler,00 of well
construction to the hollowing.
hind.Fla ul'VYIlirrRenni :es, Information Pencrsxiog Gull,
1.817 hlblt Sersire CeLIcr, Raleigh, NC 27691P-1617
24h.. For ditiaitm YWIA ONLY: hi addition to aeladitlg Ilse farm to the iiddress Pik
a�eab04•e. a1si+ suLliaii1 a copy of tills. form uiiLlui 101 dates of r:alllpletiair of well
construction to (he fal.lOhviu .
Division of Water Resources, lrndctgrnnnd 1njerlIoi Control Program,
1.8.16 Halt Service Center. Raleigh, NC 27tW9-1 I36
2 iL Far Wire:F.54RPI} IDj1FEt pi Wile.
Also submit sire cop). of ibis FLAW, u 1CLuil ;o days of comF+ietiopF uF
tircll cnosinicitnn co ILle crmiim him i1til AlepplriiTxnl or air criu*i wi
coral -tiered
rarin trii -I
'win n Iarc' II II:F L'Ictmii iiE III LFII lhr IwI 111
a lei LIILui ml Jtesoluctfi - DPE1611.i1.1%Waier klimaF
KeirLSCA1 Aug= 11.11:I

WELL CONSITRUC CON RECORD
Thy fonrl+nu be 1lsfld roc sll gk +Ir mull irk hs erl5
1. Welt Contractor Information:
1F'ar fnic'Mill Li Se D1,11.V
Brian Ewing
WOL CnIJf;I41LT N+IrrnC
4240-B
N C Well Cool{,icior Carliihmtiul1 Nii rti
SAEDACCO Inc
? . V4'e14 irtmatrl,ctian Pernik 1:; Wi0300399; 70002483
liuul2 opvllruhlr 0.YirPrrmir4lr-r.. G iltnty SLtlr_Y'aridlLr 1rofortrar#. h-.1
3. Will Vac tehcidc well MO
Water Supply Weil:
1:10eottrattal Iifealiog'Coaling 5upphl•
I' 1lndusitia fCortrnercial
❑ ImgaIinn
Olvirrliicipal/Public
rlFktsfdennml Water Sunk! aSinfJcl
I-lRcsidentrml Water Supply ts]'Iarodi
NIPP-Waer Supply Well:
❑ Woo Imam 1=11 a}> '
Eil4`r11tr1I V- IL,
r1 Ad111ifCr Recii 1r'ge
pAtinirer 9torm8c ald Ttecr135er,r
❑ AgpiF r 7�6I
❑ EN rimCruR1 Ttchn€ togi.'
❑ Ci uihermal iCluset Loopr
❑ Gtorheriunl iFleciuri JC'nolinn Retuiihl
DS.alini1% 13arricr
❑ p' orrowsiler ErRia.2ga
❑511r3GhdC11CC C'aryr{ll
❑ Tracer
®011oerIiipiuluIiimkt/21 Ren1u11c,r]
. D:Iti• Welksi Crjilrlrlered; 1/13/21 Well Mt A26
5:1_ %idI Lalrathrn:
Remediation Management Service Company
I. • I i 1 ! [if rq'pli:irbler
2650 Shenandoah Ave., Charlotte, NC, 28205
PIi v.cIII Addrea City _ ;md Zip
Mecklenburg 12710204
CVwmJ1 Pieecllrll'iuifle.iu511Nn rR1N1
ih. T:trmihasinand lJngltrrrhr In rlcpncearinlirrµte1Ili4 nnrls nr der'imil et•egro2s;
d tali field Ink' Li'loj is +JIrIUCkiu
35.210533 N-80.801887 '
9. Is lmri) Ibi 1+lrIPIji. ❑Perm>rnrnl Li 211'moron'
7. Is this a rrpair iu an rhriodll iotrait: 011ie or El blip
+
{rebel rr Ir rriNllr..fig Jr r?N+II1J war coromf+Hi fr1'r1 rlrilJ'T+Jlfl+lkl +IN'i I' Srlrf+tJ1 111...11.044r r Ire r(Ir
rr,4rlrr ulaLN 2r11 rrei r2t5 Y[ eJran 1Jr r41 der hack rtr Mrs form!.
S. Number of welbt cnielrrueeed: 1 _
F it criatfontc .1r0 uHal W rrrn'J-Irxrrr IIgAIq ' Ire'la ONLY lI'.rh rrlr WNW enrrarnreri,r+r
_5dI�5'Ilrr RAC fiJnu.
9.1'001 wan depth below land surface 20
ror I'NIHrprl' r11'yr1r, 1hifiArect1'Jr{rMtrdh-- 7iF:i".10' aAIr17 ;IVO
1♦0. SiStIE water level belie* nip of cuaiu1
fI I141+I'1. k ir.I 9 Mom.. Luiri; a.r' •'
I 1. 5"
12. Well curitinrctipii iniellirul: DRIVEN
(fl.l
c I.C. Airger. roan . i-0hlc, dlTeclelkEILerc.r
FOIl WATER sUPPJ.YWELLS ONLY;
I.la. Yield %rpaml of t er
I.113, Llisiorectiiia rapt: 4muuut:
14. WAIIk 2.01,11s
RCN 11n
R!_SI'HIP IJl1'
It.
Its
t5. {MJT R CASiliC «llr Ir1u11I-F ieil nab) OR L 7PiRR (rT amaRcahkh
FROM I TD err 1 IrFTFR TPPICKNFM,.
0 tL. j 12' 8,
I ik IN}iR4 L'rLSINC on 7T)91f11iivI.trerirlrarrl�r1l.11rlp_.
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" Jo,
NA
TD Pr.#MFI1?R J JiI,fjTtdra
20' I1. 1.5"
..
NA
NATIENTAI
Steel
THIClistSi
NA
m. rittirm.
Steel
IL
It.
Ii
it tiROIT
RAOi1
I it
RnTeltPM. F.#trLI. Mk4TlIIT.nomLaAMOUNT
ti.
n.
rt+
r4-
rr.
IL
19. 5.4.14W4.RAVPL PAC. I+r rgyllicibk}
R.
7E3
II,
1JI FE Hd II.
I[irEH_1( r %Ir*c1''dlmehgr1
{
II.
11, DRILLING LOG I nliich iddllionxl' both if iceman
FROM
0 fl,
Ii.
TO
20' fr.
IL
DPW-REPT:OJNiIBuhr,l,inihn+,R'Itnriki5Rra' tr,OK.I
R.
IL
tL
It
Ic.
It.
R-
IL,
Temporary injection point through DPT tooling
2/_ Cer irrrcationf
Brian Ewing
SiErrnurg a Fecal red W c8 Couurb'rur Dtec
AT ST*111.4 drrLY )rune• t rrrr.+b' ei0105' rMw rNJY 1A-10.1 u rY aI l J twrl5rrireirel Ire ve.ervmmlr
II'JtA 1 •bl rirCAC 07C .0frrr ry ?rt f'c'+1CL�i�LTC,(i18f2 l44 I Y I)Jrrrrirptur Shlrkllari Wend riLU o
rT .11 orals rm. and ,Jii &Mu prrrr'Ifi.W1 rya' Au 4I1r+i1 rrrwwr.
1/27/2021
23. Site d'usgrslni or riddtti'Jlrul well debility.
Ycn1 rl1Hs ,kSJ: die hick .ul fills IJQge to provide addiliol,ul i ell site ddails or well
construction derails. You nun also Mind ai1dirrfdml Iwb'c d h,ewcsSan .
;iu BRlrf7 Ai. LNb11.1CTIoNS.
Lb. Len( All Wr,ik Suhmel this Form with 3U dale of L+ampler,00 of well
construction La the Following.
hind.%Fla ill WIlirrResources, Information Pi -sensing Grill,
1A17 hlbll Sersire CeLIcr, Raleigh, NC 27691P-1617
24h.. For [uieciitm We319 ONLY: hi addition to aeladilig Ilse farm to floe iiddress Pik
a�eab04•e. area+ SuLliai1 a copy of tills form uiiLlui 101 dates of CaanIpluticith of well
c n IJ'I KLfuu lb (he fa t+Veiu .
Division of Water Resources, lrndctgrnund 1njr:elIalr Control Program,
1.836 Halt Service Center. Raleigh, NC 27fi94..1839
2.3L Farr Wit °.54RPL} Inj1Etiim Wile.
Also sublr'llit one cop). of chi& fl,rn, u IChir1 ;o days of ccMF+ietiopF uF
tircll cnoglrlrrttnn co IL1e cn,iit} him i1iil Ilepplrt,lxnl or air cpiu*i whit=
coral -tiered
rarin trii -I
'win n Iarc' II Ina L'.. pmtmii iiE nl bp, II 1r5r IIJIYe111
alrl NaLuiml itesaiactfi - DPE1011.f1.1% aicr klim LF
KeirLSCA1 Aug= 11.11:I

WELL CONSTRUC CON RECORD
Thy fonrl+nu be asfld cog sIiig}c .Ir mill lid: hw ells
1. W.11 Cuntr'ricti.r Inform/dime
1F'ar fnic'Mill Li Se D1,11.V
Brian Ewing
rli Crolnwlur Nara
4240-B
NC Well Co ulr,Icior Carl iiimLiul1 M1iinbcr
SAEDACCO Inc
V41I 1raDatrnctiun Perra4k 1:; F10300399; 70002483
lireld2 opvlfruhlr L'.rlrPrrmil4 iLr.. 1rlJrennri o-.l
Wril Ilse trim& well iI�
Water Supply 4IeIL-
ClAgrE€tIItLlrlil
IJCreolli nwI lifealiogsCoaling 5upphl•
I' Iledusiria fCantreercial
❑ Tropisms
L1M iicipal/Plrhlic
rlR sidcllnlll Water' Sunk! aSinfJcl
I-1Rcsidenu,ll Water Supply is]'Iarodf
NIla-WaIcr Supply Well:
❑hioniloiine ❑lea}> '
Eiji:ri9iii V- Ik
r1Ad111ifir Reci151r re
pAtinircr 9tormc ald Ttecrt3ler,r
❑ AgpirFr 7�61
❑ EN rimCluR1 Ttclin€ logs..
❑ Geothermal iClused Lisopi
❑ Geothertltal iilentiir JC'nolitl Rutuilll
0 7rensodwaler pk'rm1.4111ms
DSalinits 13arritr
❑ A' orrn5rlrler Er00.2gc
❑ IILN ikC11CC caul rui
❑ Tratier
®Oilier 4lr�Eiuiil Mkt 121 Reteurks]
4. NNW V4'eIICsl Crjrlrlrlel€tl; 1/13/21 We.11 Mgr A14
i.L. %fell Larrathon:
Remediation Management Service Company
I. . .1 I i I ! rif rrepli:rlble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIiv .cIiI Addrea City_ ;md Zip
Mecklenburg 12710204
VwmJ1 } ii 1 I ieiu9Eleiuol, Nn rP1N1
ih. 1.411basinired lJ.gttnrhr In depIx•eaElnhimrtelilccnnrls nr decimal rkt rersf;
d s rli Add Ink' Li '1oj Js strnekm
35.210533 N-80.801887 '
9. Is lmri) the VIrIPIji. ❑Perm>rnrnl Li 211'moron'
't 7. Is this a rrpair iu an rhriodll iow tlb � 'rs or ®hlu
+
{rill ri Ii Ir lriNllr. •i rrii F rtNriI1J Ir'1'flr4rMlril1 i'rI dlrll J'TrJrrIJIJJI ilri I'irlrrjrJr rA I' loll' rr IIr r(Ir
rr,4drr uldifef set.li a ur [41 der hack rtr Mrs form!.
S. Number of well cniiirrnieeed: 1 _
l .r uwitionre lr06u40.11 ret1 - I r.VPd, r .141Atift Ireta LIMA lI r11 role WNW cMrrrnrethilr
_wirwiI rRACfiJnu.
9. TOW wan depth beim land surface 20
r,wr I'NIHr�rJI' N'i'iJt 11rlr irh fii'L r+r7 thifi erect 16.terrrtldre- 7* ' arI l 7 ;IVO
10. SUStIE water level below nip of l'usiu1
▪ I141+I'1. k i ri 14 Mom.. Luiri; lr.r' •'
11. ISai ilk II1jnieltr 1. 5"
tJrul �,.IN
12. Well curettntctipii insetlimdl: DRIVEN
iri.
ffLI
c I.c rorger, rouwv. i-0hIr, dlirdl elkEILelc.r
FOIl WATER sUPPJ.YWELLS ONLY;
I.1a Yield Want of t er:
1313, L1i.Jnrectiiia rapt: 4muuut:
14 WAIIk V..01,11s
IRIDid 111;
DEW' HIP IJl1'
rt.
t5. {MJT R CASFNC {nrr rrou11I-F ieil ii Ni) OR L 7PiRR lit apOlcahkh
FROM I TD PR IrFTFR TIIICKNFM,.
0 rL, j 12' f1,
I 2Er IN}10 L'lLSINC Ion'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" Jo,
NA
TD PlArla I1?ir J JiI,tFT/lls
20' r1. 1.5"
..
NA
IIAPENTAI
Steel
THILIk!rPv4
NA
m. rIttirs1,
Steel
I€.
rt.
fill
it tiR01T
RAOi1
1st
RnTE1tPM. F.#trLIIVEMk4TMIT. nomLaAMOUNT
re.
n,
it.
r4
rr.
IL
24, ! WI;RAVPL PAC. I+r dywlicibk}
Casks
R.
T[r
II,
1JI FL
KS17.1_1( F%Ir*c1' ulme11•gn
{
(I.
311, DRILLING LOG I nlrich iddllionxl 4both if merman I
FROM
0 fl,
TO
20' fs.
IL
DP.Wrl[IFT:OJNi Isuhr.i nine.., RIIII'nKki5Rr. a'Iii 4r, OK.I
rt.
14
IL
IrL
rt
Ic.
IL,
It.
IR-
/L,IleriLlatb4
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
SiErmurg aFecal lied WcatCouurb'rur Dacc
AT MT*111. 4 drhr frMrl• I rrrr.'b1' erM0r7I rllw rNAY i1'rd2181 u rY aI l J tY.O.V.trirelea err.0.ra'rvmmune
u'JtA l •bl rirCAC 07C .Ofrrrr ry i ?rl Nr.',1CL�G�.TC,(V8f11%.4' Y I)Jrrrrirptur Shlrk>'ari nand riLU o
rT .11 orals rm. and ili:h bPr*J plrlr'Ifl.Wl ha' Au il,r+J1 iiI wr.
1/27/2021
23. Site dus.grslni or addlti'Jiull well delimits:
Yuu rl1Hs stye Ilia Ll;icL of fills pow to provide addiliol,iih i ell site ddiils or well
construction i1t LuEr. You nun also Mod;E[1diisoint isnLxs d rexcsSan .
;iuurcLIT Au. LNb11.1CTIoNS.
lda. I iir All Wr,ik Suhami this Form with 3U dale of z uipldloo of welt
construction to the Foliomrl
;IMAMS isf Wafer Resources, Intlrrmmiluu Pencrss.iog Gull,
1617 blab Sersire CeLIcr, Raleigh, NC 27699-1617
For [uiectitm YWIA ONLY: Ili addition to aeladitlg Ilie Fornl to floe :Iddr> S Pik
a�eob04•e. ales+ suhiiiii a copy of tills. form uiiLlui 101 dates of Lliampluticisk of well
construction Its (he fuUDINiu .
IT islen of Water Resources, lrndcrgrnund 1njr:rlIoi Control Program,
1.8.16 Halt Seance Center. Raleigh, NC 27694463n
2.3L For Wit ...54RpI} Iojrit1). WOW
Also submit owe cop). of this fuln, u Itlliu ;o chars of completion uF
tircll cnoglrlrrttnn co tLle cniip0 1141i101 Ilepplr inen1 Dr air county rellcm
cowlnlclod
rarin trii -I
e' f n h arc' II Ina Lmiarsivam III L III1r5r men
mid LIILWckl iteraiactfi - l rvGlaunl'1'.11er 11.m JLrem
KeirLuCd Alva 11.11:I

WELL CONSITRUC CON RECORD
Thy fonrlvan be lwad rue shigk .'i m1111 lrk hw ell5
1. W.11 Cuntr'ricti.r Inform/ilium
1F'ar frOcmill USe D1,11.V
Brian Ewing
▪ Crot 4rurHirn
4240-B
N C Well COiiicicior C'cr1i k Liun M1hanbcr
SAEDACCO Inc
? . V4'e14 t aDatrnctiun Perra4k 1:; F10300399; 70002483
liuul2 opvllruhlr 0.YirPrrmil4lLt. G iltnty SLtlr_Y'yri+lLr 1.9fannri. h-.1
Wril Ilse tetrad well MO
Water Supply Weil:
rlcilltLlril
IJCreolii nwI lifeariogJ'Coaling 5upp]}l
I' Ilndusiria fCantrllercial
I:tropisms
Llhililiil.iperlllhlic
rl Fktsfdennill Wti€cF Sunk. a Si nLdel
I-1Rcsidenlr,ll Water Supply is]'1arodf
ewer: -Wake Supply Well:
❑hionilorine ❑lea} 7'
Eiji:ri9iii V- Ik
r1Ad111ifir Rectiktpre
pAtinirer 5tormc ald Ttccrtimn'
❑ AgpiFFr 7�6I
❑ EN rimCluf1 Ttclrnt}L.3e}'
❑ Clauthermal iCluerd Looph
❑ Geotlicltrial illes,uii Cnsslin Rutliiill
Qttronodwaler Rum-1.4111w!
DSalinits l artacr
❑ A' orrewsier ErryjlI
❑ IILN i1C11CC caul rui
❑ Tratier
®Oilier iucpiuiil outlet. /21 Rentorks]
. D:Ih' We1ICxt Completed; 1/13/21 Well TotAl2
i.L. %fell I.urathirn:
Remediation Management Service Company
I. • I i' ! of rll'pI iiL'IC6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;md Zip
Mecklenburg 12710204
CINALD } ii 1likaiileiuuii Nn fP1N?
ih. LoIlbssinind laangltnrhr In deprx•earinhimrteskccnnrls nr rtecimol rkt rersf;
dtali IkId Int' LialativJstr,Mtkiui.
35.210533 (-80.801887 '
(1. Is Imri) Ihi 1+IrIPIji. ❑Perilla M111 Li 211'moron'
7. Is r xll this a rrpair iu tm iodiotrait: 't'rs or ®hlo
+
{rillr; la Ir l.» ilr.•i l Nrr r'FlrriIW i1 lfI rlJ.7fil1 i'rl llrrlJ'TlJrflJi i iiri I'SrlrrltJr rIII' lI l' rr Ire r11r
rr,4drr ulaLN!11 rrei rJ:h Y[eJrna ur c41 der hack el? Mrs form..
S. Number of well tniillrrueeed: 1 _
Fair Darts* lr06u 0.11 W Nret1-i &r .1LIMA lI r11 role WNW cMrrrnrethilr
_5dirmlrr RAC)'iJ ii.
9. 7urial wan depth beim land surface 20
fie urionp1l' tart rii'L r1d7 tfititdrect 16.terrrtrdre- *ND' aAIr17 ;IVO
11F0. SUStIE water' level below mittu mitt Irkcsiu1
i+ I14NI'r k'r•ri 14 Mom.. Lwri; ll.r' •'
11. Ilur elk ell eltr' 1. 5"
12. Well eurettntslipir rwetliiul: DRIVEN
iri,t
ffLI
c 1.c rorger, rou v, i-0hIr, (limo elkEILelc.r
FOIl WATER sUPPJ.YWELLS ONLY;
II Yield Want rIf t er
I.113, biilnfartiva riper 4muuut:
14 WAII k tO L
FaDid 111;
D!_SI'HIP 1'Jl1'
It.
Its
t5. {MJT R CASFNC «llr Ir1u11I-F ieil w.1:M1) OR L 7PiRR lit appJRcahkh
FROM I TD PR IrFTFR TIIICKNFM,.
0 IL. j 12' f1,
I 2Er IN}iR4 L'lLSINC Ion'r_t)91niirivr.r4rir[I�[rarup_.
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
to
Ir,
n,
1.5" Jo,
NA
TD PrArkTFI1?R J JiI,tF dWi
20' 11. 1.5"
I.
NA
11.iTEN TAI
Steel
THICl skSi
NA
mikrIttirm.
Steel
IL
It.
fit
it tiR01T
RAOi1
I sl
Rik [Eltli[. F. tFL1C Mk 4Tlllr.nomL JL AMOUNT
It.
n,
t4
ir.
IL
24, S)lNbtfiRAVPL PA€ /.I+r dywlicibk}
R.
T[r
II,
,JI FE HLl1.
I[ilr'l .1( F %Ir *c 1' ulm a 11•gn
{
Id.
11, DRILLING LOG I nliach iddllionxl 4both if merman I
FROM
0 f1,
Ii.
TO
20 ' rl,
IL
DP.Wrhtlel:OJ N IBuhr,i irdhyr+ 4µ'nIckhh Rr a'Iii 4r, OK.I
R.
14
IL
IL
It
Ic.
IL,
It.
R-
IL,
11. BCA1 #1;1i7,
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
SitPmurg aFecal lied WcitCouulb'rur Dacc
AT ST*111.4 drhr frrtrrk I rrrr.'bi' ei0105' rllw rliY ish-QN u rY aI l J t41uw ireirtL err ve.ervmmlr
u'Jrrr 1 •bi rirCAC 07C .0f140 nJ. ?rl #'t'r1CL�u�.'C,(V8t1 WI Y rwrrrrnrpsur Shirk>'ari rrrlt4 dint r'gn orals rr'r'nnd 1lr:h bPr*J plrlr'rfl.W1 ha' Au 4I1:1J1 iIwwr.
1/27/2021
23. Site dus.grslni or addlti'Jiuil well delimit?.
Yuu r11Hs use tole b icL .ul dohs pow to provide addilissnul i ell site ddiils or welt
construction Iklails. You nun ulso Mod acklilrsfuut tajges r1 hxwcsSan .
;i11 BRICf I Ai. LNs1 .1CTIONS.
Na. I iir All Wells. Suhaml this torn with 3U dale of courplerroo of welt
construction to the folkohrlrl4.
;IMAMS ul'Wafer Resources, Inr.irmmiluu Priderss.iog Gull,
1617 Malt Sersire CeLIcr, Raleigh, NC 27699-1617
241.. For [uiectitm YWIA ONLY: 1n addition to aeladitlg Ilie faun to floe :Iddaces ui
a�eab04•e. ales+ suhiiiii a copy of tills. form uiiLlui 101 dates of Canlplutiair of well
construction bake fuUDVeiU .
IT horn of Water Resources, lrndcrgrnund 1njr:eliois Control Program,
1639 Halt Service Center. Raleigh, NC 27694-1639
2.3L For Wiit °.54RPl} Iojraiiiie WOW
Also sublr'llit o11e cop). of this- fuou u Itlliil ;o days of complelioll uF
tircll cnoglrlrrttnn co tL1e crrliit} 1101101 sleporlinenl Dr air county relserc
coral -lured
rarin 1.rii -I
wFn n t arc' a 1nr Lr lrursii iiE III EFII1r,n1J11c11r
mid Nmurll iteraiRCtfi - DPSS1011. aicr klimuLF
Kelaged Alva 11.11;1

WELL CONSITRUC CON RECORD
Thy fonrl+nu be awad cog 5I1u k +Iw rr11111 Irk hs ell5
1. Welt Curltrnctur Inform/dime
1F'ar frOcmill 4ic D141.V
Brian Ewing
▪ Crotim lur H irn
4240-B
❑ C Well Cou1{,icior Carliiimtiun Numi i
SAEDACCO Inc
▪ W'e1I (wis rl,ctiun Pernik O; RI0300399; 70002483
liuuli oglilruhlr 0.YirPrrmil4lr-r.. G iltnty Slap_ Y'yri+lLr 1r 9rt'Or#. h-.1
Wril Ilse trim& well iIi
Water Supply Weil:
ClAgr citltLlril
IJCreolii nwI lifealiogiCoaling Stipp]}l
I' lledustria fCantreercial
❑ hnipi nn
L1M iicipal/Plrhlic
CJ Fktsfdenni l Water' Suppak a €i n fJcl
I-lRcsidenb,ol Water Supply ts]'Iarodf
ewer: -Wake S+upp1}' Well:
❑hionilorine 1=11 a} 7'
It1�4rllskll krIk
r1Ad111ifCr Rectiapite
rorptircr 9tormc and RecillM ,r
❑ AgpirFr 7�61
❑ EN rimCluR1 Ttclin log
❑ Ci ulhermal iClused Low
❑ Geother ial iFlentitr JC•noliri Rr<tuilll
4. Date Welikst CunillItled; 1/13/21
i.L. %fell l.11rmtturn:
Qttrolaoddwater 1{ellrcdu111w!
DSalinits 13ar ricr
❑ A' orrnyialler ErRia.2ga
❑511hGhdC11CC C'ahyr{ll
❑ Tracer
l O11Ler �ucpluiil Linder /21 Remarks)
Well fIrmr A3
Remediation Management Service Company
I'. .I Ii.!.if
lrr'PI1:nbIC6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;md Zip
Mecklenburg 12710204
t'gruril Prldecl Ideiuirlciuol, Nn fP1Nl
ih. f:inilu r>rnd I J.l1gltnlh In Ilcpncearinlirrµte1Ili4 nnrls nr der'imol rkt rrr4.;
i d t rli Add Int' Li '1oj Js strfUCkin
35.210533 (-80.801887 4Y
fr. Is Imri) the lhlrIPIji. ❑I'erillanral Li 211'moron'
7. Is this a rrpair iu an r7riodrl iowait: oyes or MIND
+
{rill ri Ii Ir lriNllr. •i rrii F 0.4.91.0 i1 lflcorlJ.7'IFI.Trr.rl llrll J.TJJ.rIJIJJI liN.i I'irlrrlm rA.' ll.lrNr r Ire ri1r
rr,4drrul(Lifef i rrei rlt5 set.liaa ur tYl der hack err Mrs form!.
S. Number of welly consrrueeed: 1 _
t er uwitinsrc orrjes'uilal W rire-Irxwr .1•11Atift LIMA lr.r11 rllr WNW iv rrnreri,Nr
_5d1�5ulrr RAC fiJnu.
9.1W wan depth beim land surface 19
for 1.0.1041. thifi erect 16.terrrtrdre- 7 17 aAIr17 ;J70rt
10. SUStIE water level below nip of l'usiu1
it IV/NH k''.ri 14 arl'rlua' L ire,; a.L' ".
11. F1ar 1Ytlk illrmrrltr 1. 5"
12. Well csiestintctiart Ir11etlitud: DRIVEN
tJrul �,.IN
(rt.
(rLI
cl.¢, rorgcr, antral. i-0hlc, dlle0 elkEILeK.r
FOIl WATER SUPPJ.Y WELLS ONLY;
I.la. Yield Want of Ir.st:
1313, bi loraetiva rape: 4muuut:
1.4 Vat= 2.0141s
IRIDid 111r
D!_tir HIP IJl1,,
rt.
t5. OIJTHR CASFNC Illlr Inu11I-F ieil nab) OR L FfER lit apOlcahkh
FROM 11TI PRMFTFR TIP1(10454
0 11' j 11' fi,
I 2Er LN}1R cot:SINc on Tt)9mci itrerirlrall rll.lrup_.
k FROM TO DLk41ESFR TDICI:lIESS MATE.1119i
Cn
II,
n,
1.5" Jo,
NA
T1} pr. lTlilla J :or stirs'
19' 11. 1.5"
I.
NA
THIr 1,1
NA
IIATIENTAI
Steel
m. rllkrsl,
Steel
IL
rt.
I.
TN, GROUT
RAOii
1st
Nn [Eltli[. F. tFL1i�Mk 4TAILnomL a AMOUNT
rt.
n,
r4
r4
rr.
IL
24, S)lNWI;RAVPL PAC. I+r dyllicibk}
rpsl�I
R.
Trr
1JI FL HLII.
l[irr'1.1( Fur *r 1' ulm e1.1.gn
{
11, DRILLING LOG I Attach iddllion it wbotifl if merman
n I
FROM
0 fl.
r.
TO
19' ft.
IL
DP.Wrhtlen:OJNi IF r,,.Mrdhy.+, R.14'rKkhh Rr• a'In 4r, OK.
r1.
14
It_
IL
It
Ic
IL,
It.
IR-
altriLlk.100
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
SieshourgaFecal lied Wc8Coiin rur Nee
AT MTlr'JI1.4 drhr frrFnll, 1 rrer.'b.' trMfr7I' Mull rliz i1'rd0.1 IIrrY JI,l J t41115f ireiraa Ire .0ItY'rimd lr
ll'JtA 1.Il riCAC OTC .Ofrrrl ru. i TA Nt','CL�G�22C,(V8IW1 I Y I>+rrrrNi rmur Srmria'an s nand i o
rTrl.1 orals rm. and AmbrrrIu plrlVld.Wl IrFJIIW 4I1:1J1 iIwwr.
1/27/2021
23. Site diagr'slni or addtti'Jiimil well delimit?.
Yuu Fluky 1k IIIe brick uI fills pow to provide addilis)l,ul ,yell site ddiils or well
construction i1m LuEr. You nun also Mind ac1dilrftmt twb'is d hxses#tin .
;ill llRiCf7 Ai, LNb11.1C IONS
lda. ihlr All Wells. Suhami this Form wiles 3U dale of courpletloo of welt
construction to the rblkono
ii11: sills "Mawr Resources, Intlrrmmiluu Precr:sxlag Gull,
1617 Malt Semler CeLlcr, Raleigh, NC 27699-1617
For [uieciilm YWIA ONLY: In :Lddiliolo Ie sending Ilse Fo€nJ to floe :Idd aces ui
a�eobo4e. ales+ suhiiii1 a copy of tills. form uiiLlui 101 dates of Llampluticisk of well
construction bale faLlowiu .
Dh illrwl of Water Resources, lrndcrgrnund 1njr:eliml Control Program,
1.8.16 Halt Service Center. Raleigh, NC 27694•.1639
2 iL Far Water.54RpI} lateen). Weil!.
Also sublr'llit sire copal• of Ali . fuln, u Itliiu ;r8 days of com1leiivn uF
tircll cnoglrlrrttnn co IL1e criiiim 1101101 llepp1nimN11 or air county Isla.=
coral -tiered
rarin Ceti -I
Isms n t an' II Ina LJ Imtr ii JIL III LI II 1FS0Iwrcul
mid Nmuill Jtesoluctfi - DPSS 1011 n1%Warr Ilmni.rcL
t#[h'L9Cd Alva 11111:1

WELL CONSTRUCUON RECORD
Thy fonrl+nu tic 1I5cii cog 5Iiiirk enlal rk,serl5
1. Welt Curltrnctur Il,trurtridrliont
1F'ar FrOcmill USe D141.V
Brian Ewing
▪ dl Carr tnwI 'T NarrnC
4240-B
NC Well Co ulr,Icior Carl iihmtiun tkiirti
SAEDACCO Inc
? . V4'e14 traoatnictiun Pernik wi0300399; 70002483
liudin opvilruhlr wv/t vrmil4lr-r.. G iltnty SLtlr_ lcaridice Pea -Um 1.11-.0
3. Wr I Use trim& wall M
Water Supply Vied:
Clt rcIIItLIral
UCreolli nwI IJiaaliogrCoaling 5upp]}l
I' Ilndusi,ia fCantrnerciak
❑ hnipi nn
L1hJIllriwipctlllhkic
r1R46idr:llnlll WtirorSunk! aSiIIfJcl
I-lRcsidentiol Water Supply is]'Iared
NIrP-Water S1upp1}' Wdl:
❑klcmiloriuc 1=11 a}> '
Eiji:I/ 1Ir1I V- Ik
rlAdlllifir Recti51ri[e
pArinircr 9tor.gc aid Ttccn� cr'
❑ AgpirFr 7�61
❑ EN rimcNR1 TgC1rn6Lw3 '
❑ Ci ulhermal iCluted Ltnlpt
❑ Geotheitrial iFlesluilgfenolitl Rrtuitll
❑ 7romdwaler p,k'rnCtlimit:r!
D5511ini13 13arncr
❑ p' orrowsiler ErRia
❑ti111WcieilCe C'arllr{ll
❑ 'soar
®O111er iucpiuiil birder /21 Mere/irks)
. D:It Wellkst Crjtlrlrlel€t1; 1/13/21 Well Mt A21
5a_ %fell L.III:Lthrn:
Remediation Management Service Company
I. • [if rrr'pli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea Cirt_ ;m d Zip
Mecklenburg 12710204
1~Vwm 11 t3llrcl ILII'Iuifleiuuii Nn fR1N1
ih. T:inil uirold Lting[tntir nr derimol rkgro2s;
idt rli field Int' LIUIativ stribtkiui.
35.210533 (-80.801887 '
9. k lore) IOi ur 211'moron'
7. Is thin a rrpair iu an rsiodil iowrit: �11'rs or El Nip
+
{rillri Ii Ir lriNllr.•i l ii F �TNrIIW i1 lflcorlJ.7'IFIITrr'rl llrllJ'TlJ'flJlkl iiri I'irlrflrJr rAI' llllrNrr IIr ri1r
rr,4drr uIdL.i'!1i remark.. Y[eJrarr LW All lilt hack rtr Mrs fr'rJu.
S. ihluuLbet of well rnielrrueeed: 1 _
i r iirddr Vte OrrjeSuilmll W rire-Irxrrr J•IIf •e ONLY Ir.r11 rllr WNW iv rrrnreri,ilr
_5dlra'II2r RAC fiJnu.
9.1'0101 wall depth helm lima surface 19
for i.0.1rp1I' lfifiArect 16.ter' ijdre- 7 ;J71lrl
14. Siitkk water level iicluw nip ref
iculiu1
f IV/NH k''.ri it Mom.. L iri,; dl.L' ".
1. F1ar 1Yr11rt iIIjnicltr 1. 5"
tJrul �,.IN
12. Well tniattntvtipli rnetlindd: DRIVEN
(ri, t
(ILI
cI.c Airger, roinn. i-0hlc, dlTeclelkEILerc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa Yield Igparit of
111r, M.9ilar ua ripe: 4muuut:
1.4 WM=t0 115
RCN l 1n
R!_tir'HIP IJl1',
rt.
rt�
t5. {MJT R CASiliC «llr rlru111-aieiI nab) OR L FfER (it amaRcahkh
FIiO rl 1111 PR ITTFR TIIICKNFM4
0 i j 11' fi,
I 2fir LN}1R cot:SINc on T1)9mci iirl!ririraIll�r1l.11rlp_.
k FROM TO DtiAlESFR TDICKl§ESS MALE JAL
n,
1.5" Jo.
NA
lli orArrr r'Illt J $ I:or L lls.
19' 11, 1.5"
NA
11.i1F•NTAI
Steel
THIr lk!rPv4
NA
m. rllkrsl.
Steel
IL
rt.
71. CIROrT
RAOi1
I r7
Nn[Fill"". ! F.#trLI. Mk4Tlllr.nomLaAMOtINT
rt.
n.
r4
rr.
IL
24, S)lNWI;RAVPL PAC. I+r dyllicibk}
Trr
1JI FL HLII.
LrirEl _1( r rn *r l''dime 11.gn
{
(I.
11, DRILLING LOG I riiich iddllionxl rbotifl it rreemary I
FROM
0 II.
TO
19' fi.
IL
DP.WrltEPllilNIBuhr,1'trdhw. RIL'rKkilRr•ctInwir,OK. I
rt.
14
IL
IL
it
tf-
Ft-
arriLlatb4
Temporary injection point through DPT tooling
2/_ ('crllfreatiom
Brian Ewing
Sieshourg a f chcni red W c8 Couurbrur Nee
AT ST41111.4 2PLY frMrl, I rrrr.'bi' ei0105' algid rliz lved{ IIrrY JI,l J t41115f ireirdL Ire.0.e.erimavir:'
u'JtA l •Il rifCAC OTC .Ofrrrl ru. i TA ivc',1CL�i�LTC,(il�li l44 I t I)Jrrrrirrnur Siorida,i nand i o
rTr�J1 orals rm. and Ambr,r,J plrll'Id.WI lFFJIIW 4I1LJ1 iIwwr.
1/27/2021
23. Site ditioslni or ad dtti'Jiimil well delimit?.
Ycn1 Alai ,LSO ate L ac6 +af digs "rage to provide addilionUh i ell site details or wel L
r0IiSIrim;Lluli Ilelails. Yoti Hul% uls(5 Ara ;E 1 iirfuur twb'es rL r,cwcsSan .
;iu BRIT. I"1 AI. LN.S11Jc IONS
lda. Len( All Wrik Suhaoi ills Farm wires 3U dale of courpkdmoo of welt
cousrnlcttpn to the rblkohri[l
1Fl►isFia ill Wycrrkr!IuurcrS, Intlrrmmiluu Pni rss.iog Gull,
1617 MAil Sersire Ctmier, Raleigh, NC 27699-1617
241. Farr [uiectiim We3b ONLY: In addition to aetrdillg the rofnl to Ilre :Iddr ss Pik
a�e�bo4'e. sisal suhiiiii a copy of tills. try uiiLlui 10 dlks of COmpluticith of vcc ll
co struKLlurl ILl the IaL]Ohviu .
Filet ialrwt of Ware Resources. lrndcrgrnurtd 1njr:riIalr Cunrrok Program,
16.36 Halt Service Center. Raleigh, NC 27iW4•.1836
2.3L Fur Wir4.°.54pp1. ! Iojl'i ion 'WOW
Also submit sire cop). of Ali . ruin, u Itltru ;8 days of i c?Mi1+ieliopF uF
Ircll cnolllrlrrttnn co tLle criiiim 1101101 ileporOrienl or air c iiu*i 'whim
conilnlcrcd
rarin trii -1
wFnnt ari'ulnFL'.lktnii instil LII51r5rIIJII111
aul NaLurll Jtesoluctfi - J7lkrs10111 n1%Warr 1.m.Larc
t#[h'L9Cd {Lg=11.1I;I

WELL CONSTRUCUON RECORD
Thy fonrl+nn bc,wad rec sIIIg}c.1' iii11IEtlle „ergs
1. Wel I' Curltrriet[.r Il,trurtridrliont
1F'ar FrOcmill 4x D1,11.V
Brian Ewing
W d1 {tulip l ur Nara
4240-B
N C Well Coulr,Icior C'crliihmLiun M1iinbcr
SAEDACCO Inc
? . V4'e14 trOristnictieu Perna*, w10300399; 70002483
liu ul2 opvllruhlr wv/f ovrmil4 l r-r.. G iltnty SLtlr_ Y'yridlL 1.9fannri
3. Well Ilse tehcidc well MO
Water Supply Well:
rt,clllttlril
UCreolli nwI Iiteraiog'Coaling 5upp]}l•
I' Ilndusiria fCantrnerciak
❑ Irt nn
L1M iicipal/Plrhlic
rl fk:sidellnlll "Wilier Sunk! l Si RLl..Icl
I-lRcsidentr,ll Water Supply i.s]'Iar'd
NrrP-Wafer S1upp1}' Wd1:
❑hionilorine ❑lea}> '
Eiji:I/arr1I V- Ik
rlAdllrifir Rectik1ri[e
pArinircr 9tormc ald Ttecn� cr'
❑ AgpirFr 7�61
❑ EN rimCNR1 T�clrnnGaet'
❑ JeuiheYmal iCluted Lin1p •
❑ Geotheitrill iilaringfenoliq Rrtuiil}
10 7renoadwaler pk'rmlimi9r!
DSalini1% 13arncr
❑ p' nnewaer Dukni2ga
❑ti1IhGhi1C11Cc caul nil
❑ 'soar
111O11kr 1ia-111iiii niggler /21 Remarks)
4. NNW Wellk0 Crjrlilrlel€nl; 1/14/21 Wel1Mgr A2
{+a_ %fell lall:athln:
Remediation Management Service Company
l • . .1 I i 1 ! rif lrepli nb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;m d Zip
Mecklenburg 12710204
CVwmJ1 } ii 1ldeiu9Eleiuol4 Nn fP1N?
ih.I:Inifltu�riiid IJngttndt' In ikl-`prerthriim4teljlcecnlrrls nr detimol rkitrrra;
ads rli Held Ink' LI01Js strf ekmi.
35.210533 N-80.801887 '
9. l3 lure) Ini 11 rIPIji. ❑eim nral ur 211rInporon'
�11 7. Is thin a rrpair iu an rxiodll iowalk: 'rs or 121h1u
+
{rillrh Ii Ir lriNllr.•i bier rFNriI1J I1'J'flr4roJ.7riHI1.6'rI dlrllJ'TrJrrIJIJJI iiri I'SrlrfJdJr rA1' llll' rr IIr AJlr
rr,4drr uldL.i'! .i remark Y[e•Jrna LW All der hack err Mrs form.
S. PluuLbretof well romarru red: 1 _
F .r iirddr Vote lr06u40l1 W Nre-Irxrrr l ONLY ir.r11 rllr WNW cMrrrnrethilr
_5dI�5'Ilrr RAC fiJnu.
9. 7'lilak wen depth beim lama surface 20
ror I'NIHrp1I' Freif t 11hr ir+l rilq rlr7 tfititdrect 1 .ter' ijdre- 7* ' Ar1r17 ;IVO
1♦0. SUSTIE water level iicluw nip of culillIC
fI I141+I'1. k''.m 9 Mom.. Luiri; a.r' •'
11. llar#2114110 iIIjnrrlcr. 1. 5"
tJrul �,.IN
12. Well i`uniilnnlipii owilind: DRIVEN
fl, I
(fl.I
c I.c rorger. roMPT. cAble. dllecl Itielc.r
FOIl WATER SUPPJ.YWELLS ONLY;
k 10 Yield ligpinl of t erg
I313, 11(.4MA:clilie ripe: 4muuut;
14 Wfti= Molls
RCN l 11I;
R!_tir HIP IJl1'
ft.
ft.
t5. OLITeR CASFNC «llr rlru11I-F ieil nab) OR L N R (it amaRcahkh
FROM I TD PR IrFTFR TPPICKNFM,.
0 11' Jj 12' O.
I 2fir LN}iRr4Lr1SINc Its'r_t)91niiikr.r4rir[I�[rarup_.
k FROM TO Drk'41ESFR TDICKl§ESS MALE JAL
to
9-
n,
1.5" Jo,
NA
T D PrArrrrI1'R J Ji I;or sr i
20' I1. 1.5"
..
NA
11.i1F•RTAI
Steel
THIr lk!rPv4
NA
w. rl[krm.
Steel
IL
rt.
7N, GROW
'FROM.
I r7
RnTE1tPM. F.#trLI. Mk4TMILDiehlaAMOUNT
It.
n.
rt+
r4
rr.
IL
24, ! WfiRAVPL PA€ k. I+r dyllicibk}
T[r
rI ,
1JI FE HLII.
areal _1( r wn *c 1' ul_eppn
{
II,
31, DRILLING LOG I nliach iddllionxl 44Ked1 it neeaaur3 I
FROM
0 fl,
ri.
TO
20' fi.
IL
DP.W-REPT:OJ Ni I,uhr, l,inihn+, R'Iµ'nri k i5 Rr. a'Iii 4r, OK. I
rt.
14
IL
IrL
it
Ic.
Ir,
Ira
R-
IL
24 arM.4.10 i
Temporary injection point through DPT tooling
21. Certification..
Brian Ewing
Signeurg a Fecal God W cit Comm rue Dtec
AT MT41111. 4 drhr frrrnll, I rrcr.+b' ei010I' rllw rl+r irr10.1 14rd JI l J tvusrrirelrtI 4r.0.ra'rvmmune
u'JtA 1 •Il riCAC 07C .0frrrl ry ?r1 f't'r1CL�(J�.:C, V8ti %'W Y I>+rrrrNi rmur SihINe♦ar., rlrld that e
rT .11 orals rm. and llii beau plrlr'Ifl.Wl ha' Au 411r+J1 iiI wr.
1/27/2021
23. Site diagrslni or ad dtti'Jlima,I well delimit?.
Ycn1 rlla, 1k Ile Lack of digs "Page to provide addilionUh ih.e1l site details ur we]L
cortslrvl LLuli Iklails. You nun ulso i li 1i ;E1 ilrmiat twb'es rl in.
;iU BRIT. f7•AI, LNb7 U["f IoNS
2da. l+Iir All Wrik Suhaml ilus Farm wires 3U dal of z uipkdloo of welt
coo$rructtpa tn.the rblkohrltl4.
1Fl►isFia if Wafer Remo rce5, Intlrrmmiluu Pni rss.iog Gall,
1617 Malt Sersire CeLIcr, Raleigh, NC 21699-1611
241. Farr [uieciiim Wedb ONLY: In addition Ie aeladitlg Ilie roam to the :Iddresa ur
a�eab04•s:. mi1s.i suhliri1 a copy of thls. fury uiiLlui iLl dirks of r:alllpletii ii of vcc ll
;symb l:Lluu Iv the FeL]Ohviu .
IT.ialen elf Water Resources, lrnderg nand InjeriIalr Control Program,
1636 Halt Seance Center. Rial Igh, NC 27iW9-1(136
24r For Wir ...54ppl} Iojritlq)e Wile.
Also submit oi,e cop). of Ali . rule, u IFhril ;ro days of coniFileliopF uF
tircll cnoglrlrrttnn co tL1e cerium U41iItil depot -limo or air county 1h'liii
coral rni icd
rarin trii -I
wFn n h ari' a Ina Lmictr ii in nI EFI,1F0IIJI1eui
alit LIILWckl JrC 0Iuctfi - l rvGlaunl'1'.11er grout.-
ReAug= 11.1I;I

WELL CONSTRUCUON RECORD
Thy fonrl+nu tic ascii fur 51.iiirk +Ir i iiiJI IIk ht �IlS
1. Welt Curltr'nctur larurnidrliont
1F'ar FrOcmill USe D1,11.V
Brian Ewing
WOLCra..t 144LTNarinC
4240-B
N C Well Cool{,Icior Carl iihmLiun M1iinhci
SAEDACCO Inc
? . V4'e14 4raoatrl,ctiun Perna*, wi0300399; 70002483
!iuld2 opvlll..thlr krlrPrrmil4lr-r.. r 11L11eY SLtlr_ W.yd+lL.r lrilfar-Uoe#. o-.l
3. Wd1 Use trim& wall M
Water Supply Vied:
flt r'clrltural
UCreolli nwI Iiteraiog'Coaling 5upp]}l
I' Ilndusiria fCantrnercial
❑ knipirni
L1M iicipal/Plrhlic
r1 fk4sfdellnlrl Vridizir Sunk! k 1€i RLzIel
I-lRcsidentrml Water Supply .s]'laredl
NIPP-Water S+upp1}' Well:
❑hioi iIoriuq 1=11 a}> '
Eiji:I/aIr11 V- Ik
r1Ad111ifCr 114..Ct1Nrr
pAtinircr 9tora8c ald Ttecn� cr'
❑ AgpirFr 7�61
❑ EN rimCruR1 T�clrnnGaet'
❑ Claulhermal iCluerd LinlpF
❑ Geothemial illaritreCooliq Rutuilhl
❑erecRodwaler p,k7rnCtlimi9r!
DSrllini1% 13arnc r
❑ A' orrn5ilrler Errtio.2gg
❑tiitbRidei ce carlru
❑ 'soar
11IO11kr wli rr 121 Mere/irks)
4. D:It WeII» Crjrlilrlel€tl; 1/14/21 We.11 Mgr A8
5a_ %fell l.11rathln:
Remediation Management Service Company
l•.' 1 I i 1! of rrepli:Ilble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea Citt_ ;urd Zip
Mecklenburg 12710204
CVwmJ1 } ii 1ldeiu9Eleiuol4 Nn fP1N?
ih. T:Init fir: ind laingltmhr In nr der'imil rkt rxr4.;
tali!Wld Ink' Li'lojJsstr, rtkiuE
35.210533 (-80.801887 '
9. I3 tore) Ihi li rIPIji ❑�e'IYri9nral ur 211 'moron'
7. Is thin a rrpair iu an rhriodll iowait: 1t'rs or El Nip
+
{rillri Ii Ir lriNllr.•i l ii F �TNr11W II.1'flr4rMlriHl1.6'r1 dlrlihnkurIJiA'1 ilri 1'11.lrrjrlr fill' llll' rr IIr rllr
rr,4drr u1dL.i'!1i r ei rk Y[eJrari LW All llrr hack rtr Mrs form!.
S. PluuLbet of well ronmirueeed: 1 _
l .r iirtdr Vte lr06.140l1 W Nre-Irxrrr.1Ira'ra} ONLY il'.rh rllr WNW enrrarnreri,r+r
_SdI II rRAC)'iJ ii.
9.1W wen depth beim lama surface 20
r,rr 1'NIHr�rr1' N'fi�r �rlr irri ril1'yr♦r7 thifi Arect 16.terrrtrdlr` *.:1;10' aril 7 ;IVO
10. SUSTIE water level iicluw nit] Irkculiu1
▪ I141+I'1. k''.ri 9 Mom.. Luiri; lr.r' •'
11. P1ar#211411.t rlijnieltr 1. 5"
t1r.1 +..IN
12. Well torAlntvtipii itwilirul: DRIVEN
(ILI
c1.c Airger. roan . i-0hIr, dITrci Itierc.r
FOIl WATER sUPPJ.YWELLS ONLY;
I1a Vivid !Wm!! 1144.111041 oftrllr'
I313, bi lnrcr4iva rapt: 4muuot:
14 WM= Molls
RCN l 1n
DEld'HIP IJl1'
rt.
t5. {MJT R CASiliC {nlr Ir1u14I-F ieiI nab) OR L FfER (it amaRcahkh
FROM 11-0 Part IrFTFR TPPICKNFM,.
0 fL. j 12' ft.
I ri. rN}10 cot:gm Iln'r_ 91niirlikr.r4rirr rrarup_.
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
n,
1.5" Jo,
NA
Trr' PlAraFI1?R 1 JiI,fjTtdra
20' ri. 1.5"
..
NA
11.iTIENTAI
Steel
THIr lk!rPv4
NA
m. rlekrsl.
Steel
IL
rt.
711, CIRI}rT
RAOi1
I h7
RnTE1tPM. F.#TrLI. Mk4Tlllr.nomL&AMOUNT
tr.
n.
rt+
r4
rr.
IL
24, 5.3.4.1414CRAVPL PA€:k► I+r dyllicibk}
rpilir
7E3
rI ,
IJI FE HLl1.
I[irEH _1( r %Ir *c 1' ulm a 11•gn
{
(I.
31, DRILLING LOG Inliich iddllionxl4botii it nmaarr3I
FROM
0 fl,
F.
TO
20' fi.
IL
nP.WrlrlPT:OJN ...ahrOmninxr.,.tI'nKki5 Rr cri.n ,OK.I
rt.
14
IL
fL
it
Ic.
Ir,
Ira
R-
IL,
Temporary injection point through DPT tooling
21. Certification..
Brian Ewing
Sieshourg a Fecal God W cat CouurL'rur Dtec
PT MT41111. 4 Au'frMrl• I rrrr.'b1' erM0r7I rllw rNle 1A-10.1 14rd JI l J t4,usrrirelrtI Ire.0.ra'rvmmune
u'JtA l •bl riCAC r7SC .Ofrrrl ry ?r1 rvt',1CL�i� 2C,(V8I1 W Y I I)Jrrrrirrnor ShINe♦ari rlrld rh,U e
rT .11 orals rm. and Ambr,rN plrlr'Ifl.Wl lrM AL. 4I1:1J1 iiI wr.
1/27/2021
23. Site diiiy;r'slni or ad dt1i1J1uiI well delimit?.
Ycn1 rlla, ose Ile Wel, .ul fills "rage to provide addilionul ire1l site details ur we] L
cordrvl LLari Iklails. Yoti Hurt ulso Ara;Eddiitouut twb'es rl h,ewcssan .
;il1l"Rt117 AI. LN.S11Jc IONS
2da. lhl( All Wrik Submit ilus Farm wires 31J dais of courplerloo of swat
cousrnlcttpn to the rblkornn .
1Fl►isFia ul'Warr keno rce5, Intlrrmmiluu Pni rss.iog Gull,
1A17 MAil Sersire CeLIcr, Raleigh, NC 27699-1617
241.. Firr [uieciiim Wedl9 ONLY: Iri addition Ie aeladitlg Ilie rofnl to the itddmss Pik
a�eab04•e. alsal Stith llrll a copy of tildk try uiiLlui iLl dirks of campletii ii of vcc ll
co struKLluu bale IaU]Ohviu .
IT.ialrm of Water Resources.lrndcrgniuird 1njr:riIalr Control Program,
1.836 Halt Service Center. Raleigh, NC 27iW4-1839
24r For Wir> ...54ppl} India pi 'WOW
Also submit oire cop). of Ali . rule, u 1Fhirl ;o days of coniileliopF uF
tircll cnoglrlrrttnn co ILle [Phut} 1101101 depplrorsere or air comity w
coniInlcrcd
rarin trii -I
wFnnh aril' a lnr Lmiarcii iiE III LIII1F0IIJII IIi
a tail ni.unl itesoluctfi - DPE161irF1%W.nier RinuLrcL
Kelagett ALVA 11.11;1

WELL CONSITRUC CON RECORD
Thy fonrl+nn bc,wad rue shitrk lr mI111 IIk „erl5
1. Wel I' Curltr'ricti.r II,Irurnideliont
1F'ar rnicrnill USe D1,11.V
Brian Ewing
edl CF P ri 4L.T Hiatt-
4240-B
NC Well Cool{,Icior C'crllfrkLiun M1iinhci
SAEDACCO Inc
We1I #aoatrswctiun PerrAk 1:; wi0300399; 70002483
liuld2 opvllruhlr kv/f vortil4 lr-r.. -1.a.a .t.i SLtlr_ Y.yd+ILr 1.9Jfantrori
3. Well Isar tehcidc well M
Water Supply Well:
UCreolli nwI Iii iliogJ'Caaling 5upp]}1
I' Ilndusi,ia fCantrnerciak
❑ knorlinn
L1M iicipal/Plrhlic
rlt{Sfdellnlll 4 diet Sunk! l Si RL1.Icl
I-lRcsidenbml Water Supply ts]'Iar'd
NrrP-Water S1upp1}' Wd1:
❑M.cmilorine ❑lea}> '
Eiji:ri9iii V- IL,
r1 Ad111iCi r Rec tarr
robrittircr 9tormc ald Recnilcr,r
❑ AgpirFr 7�61
❑ EN rimCNR1 TgC1rn6Ls3 '
❑ Ci ulhermal iCluted Lrrup •
❑ Gearlicitrial illaringfenoliq Rutuiihl
DSalini1% 13arncr
❑ A' orrn5slrler Ertuo.2 e
❑tiilbRidei c caul m i
❑ Traorr
11IO1lier uilllrr /21 Remarks)
4. D:rti` Wellk0 Crjrlrl hilt); 1/14/21 We.11 Mgr A20
5a_ %fell L.urathln:
Remediation Management Service Company
l•.' 1 I i 1! of rrepli:Ilble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI . ddrea City_ ;md Zip
Mecklenburg 12710204
CVwmJ1 Prleecl ldeiu9Eleiuol4 Nn fP1N?
ih. I:IniiJ rind Iaangltnrhr In fltirrxraElnhimrteiizecnnrls nr rtecimil rkit rrra;
ads tIi Add Ink' LiOntivJs strf,tl<JUE
35.210533 N-80.801887 '
9. l3 lure) Ihr!11 rIPI i ❑lrermanral ur 211rInporon'
7. Is thin a rrpair iu an rhriodil iowell: �11'rs or ®hlu
+
{rill ri Ii Ir lriNllr. •i rrii F 0.4,11.0 wen r4NJ.7ril1 Roil d Iri1J'TrJrrIJIJJI mod I'SrlrfJrJr rA 1' llll' rr IIr rJlr
rr,4drr ulaLl+r 1J' rrei rlth stt.li a LW All der hack rtr Mrs form.
S. Plumbbe -of well rnirlinieeed: 1 _
F .r iirddr Vote lr06u40l1 W rime-Irxwr lulrjgr' ingtr ONLY lr.r11 rllr WNW enrrarnreri,r+r
...ermlrr RAC fiJnu.
9.1'01,1 wen depth beimlr' lewd aurfaee 20
ror FNllirp1l' Nei/1. 11hr 1W fil'L r1r7 thifi erect 16.ter' ijdre- 7f ND' arr17 ;IVO
1♦0. SUStIE water level iicluw hip of culillIC
fI I141+I'1. k''.m 9 Mom.. Luiri; a.r' •'
1. LSar irik iIIlrarcltr. 1. 5"
12. Well tun tnrctipii Inletlirul: DRIVEN
fl, I
(f1.1
c 1.c Airger. roinr►. i-0hIr, dIlrci Itierc.r
FOIl WATER SUPRJ.YWELLS ONLY;
1.1a. Vivid IRpaml of t er:
I313, LM.MA:clime riper. 4muuot:
1 . WAII k Molls
Iravil l TO
DE rICIP IJl1'
ft.
rt.
t5. {MJT R CASFNC Orr rau11I-F ieil arr11) OR L N ER (it amaRcahkh
FROM I TD Pr 1 IrFTFR TPPICKNFM,.
0 11' j 12' t1,
I 2Er LN}iRs cot:SINc Ils'r_t)91niiirlrivr.r4rir[I�[rarup_.
k FROM TO Drk'41ESFR TDICKl§ESS MALE JAL
9-
n,
1.5" Jo,
NA
TO PrArrrrI1?ir J Ji I;or sr i
20' O. 1.5"
..
NA
11.iTIENTAI
Steel
THIr lk!rPv4
NA
w. rl[krm.
Steel
IL
rt.
Ii
it GROUT
R1iicts
I r7
RnTE1tPM. ! F. trLI. Mk4Tlllr.owl/aAMOUNT
tt.
n,
r4-
rr.
IL
24, ! WI;RAVPL PA€ k. I,r dyrlicibk}
R.
T[r
rI ,
1JI FE HLl1.
r[irEl _1( r wn *c 1' ul=meppn
{
(I,
31, DRILLING LOG I nlrich iddllionxl 4botifl it rreekvary I
FROM
0 tl.
F.
TO
20' ff.
IL
DP.W-REPT:OJ Ni IFuhr, immiw,., R'Iµ'r'H k hh Rr. rtIn 4r, OK. I
rt.
IL
tL
rt
if-
rt.
R-
11.
24 altritA.104
Temporary injection point through DPT tooling
h. crl�rcatiom
Brian Ewing
SitPmurg aFecal lied Wc8Comm:tor Dmc
AT MT41111. 4 drhr frrtrrk I rrrr.'bl' ei0105' rllw rl+r 1A-10.1 14rd aI l J tClustrirelrtI err.0.ra'rvamune
u'JtA 1 •Il rifCAC OSC .Oral ry ?rl rvt',1CL�(�2C,(V8t1 % Y I I)Jrrrreartur SihINe♦ar., rlrld riLU
rTrf.l orals rm. and Am beau plrlr'Ifl.Wl rrM AL. 4I1r+J1 iiI wr.
1/27/2021
23. Site diagrslni or addlti'Jiuil well delimit?.
Ycn1 rnli1 ose ate Lack of digs page to provide addilic)nUh gh.ell site Mails ur we] L
r8rtslru ;hall Lklails. You Huge ulso Ali 1l ;i[ldilrtisuut twb'cs d rxwcssan .
;ill uRlrf7 AI. CNs1 tJcL f{x[w5
2da. I iir All Wr,ik Suhami this Farm with 3U dal of courpkdmoo of welt
coo$rructipa to the rblkomrl4.
ihh NFra if Weer Reno rce5, Intlrrmmiluu Pni rssiog Gull,
1617 blab Sersire CeLIcr, Raleigh, NC 21699-1611
2.I . For [uiiectinu Wedl9 ONLY: In addition Ie seladitlg Ilie rofnl to the :Idd ress ui
2-Pa ab0Vd. a1s.i suLlloil a copy of tills. try u iiLlui 10 dirks of r:ampletrati of vcc ll
co struKLfuri Iv the IuLlOhviu .
Millen of Water Resources.lrndcrgrnund Injr:riIalr Control Program,
1636 Halt Service Center. Raleigh, NC 27iW9-1(136
2.3L Fur Wire° 54ppl} ! Iojeisioi Wile.
Also submit or,e cop). of Ali . ILA Ill u lthiil ;ro days of coniF+ielion uF
tircll cnoglrlrrttnn co ILle criiiim 11011011 llepplrtmenl or air comity irlicii
coral-ni icd
rarin dF' l -I
wFnnt ari'ulnFLmktnii iiEIII LIII1r5�IIJII111
mid LIILWml JrC0Iuctfi- lPE10I1.nl' Wnice rlinia.rcm
KeirLSCA1 Aug= 11.1I;1

WELL CONSTRUCUON RECORD
Thy fonrl+nn bc,wad cog shigk 'i iiiiJI Irk „erl5
1. Welt Curltr'nctur Il,durniirliont
1F'ar fnicrnill 4x D1,11.V
Brian Ewing
pelt {tulip lur Nara
4240-B
NC Well Coulr,Icior C'crllfrkLiun M1iinbcr
SAEDACCO Inc
We1I #aristnictieu Perna*, w10300399; 70002483
liu ul2 opvllruhlr wv/t vrmil4 l r-r.. G iltnty SLtlr_ Y'yridlL 1r 9rt'Or#
3. Well Ilse tehcidc well MO
Water Supply Well:
rt,clllttlril
UCreolli nwI Iiteraiog'Coaling 5upp]}l•
I' Ilndusiria fCanunerciak
❑ Irt nn
Olvionicipal/Puhlic
rl RAsidellnlll "Wilier Sunk! I Si RLl..Icl
I-lRcsidentl,11 Water Supply i.s]'Iaradl
NIP: -Wake Suppl Will:
0I44oi iIorine ❑lea}> '
Eiji:r111r1I V- IL,
rlAdllriCCr Rect1NFire
pArinircr 9tormc and Recr+35er,r
❑ Agpircr 7�61
❑ EN rlmcluRl T�clrnnGaet'
❑ JeuiheYmal iCluted Lrrup •
EIGeotheitnal iFlciiiii Cnsslin Rutmiii}
DSalini1% 13arncr
❑ p' orrownier Eroliri.2ga
❑SilhRiikiCC caul rill
❑ Traorr
®O1lEer Eiuffl wider 121 Remarks)
4. D:rti` Wekllxl Crjrlrl intent; 1/14/21 We.11 Mgr A32
5a_ %fell lasrathsn:
Remediation Management Service Company
I'.rifllepli:.nble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;urd Zip
Mecklenburg 12710204
CVlmJ1 Pii 1 Ideiu9Eleiuol4 Nn (P1N1
ih.I:Initd�riiid IJngttnnPL In flri rxraElnrimrteiizccnnrls nr decimal etc rrra;
idiw 1tAdd Ink' LlllltsjJswliT e.1.2mE
35.210533 N-80.801887 '
9. l3 lore) Ina 11 rIPI i ❑eim nral u r 211 'moron'
7. Is thin a rrpair iu an rsiodll iowrit: 11'rs or ®h1
+u
{riligi Ii Ir lriNllr. •i rrii F �TNrIIW i1 lfI rYrlJ.7fll1 flr'rl ila1J'TJJrrIJIJJI liNri I'Sr lrrltJr rill' llll' rr Ir+ rjlr
rr,4drr uldL.i'!1i reu&rk set.li a LW All der hack ri? Mrs form!.
S. PluuLbet of well rnirlrrueeed: 1 _
F it a drote lr06u40.11 W rime-Irxrrr.1I1x'tir ONLY ir.r11 rllr WNW cMrrrnrethilr
_5dI�5'Ilrr RAC fiJnu.
9. 7'liriak wen depth beim lama surface 20
For I'NIHI'p1I' thifiVirerlr 16.terrrtrdre- 7f :OI+' aril 7 ;IVO
10. SUSTIE water level iicluw nit] ref c,rliolr~
▪ I141+I'1. k''.ri 9 Mom.. Luiri; a.r' •'
11. llar#2114110 II jnicltr 1.5"
tJrul �,.IN
12. Well tonkinnlipu IPWillinal DRIVEN
ff, I
(fl.I
c I.c Forger, rninrl, i-0hlc, dllecr Iti elc.r
FOIl WATER SUPPJ.YWELLS ONLY;
k.lA Yield ligpinI oftr•sr:
I313, bi lnf'crtiva ripe: 4muuut:
1.4 WAIIk Molls
Iravil I
ri!_tirltIP IJl1'
ft.
ft.
t5. arrreR CASFNC «llr rrru14I-resell webs) OR um ER fir amaRcahkh
FI O rl I TO PR IrFTFR TIIICKNFM,.
0 i j 12' t1,
I 2fir rN}10 L'l1SINC Lls'r_ 91niiikr.r4rirr rrarup_.
k FROM TO DtiAlESFR TDICKl§ESS MALE JAL
9-
n,
1.5" Jo,
NA
T D PrArrrrI1'R J Ji I;or sr i
20' ri. 1.5"
..
NA
THIr 1,1
NA
11:kTEN TAI
Steel
wArltkrsl.
Steel
IL
rt.
it GROW
RAOii
I r7
RnTE1tPM. F. TrLI. Mk4TlllLnI(IJJ & AMOUNT
tt.
n.
rt+
r4
rr.
IL
24, S)lNWC.RAVPL PA€:k► I+r dyllicibk}
Trr
rI ,
1JI FE HLII.
L[irEH _1( F wnr *I l' 'dlm ehgr1
{
(I.
11, DRILLING LOG Inliich iddllionxl4botii it neeaarr3I
FROM
0 kl,
ri.
TO
20' fi.
IL
DP.W-REPT:OJ Ni I,yhr, imninv.,., RIIJL'nK k hh Fr. a'Iii 4r, OK. I
rt.
14
IL
tL
rt
if-
Ft-
arriLlk.04
Temporary injection point through DPT tooling
2/_ terlrircatiom
Brian Ewing
Sieshourg a f{bent God W cat Couurb'rur Nee
AT MT41lI1.I4 drhr frrrnll, I rrerobr eMrr7I rllw rl+r ivrd{ u rY JI l J tY.O.V.trirelea ur.0.ra'rvmmlr
u'JtA l •Il riCAC 07C .0frrrl ry ?r1 f'c'r1CL�u�22C,(V8t1 W Y I I)JrrIIrirrnur Sihlrkllar., mild riLU
r' n orals rm. and Am beau plrlr'Ifl.Wr r� AL. 4IlnJ1 iiI wr.
1/27/2021
23. Site diagrslni or ad dtli'Jlima,I well delimit?.
Ycnr Fluky ,Lie Ile Lack of digs "rage to provide addilionml ih.e1l site details ur we] L
c8hSlrur LLaff Iklails. Yoti Huge ulso Ara;Erldiirrfuut twb'es rl l'I«:CSSan .
;iU BRIT. f7•AI. LNb711["f IONS
Zda. I+Iir All Wrik Suhaml ilus Farm wires 3U dal of courpkdmoo of welt
coo$rructton to the rblkohrltl4.
i h NFra if Wafer Remorce5, Intrirmmiluri Pni rss.iog Grill,
1617 blab Sersire CeLIcr, Raleigh, NC 21699-1611
241. Fier [uiectiex YWIA ONLY: hi addition to aeladitlg Ilie rofnl to the :Iddresa Pik
a�eabo4s:. also+ 5.uhlud1 a copy of thls. fury uiiLlui iLl dirks of Llampluticith of Hell
c n truct.ruu Iv the IaL]Ohviu .
IT.ialrm of Water Resources.lrnderg nand 1njr:riIalr Control Program,
16.36 Halt Seabee Center. Rial Igh, NC 27iW9-1(136
23� Fur Wir ...54ppl} Irijei hoe 'WOW
Also submit oire cop)' of llii . rulril ?h IFhiil ;o days of CQMiFileIiopF I}F
yyckl cnoglrlrrttnn co ILle crniit} him iIiil lleppnluxenl or air comity whim
coral mica
rarin trii -I
wFnnh ari'ulnFL'.lktnii iiEIII LII51r5�IIJIYCIIi
alklNmin literaluctfi-DPE10Iinl'WagerRinut.rcL
Kelaged Aug= 11.1I;I

WELL CONSTRUC CON RECORD
Thy fonrl+nn bc,wad roc sllg}c'Ii iiiiJI irlr „ePls
1. Welt Curltr'licti.r 1111'urnirrlime
1F'ar rnicrnill USe D141.V
Brian Ewing
Veit Cr olnio ur Narn
4240-B
NC Well Coil{,icior C'crllfrkLiulr M1iinbcr
SAEDACCO Inc
V41I #aoatnietiun Pernik O; Tai0300399; 70002483
liuul2 opvllruhlr 0.YirPrrmir4lLt. - iltnt.i SLtlr_ Y'yri+lLr 1rofen7or#. h-.1
3. Wr I Use trim& will M
Waller Supply Well:
flt r'citlttlral
UCJeolli anal Iiteraiog..Coaling 5upp]}l•
I' Ilndusiiia fCantmercial
❑ hngnUnn
Llhirllricipal/Plrhlic
rl R sidcllnlll Rlti€cr Sunk! a Si II fJcl
I-lRcsidentr,rl Water Supply ls]vared
riirm-Water 5+upp1}' Well:
01..4c iIoiiuc ❑l a';'Vr]_
Eiji:ri9iii V- II,
rlAdlllifr:r Rectiar re
robrittircr 9tormc ald T{ecni5cr,r
❑ Agpircr 7�61
❑ EN rimCluR1 TgC1rp€rG,3et'
❑ Jexllhr anal iCluerJd Ltnlp •
❑ Gtodreiival illt!Juii Cnsslin Rutuiihl
DSalini1% l arncr
❑ 0rrn5ir,l er Er kai.2rr<
❑511hGi kiICC call nil
❑ '1l-aor'r
111O11Ler iiipiuiii tiilJrt /21 Reniu ks)
4. D:lti• WellINI Crjili1pItIttl; 1/14/21 We.11 Mgr B8
5a_ %fell l.lrrathrn:
Remediation Management Service Company
I'.tifrrepli:,rlbler
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Aifdrea City_ ;md Zip
Mecklenburg 12710204
Cnunli Prieecl ldeiuoleiuol, Nn fP1N?
ih. T:1nil uir ind IJngltmhr in ille`plreailmim4te1Jzccnnils nr decimal rkt rer4.;
srliA'Id Ink' Li'1oj1s+JIrlUtl<JUI
35.210533 N-80.801887 '
O. Is ILi ) Itri llrIPIji. ❑ifeim nral ur 211'moron'
7. Is thin a rrpair iu an r7riodll iowait: 1t'rs or ®hlu
+
{rrlrri rr Ir Orphn..fillrii F r;Frrrll Y.l own ror A7rlrll Tri'rl rlril J'TlJrf lJlkl llr+ri I'SrlrflrJr pJI' rllr'Nr r Irr r(Ir
rr,4drr uld6'r 2l1i reu&rk set.li a LW tYl rla hack rd Mrs form.
S. Pluritblet of well rnirlrrueeed: 1 _
F it uw2rote rrrJd,^liAll W rime-Irxwr lumlgr' ONLY ir.r11 rrlr WNW rMrarnrethilr
_5dI�5'Ilrr RAC fiJnu.
9. 7utal won depth bei m lama surface 20
ror I'NIHrprrl' di'yr1r, tfd+JPdrolr 16.terMtrdre- 7f :01+' arr17 ;IVO
11F4. SiSTIE Rotor level below Rip ofcusiul1
i+ IV/NH k i ri 14 Mom.. Luiri,; a.r' •'
11. Flar tik illjnreler: 1. 5"
tJrul �,.IN
12. Well torainrctipii um Iimd DRIVEN
rt.I
(ILI
c I.c Auger, roinr►, i-0hIr, dIlrci Itierc.r
FOIl WATER sUPPJ.YWELLS ONLY;
I1a Vivid ligpiil III€ IIIiYI of
I313, bi lnrcrtiva rapt: 4muuut:
14 Wfti= Molls
RCN 11n
a!_tirHIP IJl1'+
ri.
t5. {MJT R CASiliC {tllr nrulll-aswl ii Ni) OR L N ER (ir amaRcahkh
FRO11 I TTI PR IrFTFR TPPICKNFM,.
0 11' j 12' t1,
I 2Er LN}iRs cot:SINc Lls'r_ 91niirivr.r4rirrl�rrarup_.
k FROM TO DtralESFR TDICi:r4ESS MALE JAL
to
Il,
n,
1.5" Jo,
NA
Trr' PlArlar1?ir J JiI,tF dWi
20' t1. 1.5"
a,
NA
NA TEN
Steel
THIr lk!rPy4
NA
m. rllkrsl.
Steel
IL
rt.
I.
TII, GROUT
RAOii
1st
Nn [Eltl li. ! EMPLNVEMKNT lllr. nI(IL & AMOUNT
ti.
n.
tt,
I4
tr,
IL
24. S)lNWC.RAVPL PA€ k. I,r dyrlicibk}
rtrom
To
tl ,
1JI FL HLl1.
10rEH_1( I'wnr*rl'.111lmeh91r1
{
II,
31, DRILLING LOG Irirach iddlliorml rlredi if rrc'aarr31
FROM
0 kl,
rt.
TO
20' fi.
IL
DP.W-REPT141 Ni IFyhr, imni w,., R'Iµ'nri k hh Fr cram 4r, OK. I
rt.
14
IL
tL
if-
rt.
R-
I1.
altriLlkitbA
Temporary injection point through DPT tooling
2/_ Certifications
Brian Ewing
5ieshourg a Fecal God W cit Calara'rur Nee
AT ST41111.4 drhr firrnll, f rrrr.tr' eMrrJI' rrlul rl+r ivrd{ u rY jlatre,1 tu'rl5rrirelea Ire rieervmmlr
u'JtA 1 •Il riCAC OSC .0frrr ry ?r1 'Ci1CL�(J�.:C, V8ti %'W Y I)JrrrrNi rtur Srrlrkllari il nd thole
vim orals rm. and AmbrrrN prrruld.wl ha' Au 4I1:01 iiI wr.
1/27/2021
23. Site diagram or ud eilli irul weil detriikl;
Ycn1 r11Hi ose ate bi L .ulf dila IIe ' to provide addiliol,iih gh.ell site details ur xe]t
cortslnil;llati Iklails. Yoti Hun u1s(5 Ara 1i ;xldilHrimt twb'es rl l'Ici:nsor1 .
$LI BRICf I Ai. LNb7'LICTION5
lda. lrllr Ali Weibc. Suhami ilia torn wit in 3U dale of L+amplerloo or swrit
Lanstructipa to the rbltohri[l
kb:611la ill WIlirrkr!IuurcrS, Inrlrrmmilua Perder:swlug Lull,
1617 MAO Sersire CeLIcr, Raleigh, NC 21699-1611
241. For [uieciiim Wedb ONLY: In addition Ie aeladitlg Ilre rofnl to the Address ul
ale ab04•s:. miles+ suhiiiil a copy of tills. fury u iiLliii 10 dlks of COmpluticith of vcc ll
LEn IJ'uKLfuIL ILl the faLloveiu .
TIh ialen elf Water Resources., lrndcrg nand 1njim iIoi Control Program,
16.Itr Halt Service Center. Raleigh, NC 27fi'f4-11I36
24r Fur Veitgi° Suppl} ! Iulr,r7ips WOW
Also submit sire cop). of this- ruin, 'A Itluil ;o lays of coniileriort uF
tircll cnoglrlrrttnn co tllc criiiim U41iItil ileppinimN1I or air comity whim
conilnlcicd
rarin trii -I
Yim n t arc' II Irr L'.. pmtr ii iiL III L I II lh IIJII ui
mid Nmuril itesoluctfi - DPE1011a aicr IlmuLF
RCVLuCd 2/11.1gLQX 11.1I:I

WELL CONSITRUC CON RECORD
Thy fonrl+nu be rash roc 51.iiirk .'i m1111 Irk hw ell5
1. %V t Contractor Information:
1F'ar fnicrnill USe DN1.V
Brian Ewing
W d1 CrotnwI r'T NarrnC
4240-B
❑ C Well Coulr,Icior Ccrliihmtiun M1iinhci
SAEDACCO Inc
▪ W'e1I #aoatrl,ccian Pernik 1:; w10300399; 70002483
liuul2 opvllruhlr wv/f ovrmil4 lr-r.. G iltnty SLtlr_ Y'aridice 1r 9rtfor#
3. Well Ilse trim& well iI�
Water Supply Weil:
UCJeol i nwI lifealiog'Coaling 5upphl•
I' lledusitia fCantreereial
❑ Imgalrnn
EffsloinicipaliPublic
CJ Rtsidenaml Water Sunk! a Si n fJcl
I-lRcsidenbml Water Supply ts]'larodf
M1rr:-Wake Supply Well:
❑hionllotion 1=11 a;Ct]_
Eiji:I/ 1tr11 WkrIk
r1Ad111ifCr Rectiar re
iArirtircr 9tora8c ald Ttecr,35er,r
❑ AgpirFr Tal
❑ EN rimCtuR1 Ttchn€ togi..
❑ Ci uthermal iClused Loopt
❑ Geodoeitrtal iFIciiiii Cnsslim Retliiii
DSalini1% 13arncr
❑ p' orrn5rlrler ErRia.2ga
❑ IILN IC11CC C'aiMrtll
❑ Tratier
®011oer ucpiuiu liimkt 1/21 Reniurks)
4. D:Iti` WeII» Crjilrlrlel€tl; 1/14/21 We.11 Mgr B16
i.L. %fell Location:
Remediation Management Service Company
I. • I i' ! [if rq'pli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM Icpt Addrea City_ ;md Zip
Mecklenburg 12710204
Cnrintll Prldecl ILleiuifleiuolr Nn rR1N1
ih. T:Inil isinand I J.l1gtttrnh' In drturearinrimrtesilccnnrls nr derimil et•egrrra;
dsrliA'Id Ink' LII21[ Jsstr,MtkiUI
35.210533 N-80.801887 '
9. Is lmri) Ihi l+leIPI i OPerillginred ur 211'moron'
7. is this a rrpair iu an rsiodll iotrait: 11'rs or El Nip
+
{rill ri la Ir l.» ilr. •i rrii F �TNrIIW i1 lfl cor•'J.7ril1 fro'rI l Aril J'TJJIrIJIJJI mod I'irlrrltJl 111.. ohernirr Ire rJ1r
rr,4rlrr uldifef rrei rlt5 Y[ eJrnri ur [41 der hack rtr Mrs form!.
S. Number of well consirueeed: 1 _
t er criationte lr06u40.11 W rime-Irxwr .1•11Atift ONLY 11'.rh rllr WNW ivarrnreri,Nr
_5d1�5'Ilrr RAC fiJnu.
9.7001 wan depth helm land surface 20
r,wr I'NIHrJrJI' N'f1�1 �rrr iirl dI'yJ1l, lfifiReed 1 .territldre- 7 ' aAIr17 ;I Oat
10. Stitic water level below nip of l'usiu1
it IV/NH k''.ri 9 MomV...writ; a.L' •'.
1. llurtraiale iIIjnrcli : 1. 5"
12. Well i`uretinrctipii inietlttul: DRIVEN
iri,t
(rl.t
c I.C, airger, roinn , i-0hlc, dlTeclelkEIL etc.
FOIl WATER sUPPJ.YWELLS ONLY;
Oa. Yield %rpamI oft er:
I.113, fliisiorecitiuu rapt: 4muuut:
1.. WAIIk V..01,11s
Iravil l ,n
R!_tir'HIP IJl1'
rt.
t5. OIJTHR CASiliC «llr rrou11I-F ieil nab) OR L FfER (rT amaRcahkh
FROM 11-0 Pere IrFTFR TPPI(P F5t4
0 tL. j 12' tr.
I ik IN}iR4 L'lLSINC Iln'r_t)91niirivr.r4rir[I�[rarup_.
k FROM TO DLk'41ESFR TDICI:lIESS MALE JAL
to
n,
1.5" Jo,
NA
TD otorF?YR J Jiifirrstirs'
20' ft. 1.5"
..
NA
11.iTIENTAI
Steel
THILi;spv4
NA
m. rIttirs1,
Steel
IL
rt.
i1I, GROUT
RAOii
I it
Nn[Eltlii. ! F.#TrLI.V Mk4TllMT.nI(IJJJkAMOtINT
tt.
n,
i4-
rr.
IL
24, ! WI.RAVPL PA€ /. I+r dyllicibk}
rt.
T[r
II,
,JI FL HLl1.
girEl_1( r'%IF*r1' ulme11•gn
{
(I.
11, DRILLING LOG Amoth iddllionxl rbotifl if nmaarr3I
FROM
0 fl,
ri.
TO
20' fr.
IL
DP.W-REPT:OJ Ni IFl.r, l,irdhn+, 411.'nK k hh Rr• a'Iii 4r, OK. I
rt.
IL
tL
it
Ic.
IL,
It.
IR-
artriLlar,b4
Temporary injection point through DPT tooling
2/_ Cerliiicatiila[
Brian Ewing
Sieshourg a Fecal red W c8 Couurb'rur Dtec
AT MT411I1.4 2fiLY frrtrrk I fry retry eM0r7II' rllw rliz 1A-120 .1 Ilyd J I,l J t41115f ireiraa err vee'rimd Are
u'JtA 1 •bl riCAC OTC .Ofrrrl ry i ?rt rve7.4CLu.TC,AV8I1 WI Y I)Jrrrrirptur Srdlikllari mild dint d]
r' n orals rm. and AmbJ,r,J plrlVld.W1 ale JIIW ,I,r+J1 riIwwr.
1/27/2021
23. Site dat:rslni or aiddlli'Jiuil well delimit?.
Ycn1 r11H1 use die hick .ul fills pow to provide addilionUh i ell site delatils or well
construction derails. You nun also Mod;E[1dilHfuut Iwb'i AL nei;cssin .
;iU BRlrf7 Al. LNb11.1CTIoNS.
Ada. lhl( All Wells: Suhrmi this Form within 3U dale of courpkdmoo of welt
construction to the hollowing.
ilh Nblia Wafer Resources, Inrrrrmisiluu Pni rsxiog Gull,
1A17 hlblt Sersire CeLIcr, Raleigh, NC 27691P-1617
24h.. For lutecium YWIA ONLY: hi addition to aeladitlg Ilse farm to floe :hddress Pik
a�eabo4•s:. bleat suLliai1 a copy of tills. form uiiLlui 10 dates of CaanIpluticith of well
construction to [he faLlowiu .
Division of Water Resources, lrndcrgrnund 1njr:rlIalr Control Program,
1.8.16 Halt Service Center. Raleigh, NC 27fi'f4•.1836
2.3L Fur Wites°.54ppl). ! Iojrs.iiim Wile.
Also submit sire cop). of ilii. FLAW, u ICLuii ;o days of coni+ieriott uF
tircll cnoglrlrrttnn co ILle cnliit} 1101101 AlepplriimN1I or air c iu*i wise=:
coral -tiered
rarin trii -1
wFnnt.Jn'ulnrLrtmtrii ilrIII EFI51r5rIIJII111
alai NaLuinl itesoluctfi - DPIS 1011 11.1%Warr ilG'{JLF
KeirLuCd Aug= ILI I:I

WELL CONSITRUC CON RECORD
Thy fonrl+nn bc,wad cog sIiig}c.Ir iiiiJI Irk „eFIS
1. %'L11I. Curltr'ricti.r II,Irurnileliont
1F'ar rnicrnill USe DN1.V
Brian Ewing
ed1 CF P ri 4L.T Nara
4240-B
NC Well Co ulr,Icior C'crl lfrkLiun Nii rti
SAEDACCO Inc
V41I 1raoatrswctiun PerrAk O; wi0300399; 70002483
!ix./ ul2 opvllruhlr wv/f vrmil4 l r-r.. - iltnty SLtlr_ Y'yridlL Peant'Or#
3. Well Isar tehcidc well M
Water Supply Well:
UCreollie nwI Iiferaiog'Cooling 5upp]}i
I' Ilndusi,ia fCantrnercial
❑ Imga1snn
L1M iicipal/Plrhlic
rlt{Sfdellnlll Vridier Sunk! l Si RLl..Icl
I-lRcsidenbml Water Supply ts]'Iarell
NOP-Water S1upp1}' Well:
❑I4ioi iIorine ❑l a';1rr]_
Eiji:ri9iii V- IL,
r1Ad111iCi r Recl151rr
robrittircr 9torm8c iid Recni5cr,r
❑ AgpirFr 7�61
❑ EN rimcrMil TgC1rn6Ls3 '
❑ Ci ulhermal iCluted Lrrupr
❑ Georlicitrial illaringfenoliq Rutuiih}
10 7reffadwaler p,k'rmlimi9r!
DSalini1% 13arncr
❑ A' orrowiler Ertuo.2gC
DN'abwideicc caul m i
❑ '1l-aorr
®Oilier iipiuin Niggler 121 Remarks)
4. NNW V4'eIICxl CrjrIilpitIttI 1/14/21 1t'e11 Mgr B6
5.1_ %fell Lasrathln:
Remediation Management Service Company
I'.tifrrepli:,rlble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI . ddrea City_ ;md Zip
Mecklenburg 12710204
Cnunty, P+1dee11deiuifciuol4 Nn fP1N?
ih. l:inilb ind 1aangltnrhr In fltir xrarinhimrteiizccnnrls nr rterimol rkt rersf;
dew 1t Add Ink' Li '1obj 1 strnekmi
35.210533 N-80.801887 '
9. is lure) the rIII i ❑�elYri9nral ur 1planporon'
7. Is thin a rrpair iu an rhriodil iowait: 11'rs or ®hlu
+
{rill ri Ii Ir lriNllr. •i rrii F 0.4,11.0 wen corlJ.7rirll f Cori lla1J'TJJrrIJIJJI liNri I'irlrrltJr rlJl' llll'Nr r Ire rJlr
rr,4drr uldifef stt.li a LW All der hack rtr Mrs form.
S. Pluunbbe -of welly rniillinieeed: 1 _
F it iirddr Vote lr06u40.11 W rime-Irxwr l411tgr' ira'rtr ONLY lr.r11 rllr WNW ciroarnreri,r+r
_5dI�5'Ilrr RAC fiJnu.
9.1W wen depth beimlr' lama surface 20
ror I'NlHrp(I' N'i'iJt 11r4r irh' diq r+17 lfifiReed 16.terrrtrdre- 7* ' AAI l 7 ;IVO
1♦0. SUStIE water' level iicluw hip ofculiu1
i IV/NH k''.m 9 Mom.. Luiri; a.r' •'
1. LSar irik iIIjnrrler: 1. 5"
tJrul �,.IN
12. Well tun tnrctipii Inletlirul: DRIVEN
fl, I
(ILI
c I.c Airger. roinr►. i-0hIr, dIlrci Itierc.r
FOIl WATER SUPRJ.YWELLS ONLY;
Oa Vivid IRpaml t er:
I313, L1i lnrac ua riper. 4muuut:
1.4 Wfti= Molls
Iravil l 11I;
R!_tir'HIP rJl1'
ft.
rt.
t5. {MJT R CASFNC Orr rau11I-F ieil ii Ni) OR L N ER fit amaRcahkh
FROM I TD Pr 1 IrFTFR TPPICKNFM,.
0 11' j 12' t1,
I 2Er LN}iRs cot:SINc Its'r_t)91niirivr.r4rir[r�[rarup_.
k FROM TO DtiAlESFR TDICKr4ESS MALE JAL
to
9-
n,
1.5" Jo,
NA
T D PlArlar 1?ir J Ji l:W SWi
20' 11.1. 1.5"
..
NA
11.iTIENTAI
Steel
THILIk!rPv4
NA
w. rl[krm.
Steel
IL
rt.
711, GROUT
RAOi1
Nn[Eltlii. ! F. trLI. Mk4TlllLnI(IJJJkAMOUNT
tt.
n,
rt+
r4
rr.
IL
24, ! WC.RAVPL PA€ k. I,r dyrlicibk}
rt.
T[r
rI ,
,JI FL HLII.
girEl_1( r'rn *cl' ulme11•gn
{
(I,
11, DRILLING LOG I ntrach iddllionxl 4robe it nm as n. I
FROM
0 tl.
F.
TO
20' ff.
IL
DP.W-REPT:OJ Ni IFl.r. i ir1Fw,., .tI 'nK k hh Fr. a'In ,ftr, OK. I
rt.
14
IL
tL
rt
Ic.
n,
It.
R-
I1.
24 arriLlar.b4
Temporary injection point through DPT tooling
(crl�rcatiom
Brian Ewing
SitPmurt a let al God W cat Comm:tor Dote
AT MT41lI1.I4 drhr frrFml, I rrer.'bi' arfro' rllw rl+r irr10.1 u rY aI l J t41ustrirelea Ire.0.ra'rvamlr
u'JtA l •bl rifCAC 07C .0frrrl ry ?rl f't'r1CL�(J�.:C, V8ti %'W Y I>+rrIrNi rtur SihINe♦ar., rrrld that e
rTg.1 orals rm.and Am beau plrlr'Id.WI rrM AL. 4I1r+J1 iiI wr.
1/27/2021
23. Site diagrslni or ad dlti'Jiuil well delimit?.
Ycn1 rlla, ose ate bi L ill digs "Page to provide addilionul gh.ell site Mails ur we]L
cordrur LLari iklails. Yoti Hun ulso Ara 1i ;i 1 ilHrimt twb'es rl ock:nsirk .
;ill uRlrf7 Al. CNs1 tJcL f{x[w5
2da. Ihlr All Welk Suhami this Farm wires 3U dale of courplerloo of welt
cooSlractipn to the rblkomrl4.
kb:611ra ulWaferkr!Iuurce1, Inr.irmmiluu Pni rssiog Gull,
1617 Malt Sersire CeLIcr, Raleigh, NC 21699-1611
2.I . For [uiectirm Wedl9 ONLY: Iri addition to aeladitlg glee rofnl to the :Idd aces ui
a�eab04•e. miles+ suhl/di a copy of tills. try uiiLlui iLl dirks of r:ampletrati of 11c11
c n tructfuri Iv the faLle.veiu .
IT.ialrm of Water Resources.lrndcrgrnund 1njr:riIalr Control Program,
16.36 Halt Service Center. RialeIgh, NC 27iW9-1(139
24r For Wir ...51mA. ! Indris ape 'WOW
Also submit oi,e cop). of Ali . ILA Ill u Ithiil ;o days of coltiieliopF uF
tircll cnoglrlrrttnn co IL1e criiiim II Jilin lleportmenl Dr air calmly irlitzn
COnimirnircd
rarin trii -I
wFn n t .Jac' II Ina Lr trurcii ilr nI EFI51m IIJIICII1
mid Nmunal itesoluctfi - DPIS1011a aicr 11.muLF
Reh'LuCd Aug= ILII;I

WELL CONSITRUC CON RECORD
Thy fonrl+nn bc,wad rue shitrk lr mI111 IIk „erl5
1. Wel I' Curltr'ricti.r II,Irurnideliont
1F'ar rnicrnill USe D1,11.V
Brian Ewing
edl CF P ri 4L.T Hiatt-
4240-B
NC Well Cool{,Icior C'crllfrkLiun M1iinhci
SAEDACCO Inc
We1I #aoatrswctiun PerrAk 1:; wi0300399; 70002483
liuld2 opvllruhlr kv/f vortil4 lr-r.. -1.a.a .t.i SLtlr_ Y.yd+ILr 1.9Jfantrori
3. Well Isar tehcidc well M
Water Supply Well:
UCreolli nwI Iii iliogJ'Caaling 5upp]}1
I' Ilndusi,ia fCantrnerciak
❑ knorlinn
L1M iicipal/Plrhlic
rlt{Sfdellnlll 4 diet Sunk! l Si RL1.Icl
I-lRcsidenbml Water Supply ts]'Iar'd
NrrP-Water S1upp1}' Wd1:
❑M.cmilorine ❑lea}> '
Eiji:ri9iii V- IL,
r1 Ad111iCi r Rec tarr
robrittircr 9tormc ald Recnilcr,r
❑ AgpirFr 7�61
❑ EN rimCNR1 TgC1rn6Ls3 '
❑ Ci ulhermal iCluted Lrrup •
❑ Gearlicitrial illaringfenoliq Rutuiihl
DSalini1% 13arncr
❑ A' orrn5slrler Ertuo.2 e
❑tiilbRidei c caul m i
❑ Traorr
11IO1lier uilllrr /21 Remarks)
4. D:rti` Wellk0 Crjrlrl hilt); 1/14/21 We.11 Mgr A28
5a_ %fell L.urathln:
Remediation Management Service Company
l•.' 1 I i 1! of rrepli:Ilble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI . ddrea City_ ;md Zip
Mecklenburg 12710204
CVwmJ1 Prleecl ldeiu9Eleiuol4 Nn fP1N?
ih. I:IniiJ rind Iaangltnrhr In fltirrxraElnhimrteiizecnnrls nr rtecimil rkit rrra;
ads tIi Add Ink' LiOntivJs strf,tl<JUE
35.210533 N-80.801887 '
9. l3 lure) Ihr!11 rIPI i ❑lrermanral ur 211rInporon'
7. Is thin a rrpair iu an rhriodil iowell: �11'rs or ®hlu
+
{rill ri Ii Ir lriNllr. •i rrii F 0.4,11.0 wen r4NJ.7ril1 Roil d Iri1J'TrJrrIJIJJI mod I'SrlrfJrJr rA 1' llll' rr IIr rJlr
rr,4drr ulaLl+r 1J' rrei rlth stt.li a LW All der hack rtr Mrs form.
S. Plumbbe -of well rnirlinieeed: 1 _
F .r iirddr Vote lr06u40l1 W rime-Irxwr lulrjgr' ingtr ONLY lr.r11 rllr WNW enrrarnreri,r+r
...ermlrr RAC fiJnu.
9.1'01,1 wen depth beimlr' lewd aurfaee 20
ror FNllirp1l' Nei/1. 11hr 1W fil'L r1r7 thifi erect 16.ter' ijdre- 7f ND' arr17 ;IVO
1♦0. SUStIE water level iicluw hip of culillIC
fI I141+I'1. k''.m 9 Mom.. Luiri; a.r' •'
1. LSar irik iIIlrarcltr. 1. 5"
12. Well tun tnrctipii Inletlirul: DRIVEN
fl, I
(f1.1
c 1.c Airger. roinr►. i-0hIr, dIlrci Itierc.r
FOIl WATER SUPRJ.YWELLS ONLY;
1.1a. Vivid IRpaml of t er:
I313, LM.MA:clime riper. 4muuot:
1 . WAII k Molls
Iravil l TO
DE rICIP IJl1'
ft.
rt.
t5. {MJT R CASFNC Orr rau11I-F ieil arr11) OR L N ER (it amaRcahkh
FROM I TD Pr 1 IrFTFR TPPICKNFM,.
0 11' j 12' t1,
I 2Er LN}iRs cot:SINc Ils'r_t)91niiirlrivr.r4rir[I�[rarup_.
k FROM TO Drk'41ESFR TDICKl§ESS MALE JAL
9-
n,
1.5" Jo,
NA
TO PrArrrrI1?ir J Ji I;or sr i
20' O. 1.5"
..
NA
11.iTIENTAI
Steel
THIr lk!rPv4
NA
w. rl[krm.
Steel
IL
rt.
Ii
it GROUT
R1iicts
I r7
RnTE1tPM. ! F. trLI. Mk4Tlllr.owl/aAMOUNT
tt.
n,
r4-
rr.
IL
24, ! WI;RAVPL PA€ k. I,r dyrlicibk}
R.
T[r
rI ,
1JI FE HLl1.
r[irEl _1( r wn *c 1' ul=meppn
{
(I,
31, DRILLING LOG I nlrich iddllionxl 4botifl it rreekvary I
FROM
0 tl.
F.
TO
20' ff.
IL
DP.W-REPT:OJ Ni IFuhr, immiw,., R'Iµ'r'H k hh Rr. rtIn 4r, OK. I
rt.
IL
tL
rt
if-
rt.
R-
11.
24 altritA.104
Temporary injection point through DPT tooling
h. crl�rcatiom
Brian Ewing
SitPmurg aFecal lied Wc8Comm:tor Dmc
AT MT41111. 4 drhr frrtrrk I rrrr.'bl' ei0105' rllw rl+r 1A-10.1 14rd aI l J tClustrirelrtI err.0.ra'rvamune
u'JtA 1 •Il rifCAC OSC .Oral ry ?rl rvt',1CL�(�2C,(V8t1 % Y I I)Jrrrreartur SihINe♦ar., rlrld riLU
rTrf.l orals rm. and Am beau plrlr'Ifl.Wl rrM AL. 4I1r+J1 iiI wr.
1/27/2021
23. Site diagrslni or addlti'Jiuil well delimit?.
Ycn1 rnli1 ose ate Lack of digs page to provide addilic)nUh gh.ell site Mails ur we] L
r8rtslru ;hall Lklails. You Huge ulso Ali 1l ;i[ldilrtisuut twb'cs d rxwcssan .
;ill uRlrf7 AI. CNs1 tJcL f{x[w5
2da. I iir All Wr,ik Suhami this Farm with 3U dal of courpkdmoo of welt
coo$rructipa to the rblkomrl4.
ihh NFra if Weer Reno rce5, Intlrrmmiluu Pni rssiog Gull,
1617 blab Sersire CeLIcr, Raleigh, NC 21699-1611
2.I . For [uiiectinu Wedl9 ONLY: In addition Ie seladitlg Ilie rofnl to the :Idd ress ui
2-Pa ab0Vd. a1s.i suLlloil a copy of tills. try u iiLlui 10 dirks of r:ampletrati of vcc ll
co struKLfuri Iv the IuLlOhviu .
Millen of Water Resources.lrndcrgrnund Injr:riIalr Control Program,
1636 Halt Service Center. Raleigh, NC 27iW9-1(136
2.3L Fur Wire° 54ppl} ! Iojeisioi Wile.
Also submit or,e cop). of Ali . ILA Ill u lthiil ;ro days of coniF+ielion uF
tircll cnoglrlrrttnn co ILle criiiim 11011011 llepplrtmenl or air comity irlicii
coral-ni icd
rarin dF' l -I
wFnnt ari'ulnFLmktnii iiEIII LIII1r5�IIJII111
mid LIILWml JrC0Iuctfi- lPE10I1.nl' Wnice rlinia.rcm
KeirLSCA1 Aug= 11.1I;1

WELL CONSITRUC CON RECORD
Thy fonrl+nn bc,wad roc sIiig}c.Ir iii1lIEirlr „ergs
1. Welt Curltr'atctr.r Inform/dime
1F'ar rnicrnill USe D1,11.V
Brian Ewing
▪ Veit {tulip lur Nara
4240-B
NC Well Coulr,Icior C'cr[IfrkLiun M1iinbcr
SAEDACCO Inc
? . V4'e14 traristnictiun Pernik O; 1r10300399; 70002483
liu tin owllruhlr 0.v/t vemil4 !Lt. G iltnty SLtlr_ Y'yridlL 1roferta r#
3. Wdl Use tehcidc will M
Waller Supply Well:
cillttlral
UCJeor i nwI Iiiaariog'Coaling 5upp]}l•
I' Ilndusiria hart ercial
❑ hnt Lhnn
L1M iicipal/Plrhlic
0 R rsfdr:Ilnlll Vridizr Sunk l Si RL1.Icl
I-lRcsidentr,ll Water Supply i.s]'Iaredl
riir:-Water Supply Well:
❑h ioniloiiuc ❑lea}>'
Eiji:ri9iii V- IL,
rlAdllrifr:r Rectiktrim
pArinircr 9tori.gc And T{ ecni,cr,r
❑ AgpirFr 7�61
❑ EN rimCluR1 TgC1rp€rG,3et'
❑ Ci uthermal iCluarJd Luny •
❑ Gtotheiiiial illea111ii+CnssllEl Rutuiih}
DSalini1% l arncr
❑ p' orrn5,lrler ErRio.2ga
❑5111WcieUCC Carlmi
❑ Traor'r
11IO1lEer 1iap11iIIi tiialrt 121 Rem/Irks]
4. D:rti` Wellk0 Crjrlrlrlel€tl; 1/14/21 We.11 Mgr A30
5a_ %fell L.11rathrn:
Remediation Management Service Company
I'.rifrrepli:,Ilb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIiv .cIiI rlifdrea City_ ;urd Zip
Mecklenburg 12710204
Cnuntl Pii 1 ldeiu9Eleiuol4 Nn (P1N1
h. Lili l hind Iaangltnrhr In iPrglretaElnriM tetiNarcnnrls nr dreimil etc rersf;
idiw 1t Add Ink' Li '1oj Js strf,tl<JUE
35.210533 N-80.801887 '
9. Is ILi ) ION! 1irIPIji ❑I iYri9nral ur 211'moron'
7. Is thin a rrpair iu an rxialioll wall: 11'rs or 121h1u
+
{rill ri la Ii lriNllr. •i rrii F �TNrIIW wen r4NAlril1 i rI dlrrl J'TrJrf lJlkl iiri I'SrlrfJrJr rA 1' 111l' rr Irr rJlr
rr,4drr uldL.i'!1i reu&rlt5 set.li a LW All [Irr hack rtr Mrs form!.
S. PluuLbet of well tlnirlrrueeed: 1 _
F it uwdrote lr06u40l1 ve - I r.VPd, r .141104 I11.4r ONLY lr.r11 rllr WNW enrrarnreri,r+r
_5dI�5'Ilrr RAC fiJnu.
9.1'01pl Fell depth beim lama surface 20
r,rr I'NIHr�rJI' N'fi�4 Ir,r ire rii'L r+r7 thifiViri,rlr 16.terrrtldre- 7f ND' aril 7 ;IVO
1♦4. SiStIE weter Ie►r1 iicluw nit] ref cuiiu1
fI I141+I'1. k''.m 9 Mom.. Luiril; a.r' •'
I L kneel ilk illjnrrler. 1. 5"
tJrul �,.IN
12. Well tonal retipu IPW111 141: DRIVEN
rt.I
(rl.I
c I.c rorger. roan . i-0hlc, dllecr Iti eic.r
FOIl WATER sUPPJ.YWELLS ONLY;
Oa Vivid ligpinI rift ere
Ilia, bi.lnrcrtiva riper. 4muuut:
14 WM= V.01,11s
kaviw I
R!_tirltIP IJl1'
ft.
t5. OUTIiR CASFNC «llr rl1u141-aieiI web) OR um ER (it amaRcahkh
FROM I TD PR IrFTFR TPPICKNFM,.
0 tL. j 12' t1,
I 2fir IN}10 L'l1SINC Its'r_t)91niirivr.r4rirrl�rrarup_.
k FROM TO Drk'41ESFR TDICKl§ESS MALE JAL
n,
1.5" Jo,
NA
TO PrArrrrI1?ir J Jiifirrsra
20' II. 1.5"
..
NA
NATIENTAI
Steel
THIr lk!rPv4
NA
m. rllkrsl.
Steel
IL
rt.
Ii
711, GROUT
I r7
RnTE1tPM. F. trLI. Mk4TlIILoI€rlraAMOtINT
ti.
n,
14
rr.
IL
24, S)lNWC.RAVPL PAC. I+r dyrlicibk}
Trr
II,
1JI FE HLII.
IrirEH _1( r %IF 1' ulm eh..Pn
{
II.
31, DRILLING LOG I nliich iddllionxl tilredi if rrixoss r I
FROM
0 kl,
ri.
TO
20' 9.
IL
DP.W-REPT:OJ Ni IFyhr, imninyra, RIIµ'nK k i5 Rr. a'Iii 4r, OK. I
rt.
14
IL
tL
it
Ic.
I1,
It.
R-
It,
21. altriLlk104
Temporary injection point through DPT tooling
2/_ (crl�icatiirae
Brian Ewing
Sieshourg aFetal God WcitComm.:tor Dtec
AT ST41111.4 drhr frrrnll. I rrer.'bi'trrfr7I Mull rNAY 1A-1 .1 u rY JI l J tClusrrlrelrtI4i.0rra'rvmmlr
u'Jrrr l •Il efCAC 07C .Ofrrrl nJ. ?r1 rvI',1CL�u�22C,(V8f1 W Y I I)JrrrrNMrrmur Sihlrkllar., nrnd that e
rTg.1 orals rm. and Ambr,r J plrlr'If1.Wl rrM AL. 411r+J1 iiI wr.
1/27/2021
23. Site dtikarslni or addtti'Jiima,I well delimit?.
Yuu rllli, 1k ate Ll ick of digs Ile ' to provide addilionUh ,roll site details ur xe] [
cortsl il;llali Lklails. You Huge ulso Ara;Erldilrrfuut taa,Lxs rl r,ewcsSan .
$GluR1.r11AI. CNS7'11C"Lf{?N5
2da. ihlr Ali Wrik Suhaoi ibis Form within 3U dale of courplerloo of swrit
cooSlractipn to the rblkohrltl
i h NFra ill Wslrrrkriuorcr5, Inrrrrmmiluu Pni rss.iog Gall,
1617 blab Sersire Ceeilcr, Raleigh, NC 21699-1611
241. Fier [Mace/ We319 ONLY: In :Lddiliorr to aeladitlg Ilie ro€nl to the :Idd ress ur
a�eabo4•s:. a1s.i suhluil a copy of tildk fury uiiLlui 101 dlks of r:alllpletii ii of vcc ll
tim>struKLJuIL Iv [Irr IaLle.veiu .
Millen of Water Resources, lrndcrgrnuird 1njrTlIoi Control Program,
16.Itr Halt Senile Center. Raleigh, NC 27fi'f4-1636
24r Fur Witgi° Suppl} Iojrit1)i WOW
Also submit oi,e cop). of ihi& ruin, u IFhirl ;o days of coltiileliopF uF
tircll cnoglrlrrttnn co tLle comm lirliltil lleppininenl or air cpiu*i whim
corairrucicd
rarin trii -I
wFn n h arc' a Inn L'Ictr ii in nI trl, lr50liiikeu1
alkl atur t iteraluctfi - DPE1011.a Wake Rinut.rcL
Kelaged Aug= 11.1I;I

WELL CONSTRUCUON RECORD
Thy fonrl+nu tic ascii fog 51.iiirk .'i sII111 i'I hw erl5
1. Wo11 Curlrr'atcti.r Inform/dime
1F'ar frOcmill USe D141.V
Brian Ewing
WOLCFP ra4lr'rNarrnC
4240-B
NC Well Coulr,Icior Carliihmtiul1 tkiinhci
SAEDACCO Inc
V41I 1 ooatrl,ctiun Pernik*, w10300399; 70002483
liuul2 opvllruhlr 0.YirPrrmil4lr-r.. G iltnty SLtlr_Y'yridice 1r 9rt'Or#. h-.1
Wril Isar tehcidc well M
Water Supply Weil:
1:10eoltraital IifeariogJ'Ceoling 5upp]}l
I' Iledusi,ia fCantreerciak
❑ hnipi nn
L1M iicipal/Plrhlic
r1 R4sidr:Ilnlrl Water' Sunk. a €i n fJcl
I-lRcsidenuml Water Supply is]'Iarodf
M1rr:-Wake Supply Well:
❑hioni!mine 1=11 a}> '
Eiji:I/melt V- Ik
r1Ad111ifCr Rectiar re
pArinircr 9tora8c ald Ttecn� cn
❑ AgpirFr 7�6I
❑ EN rimCruR1 TgC1rp€rG,3et'
❑ geothermal iCluset Loolit
❑ Geotheiiilal iFlentitr JC'nolimn Retuiihl
DSalini1 13artacr
❑ p' orrn5rrrler ErRia.2ga
❑SIILNUICIICC C'aryr{ll
❑ Traor'r
®O11oer i ucpilui, tinder 1/21 Ren oaks)
4. D:It V4'eklltxl Crjilrlrlel€tl; 1/14/21 1t'ea1 Mgr A18
i.L. %fell Location:
Remediation Management Service Company
I. • I i' ! [if rrepli:irbler
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea Cit,_ ;m d Zip
Mecklenburg 12710204
CoNmall t31uec1 Ideiuifleiuol, Nn fP1N?
ih. l:lnir r>rnd IJIrgltnrh' In deprrethrhimrteiizecnnrls nr derimol et•egrrra;
ds rli IkId Ink' LIVIativ1 strnekmr
35.210533 (-80.801887 '
(1. I3 lure) Ihi l+lrIPIji. ❑lrermanral ur 211 'moron'
7. Irs s this a rrpair iu an iodil iowait: 11'rs or El Nip
+
{rillri la Ir lriNllr.•i l ii F IiTNrIIW i1 lfIrYrlJ.7fil1 i'rl r IIr NIr
rr,4drr uIdL.i'!1i remark.. Y[eJrnri LW All der hack cd Mrs forJu.
S. Number of well cnirlrrueeed: 1 _
r r Ilw2ronte lr06.140.11 W rire-Irxwr ONLY lI'.rh rllr WNW iv krrnrethilr
_5drra'II2r RAC fiJnu.
9.1'0101 wan depth beimlr' lane surface 20
r,wr I'NIHr�rJI' N'fi�r �r1r irri r i r+r7 thifi Arect 16.terlrtrdre- 7iF:i;10' aril 7 ;IVO
11F0. SiStIE water' level iteluw nip of cusiu1
i+ IV/NH k''.r•i 9 Mom.. Luiri; a.r' •'
1. 1. 5"
12. Well i`uretinrctipi Imetlied: DRIVEN
iri,t
ffLI
cI.c Airger. roan . i-0hIr, dIi l Itietc.r
FOIl WATER sUPPJ.YWELLS ONLY;
k.la. Vivid lrpaml 11A4.11104 of t er!
1313, LtiilnfaL ua rapei 4muuut;
14 WAIIk Molls
RCN 11n
R!_tir'HIP rJl1'
rt.
t5. {MJT R CASiliC «llr rfou11I-F ieil nab) OR L FfE.R (it amaRcahkh
FROM I TD PR IrFTFR TPPI€'KNFFt4
0 it. j 12' f1,
I 2Er rN}10 L'lLSINC Lln'r_ 91niirivr.r4rirr rrarup_.
k FROM TO DtiAlESFR TDIrlifiESS MALE JAL
6.
n,
1.5" Jo,
NA
TD Pr.#oFIPirt J Jiifirrsr's'
20' ft. 1.5"
..
NA
IIATIENTAI
Steel
THICl stSi
NA
m. rllkrsl.
Steel
IL
rt.
Ii
7II, GROUT
RAOi1
I h7
Nn[Eltlii. ! F.#tFLI. Mk4TllMT.nomLaAMOUNT
ri.
n,
r4
rr.
IL
24, ! WI;RAVPL PA€ /. I+r dyrlicibk}
rims:
R.
if El
II,
1JI FL HLII.
1[irEl_1( rwnr*rl' ulme11•gn
{
(I.
11, DRILLING LOG I nliich iddllionxl rbotifl if r1ce,... ilr3' I
FROM
0 ti.
ri.
TO
20' ft.
IL
DPW-REPllilNIBuhr,l,Mrdhy+ Rµ'rKkhhRr.a'In4r,OK. I
rt.
14
IL
rL
it
if -
FL.
It.
R-
IL
,
21.ar it.04
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a Fecal red W c8 Couurb'rur D tec
AT MT41lI1.I4 drhr frrFnY. I frenAry cor4j5. rllw r2+Y 1A-10.1 14rd iwarsJ t41uw irJIrtL rlr.0.ra'rvmmlr
u'Jt14 l •Il riCAC OTC .Okra+ nJ. ?r1 rvc',1CL�u�.TC,(V8f1 WI Y I)Jrrrrlrr'rrcor ShINe♦ari iIrIIlr dint r' n orals rm. and Amb,rrrJ plrlr'Id.W1 rrF JIIW 4I1:1J1 iIwwr.
1/27/2021
23. Site diagrslni or aid dtti'Jiimil well delimit?.
Ycn1 PIA!' ose die kxicL of fills pow to provide addilicsl,ul i ell site ddiils or well
r8rtstru ;Llali Retails. You Hun also Milo 11;xldilrftiat taag7es rL h,cccsSan .
$L1IlRiCf7 Ai. LNb11.1CTIoNS.
2da. Len( Ali Wells. Suhmel ibis Form within 3U dale of completion of writ
Lom5rructtpa Lathe Following.
1Fl►isFra ul'Water Resources, Intlrrmmiluu Pni rs.iog Gull,
1.817 hlblt Sersire CeLter, Raleigh, NC 27699-1617
241.. Fier dailiim YWIA ONLY: hr addition to aeladitlg the ro€nl to floe :addaces Pik
a�eabo4•e. alsar suhlul1 a copy of tills. tint uiiLlui 101 dates of COmpluticith of well
co strut ruIL ILl the faLlowiu .
IT ialen of Warier Resources, lrndcrgrnund Cunrrok Program,
1.836 Halt Service Center. Raleigh, NC 27tW9-1 I36
2.3L Fur Wir °.54RPl} 4le IDj1FEt pi WOW
Also submit sire cop). of ilii . ruin, u ICLuii ;o days of coltriletion uF
tirckl cnoglrlrrttnn co tLre cchit} 1i41i101 lleppin,rienl or air comity wise=
cooly nlcled
rarin trii -I
e' fit n t arc' II Ina L'Imtr ii iiE III LI I5lr5r Iwrcui
aui LIILui ml itesolQCtfi - 3)1.kr5I0I1*f' Wake am.Larc
Rch LuCd Aug= 11.1I;I

WELL CONSTRUCUON RECORD
Thy fonrf+nu tic rlscii roc 5Iiiirk mI111EIrk hlell5
1. Welt Curltr'rieti.r II,Irur>widrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
W dl Cnnirl4r r'T NarinC
4240-B
NC Well Coui{,icior CarllfrkLiun Niirti
SAEDACCO Inc
V41I 1raoatrswctiun Perrpk 1µ; 11i0300399; 70002483
liu uli oglilruhlr wv/f vrmil4 !Lt. - it th SLtlr_ Y'yridlL 1.9ferteriri
3. Wr I Use trim& wall M
Water Supply Vied:
flt r'clEltural
UCJeorllcTnwI IiiaariogrCoaling 5upp]}l
I' 1lndusi,ia fCanunercial
❑ hnipi nn
L1M iicipal/Plrhlic
rl fk:sidellnlll WtiECF Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
NOP-Water S+upp1}' Well:
❑I4ioi iIoriuc 1=11 a}> '
I [1j4`ri9iii V- Ik
rlAdlllifir Recti51rire
pArinircr 9tormc and Ttecn� cn
❑ AgpirFr 7�61
❑ EN rlmcruRl TgC1rn6Lw3 '
❑ Jouiherm;rl iCluted Lin]pF
❑ Geodreitrial illes,uii Cnssliu Rrtuilll
DSalini1% l arncr
❑ A' orrn5lrrler Erryin.2r4
❑ IILN ICilcC Cali MI
❑ 'soar
®O11rer LIINICr /21 Renlulks)
D:Iti• VielI» Crjrlrlrlel€tl; 1/14/21 We.11 Mgr B13
5a_ %fell t.11rLthrn:
Remediation Management Service Company
I'. tiflrr'pli:nt71e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI . ddrea . City _ ;ind Zip
Mecklenburg 12710204
CVwmJ1 t31eec1 ldeiu9Eleiuol4Nn fP1N?
ih. Linibuir iiid Iaangttntir In lP12-prxrarinlimlteiilccnnrls nr drtimol kt rrra;
ids rli Add Int' LIVIativ rrmcl<JUE
35.210533 (-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an rxiodioil writ: 11'rs or IR ND
irirrfh it Ir iriNllr•,f+ll,Nlr �TNrIIW oqu'l 4r l 'illffi'rI ilrllJ'TJJ'rIJIJJI iIN'i I'tirlrrldJ' fA" ill) Nrr II rilr
rr,4drr uIdL.i'!1i remark.. Y[eJrnri LW All [I1r hack ri? Mrs form!.
S. PluuLbet of well tlnirlrrueeed: 1 _
ii rddr Vte oreMArilal W rire-Irxrrr l ONLY n'.rh rllr WNW cMkrrnreri,Nr
_5dI�5'Ilrr RAC fiJnu.
9. Tuts) wall depth helm lima surface 19
for I'NIHI'p1I' lfifiArlrfi(e.terlrtrdre- 7 ' Aril2cir ;IVO
11l0. SUSTIE water' level iicluw nip ofcusiu1
if IV/NH k''.ri it all'om... iri,; a.L' ".
1. 13or 1Yt11t illjnrelcr 1. 5"
12. Well i`riidilniZipii militia; DRIVEN
(ri, t
(fl.I
c I.C, rorger, roinn , i-0hlc, dlTecl IL ere.
FOIl WATER SUPPJ.YWELLS ONLY;
Oa Yield IRpartt of
111r, biilnfai ua rapt: 4muuut:
1.4 WAIIk 70 115
RCN l 1n
R!_tir'HIP IJl1',
ft.
t5. OLITHR CASiliC «llr Prou141-renoil ii Ni) OR um ER (it amaRcahkh
FROM 11-0 PR ITTFR TPP11(1 F5'4
0 11' j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirivr.r4rir[I�[rarup_.
k FROM TO IitiAlESFR TDICKl§ESS MALE JAL
Cm.
n,
1.5" Jo,
NA
T1} pr.# lTrrllt J $ i firr L lls.
19' II- 1.5"
I.
NA
THIr 1,1
NA
IIATIENTAI
Steel
mATlckrsl,
Steel
IL
rt.
7N, GROUT
FROM.
I h7
NATE'Itni. F.#TFL1i> Ii1kwTlliLnI(IJJ & AMOUNT
It.
n,
rt+
r4
rr.
IL
24, ! WI;RAVPL PAC. I+r dyllicibk}
T[r
1JI FL HLII.
10rEH_1( Fwnr*r1''dlmehgr1
{
II.
11, DRILLING LOG I nlrach iddllionxl wbotifl if rreemary I
FROM
0 fl,
TO
19' fi.
IL
nP.WrltlPT:OJNIFl.r.i irdhn., RIIµ'nKkh5 Rr cril.n ,OS.I
rt.
14
IL
rL
it
Ic.
Ir,
Ira
R-
IL
21. Br_M.t3RbA
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a Fecal red W c8 Caurrserur Nee
AT MT41lI1.I4 Au. fatal, I rrrroiry eMrr I' rllw r♦+Y 1A-10i 4rrY JI,l J t111115 ireira Ire.0ItY'rimavir
u'JtA l •bl riCAC OTC .Warr) ru. i TA rvt'i1CL�(�L'C A.041 %'W Y I)JrrIIrNi rmur Standard mist riLU o
r' n orals rm. and Ambr,rN plrlVlfl.Wl Fa' Au 4I1LJ1 iiI wr.
1/27/2021
23. Site ditioslni or iiidt1i'J1u1I well delimit?.
Ycn1 anal 1k ate L ac6 of digs "rage to provide addilicsnul Ii.e111 site details ur we] L
L'8IiSIrur;Llali LLelalls. You Hun ulst5 Breda ;E[1diirmiut tkJ ws rI r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I iir All Wrik Suhaoi ilus Farm wires 3U dale of courplermoo of swat
coEI rnlcttpn to the rblkohrltl
ii1►:iNFia ul'V4'rrirrkrrluurce1, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uiectiex We319 ONLY: Iri addition Ie aeladitlg Ilie rofnl to the :Idd r>sa Pik
a�eabo4's:. miles+ Stith loll a copy of tills. try uiiLlui iLl dlks of I:ampletii it of vcc ll
c n tructluu ILl the IaL]Ohviu .
I"h imam of Water Resources, lrndcrg nand 1njr:riIIall Control Program,
1636 Malt Service Center. Raleigh, NC 27iWcr-I(136
24r For Veir ...54ppl} Iojraion 'WOW
Also submit olhe cop). of phi& ruin, u Itlhru ;8 hays of COritpieliopF uF
tire)) cnoglrlrrttnn co ILle cnlrut} 1141i101 IleppfrlimN1I or air c iiu*i w it=,;
coniImcicd
rarin trii -1
wFnnh an'ulnFL'.lktnii instil LII51r5rIIJIYCIIr
slag LIILur 11 itesoluctfi - 3)1kr5I011*f' W.nicr aC{JLrc
Keh'L9Cd {i.aLlr# hi I.I

WELL CONSITRUC CON RECORD
Thy fonrl+nu tic 1lscii Gut sllu;k +Iw Irlllll trk ht ell5
1. Wel L Curltrrichir iInforlriitllin
1F'ar FrOcmill 4ic D141.V
Brian Ewing
eN11. Cnnirl4rr'r NarrnC
4240-B
NC Well Coui{,icior Car[IfrkLiun r:iirti
SAEDACCO Inc
?. V4'e14 t aristnietieu Pernik O; 11i0300399; 70002483
liuuli oglilruhlr 0.YirPrrmil4lr-r.. G iltnty SLtlr_Y'yri+lLr 1r 9rtfor#. h-.1
3. Well ilse term& well MAO
Water Supply Well:
UCreotli nwI lifeatlogrCoaling Stipp]}l
I' 1lndusi,ia fCantrnerciai
❑ hngai nn
L1hiiLtril.ipctllrhlic
0 t{Sfde'ln111 Water Sunk. l Si RLICl
I-lRcsidentrml Water Supply tsltamdt
NIPP-Waer S+upp1}' Well:
D Imam 1=11 a}> '
nji:I/arr1I V- IL,
r1Ad11rifir Recii51I re
pAtinircr 9tora8c ald Ttecrrr5er,r
❑ AgpiFFr TJ:6I
❑ EN rimCruR1 Ttchnoto
❑ Ci ulhermal IClused Loopt
❑ GeothermalIFIciiiii toolinnRetliiiil
4. Dine WetICxl Crjrlrlrlel€tl; 1/14/21
i.L. %1'eil Location:
OCko toddlware.F 1{e111cdu111wl
I SRiinii313arricr
❑ p' orrnirrller ErRig2ga
❑tiilr3GidC11CC C'aryr{ll
❑ Trour'r
®O1ller ie plaid wlJrt /21 Remarks)
1�'eal ill`mr A5
Remediation Management Service Company
I. • of rrr'pli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PItimenI Addrea Cit... ;md Zip
Mecklenburg 12710204
Cnuatll Prldecl Ideiu9rleiuol4Nn fP1N?
ih. 1.41ihminand laingluttir nr derimol d•egrrra;
rdt rli Add Int' LIUIativ strlT,tkiul
35.210533 (-80.801887 '
9. 13 Imri) Ihi l+l rIPIji. ❑I'eim nral Li 211 'moron'
7.Isthis arrpairivanr7riodiollwrit: 11'rs or El Nip
frill ri Ii Ir lriNllr. •i lrii F �TNrIIW i1 lfI r4r•'J.7'iHifrr'rl llr�l J'TlJ'fl Jlkl iiri I'SrlrfldJ' rA i' llil'Nrl' Ile rilr
rr,4drr ulaL.i'!11 remark:.. Y[eJrnrr ur r41 der hack el? Mrs fr'rJu.
S. Number -of welly consirueeed: 1 _
i r cridoore Orrjevuilmll W Nretl-Irxwr J•IIf ' !WM' ONLY ir.r11 rllr WNW ivarrnrethilr
_SdI II ro )'iJnu.
9.1W wan depth helm lewd surface 19
for I'Nllirp1l' thifi erect 16.terrrtrdre- 7 ' aAIr17 ;IVO
10. Stitic water level below nip of t:4101.11
▪ I141lI'r k'rri it Mom.. L ire; a.L' •'+
11•• leer sine Ilijnreltr 1. 5"
thu +.SIN
12. Well cuidtlnrctian inmtlia(i: DRIVEN
f ri.
(fled
cLe. rorger,roinn,t hlc,dlleclelkEILeic.r
FOIl WATER sUPPJ.YWELLS ONLY;
1.14. Yield %rpam l 11A4.11104 oft err
1313, biilnrarl2ua rapt: 4muuut;
1.. WAIIk 70111s
RCN 11n
R!_tii'HIP rJl1',
rt.
t5. {MJT R CASiliC «llr Ir1u11I-F ieil nab) OR L FfER .fit appJRcahkh
FROM 111"i PR ITTFR TPPI('P FM4
0 i j 11' ti,
I 2Er 0'40 C#L1INC on 7T)91f11iivirrerirlrarr r1l.11rlp_.
k FROM TO DLk'41ESFR TDICKl§ESS MATE111.9i
6.
n,
1.5" Jo.
NA
lli ritorel-Nit 1 $I:or min'
19' Ii. 1.5"
I.
NA
NATF•ATAI
Steel
THIClistSi
NA
st..kTlrttrsl,
Steel
IL
It.
Ii
iN, tiR01T
RAOi1
I r7
Nn[Eltli[. EMPLI.VEMKNTlIILnomLaAMOUNT
tt.
n,
it+
l4-
rr.
iL
24, ! WI;RAVPL PA€ /. I+r dyrlicibk}
rprril
Trr
,JI FL Hd II.
LrirEl _1( r rn *r l' u1-e 11•gn
{
II,
11, DRILLING LOG I nliich iddllionxl rLledi if rieccoory I
FROM
0 r1,
ri.
TO
19' fr.
IL
DP.WrItlPllilNlF r,1'Mrdhx+,.tI'nK(ki5Rr a il.n OK.I
rt.
IL
tL
It
Ic
It.
R-
IL,
24 arrliA. 4
Temporary injection point through DPT tooling
2/_ Cery�rcatirra.
Brian Ewing
Sieshourg a Fecal red W c8 Couub:rur Dtec
AT MTrr'JI1.4 drhr frMrl, I rrer.'bi' ei010I' rllui rNAY 1A-10l LIrrY .11.4:tre,1 tyietwireirtL err ve.ervmmlr
u'JtA 1 •bi rirCAC OTC .Offal nJ. i TA rvc','CL'u'.TC,(V8f1 WI Y I>+rrrrNH'rnor ShjNdards Wend r♦i,U o
r'rJl1 orals r+'r'and 1lr:h br,r J plrlurfl.Wl rFF Jryr. 4I1LJ1 iiI wr.
1/27/2021
23. Site dr t;rani or aidditi'JiiJil well delimit?.
Ycn1 rl1Hs 1k O die hick of fills pew to provide addilirsnul i ell site ddiils ur we]
construction derails. You nun also Mod ;x1dilrrfdlul twb'es rl r,r:wcsSan .
;iu uRlrf7 Ai. INb11.1C IONS
lda. Ihlr All Wr,ik Sehami this Fnrm within 3U dale of coorplerloo of swill
construction to the rblkomrl4.
lFh Nblla u1-19iicrr'Remo rces, Intlrrmrsiluu Pencessalug Gull,
1A17 hIAII Sersire Ce Llcr, Raleigh, NC 27699-1617
24b. For [ukcillm YWIA ONLY: hi addition to aeladitlg Ilse foal to tree iiddress Pik
a�eabo4•s:. alsar suhiii1 a copy of tills. fonii uiiLlui i0 dates of L:Ompletiith of well
construction ILl [he faLlowiu .
abh imam of Water Resources, lrndergrnurrd luleciIoiu Cunrrol Program,
1.8.16 Hair Service Center. Raleigh, NC 27fi'f4•.1836
2.3L Fur Wirer.54ppl} 1ojessi im WOW
Also sublr'lli[ owe cop). of ihi . flan, u Itliru ;l8 treys of CQniFijeliOn uF
tircll cnoglrlrrttnn co IL1e criiiim 1101101 rlepplrtirienl or air county wise=
coral -lured
rarin tail -I
e' fl n t an' II Ina L'Imtr ii iiE III twlt 1r5r IIJIICIII
alrl LIILWmJJtesoluctfi-l)FkEI0I1ni%Waicrklimar9L
Keh Lgtd 4111.11;I

WELL CONSTRUCUON RECORD
Thy fonrl+nu tic mad roc sllu;k +Ir mI111 IIk hs ell5
1. V4'o1 t Cuntrocti.r Il,iluririrrliont
1F'ar rnicsnill 4ic DN1.V
Brian Ewing
rri Cnn4rl44r'r NarinC
4240-B
NC Well Co ui{,Icior Carl lfrmLiun Nii rti
SAEDACCO Inc
V41I 4ralostra,ctiun Perralk *; 11i0300399; 70002483
lirruL2 1 pvliruhir k.v/f orrmir4 iLr.. 1rlfarteriri
Veal Use taw& will Male
Water Supply VIeIL-
ClAgr1'cIlltnral
UCreolli nwI Iiiearing'Cooling
I' 1lndusi,ia fCantrnerciak
❑ hntmLhnn
L1M iicipal/Plrhlic
17 R s iellnlll Wtror Sunk. I Si RLzIel
I-lRcsidentiol Water Supply .s]'Iamdl
NOP-Water Supply Well:
❑hicmiloriuq ❑l a}>ary
Eiji:ri9iii V- IL,
rlAdlllifir 1 ecti5arire
pArinircr 9tormc and Recr,3ler,r
❑ Agpircr 7aa I
❑ EN rimCluR1 Trclori*et'
❑ JeuiheYmal iCluted Linlpl
❑ Geoheitrial illes,uii Cnssliu Rrtuiihl
DSrllini1% $arnc r
❑ 0rrowsfier Erolig2r4
❑51rhFhikCICC Cali MI
❑ Traorr
®O11ier iucpluiil uilirr /21 Rernniks)
. D:it.V Viekllsl Crjtlrlrlel€tl; 1/14/21 We.11 Mgr B15
5a_ %fell LAI:3t0ton_
Remediation Management Service Company
I'.'1 Ii1'rifrrepI iiL'Ie6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI A dlse Citr_ ;end Zip
Mecklenburg 12710204
VwmJ1 Pieeclldeiu9rle.iuol, Nn fP1N?
ih. f:urlil iiid IJngttmhr In dri rxrsinlimltetilccnnrls nr drtimal rk•egrrra;
� d s rli Add Int' Li '1oj is surf ekm i.
35.210533 (-80.801887 '
9. I3 lure) Ihi VI rIPIji. ❑Ieim nrnl ur 211rInporon'
7. Is thin a rrpair iu an rxiodiotl writ: 11'rs or IR ND
+
{rrlrri rr Ir rrphn.,f+2lrii F rTNriI1J Ir'1'fIF r llrrllfCo'ri rlrllJ'TJJ'rIJIJJI llrl'i I'SrlrflrJ' M rllrrNrr IIr NIr
rr,4drr uld6'r2.i r ei rk:h Y[eJrarr LW [41 dm hack nr Mrs form!.
S. Plumb'- of well ronmirueeed: 1 _
F it uwrrljVte oreMArrlal W rime-Irxwr 11110' ingtr ONLY mull air WNW rnrrarnreri,r+r
_.artmIlrr RAC fiJnu.
9. 701,1 wail depth helm lane surface 19
for I'NIHrp1I' irri dl'pi1r, tfdij ortvit 16.ter' ijdre- *.:1;10' aAIr17 ;afro
11F0. SUSTIE wrter' Ie►r1 iicluw o►p lrf cusiu1
i+ IV/NH k'.ri 9 mom! L irii rr.t' ".
11. Fiat 4ik iIIrrarcltr 1. 5"
tJrul �,.IN
12. Well i iieirtnretipti owiluuJ: DRIVEN
iri,t
(rl.I
c I.c Airger, rti4nr►, i-0hlc, dllecielkEILerc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa Yield ligpinI 1144.11104 of
I313. fitisioreritiito rapt: 4muuot:
14 Wfti= Molls
Iraviw l 11;
R!_tir'HIP rJl1',
ft.
t5. {MJT R CASiliC {nlr Ir1u14I-F ieil web) OR um ER (it amaRcahkh
FROM 11-0 PR ITTFR TPP11(1 F5'4
0 11' j 11' O.
I 2fir LN}1R cot:SINc as T_t)91niirlikr.r4rir[I�[rarup_.
k FROM TO Drk'41ESFR TDICI:I§ESS MALE JAL
6.1.
n,
1.5" Jo.
NA
T1} pr.# lTrrl'R J $ I,tFT L lls.
19' II- 1.5"
I.
NA
NA
IIATIENTAI
Steel
m. TI[krm.
Steel
IL
rt.
Ia
it GROW
RAOi1
I rI
Nn[Eltlii. ! F. TrL C Mk4TlllLnI(IJJaAMOUNT
tt.
n.
ti,
r4
ir.
IL
29. S)lNWC.RAVPL PA€:k► I+r dyrlicibk}
T[r
rI ,
,JI FE H[II.
rrirr'i _1( I' wnr *r 1' ulme 11.gr,1
{
II.
11, DRILLING LOG I roach iddllionxl wbotifl if nm aaur3 I
FROM
0 fl,
ri.
TO
19' 9.
IL
DP.W-REPllil Ni I suhr,,rirdhn+, R'Itnrc k i5 Rr. a'Iii 4r, OK. I
rt.
14
rL
tL
rt
If-
rt.
Ft-
arriLlar,b4
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
SitPmurg afehcniGod WcitCouurb'rur
AT MT41111. 4 drhr frMrr. I rrrr.+b' eirr7I' Mad riiY ived{ 14rd ilars'J tu'rurrirelea Ire aeerin2avire
Huth 1•Il rirCACOTC.0frrr.). ?ri NC,1CL�G�.TC,tV8I1W IYI)rrrrrnrrnorSiorida,i mid
vim orals rrrr'r+nd 12ii b,rrrJ prrrr'Ido4lFF JIIW 4I1L01 iIwwr.
1/27/2021
23. Site dtii4;l'slni or ad dtli'Jiuil well deriiil9;
Ycn1 rl1Hs ate Wel, +af 11111a "Page to provide addilionul i:•e1l site details ur we]L
r8rtslro ;Llali i1t LuEr. Yoti Hun also Ara ac1dilHfuut tames rl r,ewcsSan .
;iu BRIT. I"1 Ail. LNb711["f IONS
lda. I iir All Wr,ik Submit ilus Form with 3U dale of courpkdmoo of welt
cooSlractipn to the Foltom[14.
i h Nish ul'Wacrrkr!Iuurce1, Int[rrmrsiluu Pni rsstog Lull,
1A17 MAil Semler Ctmier, Raleigh, NC 21699-14511
241. Ettaulectiim Wedb ONLY: In :Lddilioil CO aeladitlg Ilie rofn7 to the itddmss Pik
a�eabo4's:. a1sa1 suhloll a copy of tills. try uiiLlui iLl arks of Ciampluticith of vcc ll
co str uKLluri Iv (he IuUtidN ai .
abh islen of Water Resources, lrndcrgniund 1njr:riIoiu Cunrrok Program,
16.36 Halt Service Center. Raleigh, NC 27iWcr-I(136
2.3L Fur Veirgi° S4ppl} ! Iojetsioe 'WOW
Also submit sire cop). of this- ruin, u iF[ ;i8 lays of coni1leIiorl uF
tircll cnoglrliettnn co tLe criiiim U JiItil dep rorser1l or air c iiu*i 'whim
cony rucicd
rarin trii -I
wFnnh arc' IIIIFLmktreritrirrl LII51r5�IIJIYCIIi
aryl NaLurll rtesaiactfi - DPIS1au n1%Warr IlmarcL
taielaged Aug= 11.11:1

WELL CONSTRUCUON RECORD
Thy fonrf+nu tic rlscii roc 5Iiiirk mI111EIrk hlell5
1. Welt Curlir'rieti.r II,Irur>widrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
W dl Cnnirl4r r'T NarinC
4240-B
NC Well Coui{,icior CarllfrkLiun Niirti
SAEDACCO Inc
V41I 1raoatrswctiun Perrpk 1µ; 11i0300399; 70002483
liu uli oglilruhlr wv/f vrmil4 !Lt. - it th SLtlr_ Y'yridlL 1.9ferteriri
3. Wr I Use trim& wall M
Water Supply Vied:
flt r'clEltural
UCJeorllc'TnwI IiiaariogrCoaling 5upp]}l
I' 1lndusi,ia fCanunercial
❑ hnipi nn
L1M iicipal/Plrhlic
rl fk:sidellnlll WtiECF Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
NOP-Water S+upp1}' Well:
❑I4ioi iIoriuc 1=11 a}> '
I [1j4`ri9iii V- Ik
rlAdlllifir Recti51rire
pArinircr 9tormc and Ttecn� cn
❑ AgpirFr 7�61
❑ EN rlmcruRl TgC1rn6Lw3 '
❑ Jouiherm;rl iCluted Lin]pF
❑ Geodreitrial illes,uii Cnssliu Rrtuilll
DSalini1% l arncr
❑ A' orrn5lrrler Erryin.2r4
❑ IILN ICilcC Cali MI
❑ 'soar
®O11rer LIINICr /21 Renlulks)
. D:It WeII» Crjrlrlrlel€tl; 1/15/21 We.11 Mgr B17
5a_ %fell t.11rLthrn:
Remediation Management Service Company
I'. tiflrr'pli:nt71e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI . ddrea . City _ ;ind Zip
Mecklenburg 12710204
CVwmJ1 t31eec1 ldeiu9Eleiuol4Nn fP1N?
ih. Linibuir iiid Iaangttntir In lP12-prxrarinlimlteiilccnnrls nr drtimol kt rrra;
ids rli Add Int' LIVIativ rrmcl<JUE
35.210533 (-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an rxiodioil writ: 11'rs or IR ND
irirrfh it Ir iriNllr•,f+ll,Nlr �TNrIIW oqu'l 4r l 'illffi'rI ilrllJ'TJJ'rIJIJJI iIN'i I'tirlrrldJ' fA" ill) Nrr II rilr
rr,4drr uIdL.i'!1i remark.. Y[eJrnri LW All [I1r hack ri? Mrs form!.
S. PluuLbet of well tlnirlrrueeed: 1 _
ii rddr Vte oreMArilal W rire-Irxrrr l ONLY n'.rh rllr WNW cMkrrnreri,Nr
_5dI�5'Ilrr RAC fiJnu.
9. Tuts) wall depth helm lima surface 19
for I'NIHI'p1I' lfifiArlrfi(e.terlrtrdre- 7 ' Aril2cir ;IVO
11l0. SUSTIE water' level iicluw nip ofcusiu1
if IV/NH k''.ri it all'om... iri,; a.L' ".
1. 13or 1Yr11t illjnrelcr 1. 5"
12. Well i`riidilniZipii militia; DRIVEN
(ri, t
(fl.I
c I.C, rorger, roinn , i-0hlc, dlTecl IL ere.
FOIl WATER SUPPJ.YWELLS ONLY;
Oa Yield IRpiRP nft er'
111r, biilnfai ua rapt: 4muuut:
1.4 WAIIk 70 115
RCN l 1n
R!_tir'HIP IJl1',
ft.
t5. OLITHR CASiliC «llr Prou141-renoil ii Ni) OR um ER (it amaRcahkh
FROM 11-0 PR ITTFR TPP11(1 F5'4
0 11' j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirivr.r4rir[I�[rarup_.
k FROM TO Drk'41ESFR TDICKl§ESS MALE JAL
Cm.
n,
1.5" Jo,
NA
T1} pr.# lTrrllt J $ i firr L lls.
19' II- 1.5"
I.
NA
THIr 1,1
NA
IIATIENTAI
Steel
mATlckrsl,
Steel
IL
rt.
7N, GROUT
FROM.
I h7
NATE'Itni. F.#TFL1i> Ii1kwTlliLnI(IJJ & AMOUNT
It.
n,
rt+
r4
rr.
IL
24, ! WI;RAVPL PAC. I+r dyllicibk}
T[r
1JI FL HLII.
10rEH_1( Fwnr*r1''dlmehgr1
{
II.
11, DRILLING LOG I nlrach iddllionxl wbotifl if rreemary I
FROM
0 fl,
TO
19' fi.
IL
nP.WrltlPT:OJNIFl.r.i irdhn., RIIµ'nKkh5 Rr cril.n ,OS.I
rt.
14
IL
rL
it
Ic.
Ir,
Ira
R-
IL
21. Br_M. RbA
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a Fecal red W c8 Caurrserur Nee
AT MT41lI1.I4 Au. fatal, I rrrroiry eMrr I' rllw r♦+Y 1A-10i 4rrY JI,l J t111115 ireira Ire.0ItY'rimavir
u'JtA l •bl riCAC OTC .Warr) ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)JrrIIrNi rmur Standard mist riLU o
r' n orals rm. and Ambr,rN plrlVlfl.Wl Fa' Au 4I1LJ1 iiI wr.
1/27/2021
23. Site ditioslni or iiidt1i'J1u1I well delimit?.
Ycn1 anal 1k ate L ac6 of digs "rage to provide addilicsnul Ii.e111 site details ur we] L
L'8IiSIrur;Llali LLelalls. You Hun ulst5 Breda ;E[1diirmiut tkJ ws rI r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I iir All Wrik Suhaoi ilus Farm wires 3U dale of courplermoo of swat
coEI rnlcttpn to the rblkohrltl
ii1►:iNFia ul'V4'rrirrkrrluurce1, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uiectiex We319 ONLY: Iri addition Ie aeladitlg Ilie rofnl to the itddmss Pik
a�eabo4's:. miles+ Stith loll a copy of tills. try uiiLlui iLl dlks of I:ampletii it of vcc ll
c n tructluu ILl the IaL]Ohviu .
I"h imam of Water Resources, lrndcrg nand 1njr:riIIall Control Program,
1636 Malt Service Center. Raleigh, NC 27iWcr-I(136
24r For Veir ...54ppl} Iojraion 'WOW
Also submit olhe cop). of phi& ruin, u Itlhru ;8 hays of COritpieliopF uF
tire)) cnoglrlrrttnn co ILle cnlrut} 1101101 IleppfrlimN1I or air c iiu*i w it=,;
coniImcicd
rarin trii -1
wFnnh an'ulnFL'.lktnii instil LII51r5rIIJIYCIIr
slag LIILur 11 itesoluctfi - 3)1kr5I011*f' W.nicr aC{JLrc
Keh'L9Cd {i.aLlr# hi I.I

WELL CONSITRUC CON RECORD
Thy fonrl+nn be 1lsfld rec sll gk ,lr I!l I111 t'I ii erl5
1. Wel L Curltrnctur Infornirrtiose
1F'ar frOcmill 4ic D141.V
Brian Ewing
Weft CF P ri 4L.T Hire
4240-B
NC Well Cool{,Iciar C'crllfrkLiun Nitro
SAEDACCO Inc
W'e1I 1rtmatractian Pernik Or; w10300399; 70002483
lirrrd2 opvliruhlr 0.Yirovemir4lr-r.. ( IILIIrY SLtlr_WiridlLr 1rofortrar#.
3. Weil Irse term& well MAO
Water Supply Well:
UCreotli nwI IifeatiogiCoaling 5upph1•
I' 1ledusiiia fCantreercial
❑ In3gai nn
Llhiilttil.iperllrhlic
rlFkcsfdennml Water Sunk! aSiRfJcl
I-1Rcsidenlr,ll Water Supply is]'Iarodl
M1rr:-Wake Suppl Wdl:
❑hianiIoiine 1=11 a}> '
Eiji:I/ 1tr1I V- IL,
r1Ad111ifir Recii51I [e
pAtinirer 9torm8c ald Ttecr,3ler,r
❑ AgpiF r T{6t
❑ EN rimcruR1 Ttchn togi..
❑ Ci uthernial IC'lusrd Loopr
❑ Geotherrrial iFIc iiii1 JC•noling Retltiill
. Date WeIICsI CunilPItIttI; 1/15/21
❑ u_ %fell Locution:
Qttreni dwaret Rum-1.4111w!
DSRlinit% 13arricr
❑ p' orrowsiler Erryio.2r4
❑tiIIf3GhdCIICC caul nil
❑ Traorr
®O11ier iiipiuiil under 121 Remarks)
1�'ell JTmr B9
Remediation Management Service Company
I. . ' I I i I ' [if rrepli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PInokuI Addrea Cit... ;Ind Zip
Mecklenburg 12710204
t'lnuntl t}leecl Ideiuifciuol, Nn (P1N1
h. 1.41ihmin iiid 1aingltnihr nr der'imil et•egrrrs;
idt rli Add Ina' LIUIativ strf,tl<Jui
35.210533 (-80.801887 '
9. l3 turd Ihi 11ur 211'mporon'
7. is this a rrpairiu an rhriodir
iowrit: 11'rs or ElN
+u
{reheat rr Ir rriNllr.•i lrii F r;FrrrIIW war l 'illfri'rl I'SrlrratJr rill' lI lrNrr IIr rJlr
rr,4drr ulaL.i'!11 rrei rJ:h set.li a LW All der hack rtr 0.116.1orJu.
S. Nuttier of welbt cniislrrueeed: 1 _
F it criatiootc OrrMAI40.11 W rire-Irxrrr J•IIf ' !WM' ONLY lI'.rh rrlr WNW enrrarnreri,r+r
satviirro )'iJnu.
9.1'001 wan depth helm lewd surface 19
for I'NIHrp1i' dl'LJr+r, thifi r'rect1'Jr{rrrtrdre- 1*. 00' a hid 2cir ;IVO
11F4. Stitic water' level below nip ofl'usiu1
i+ IV/NH k'.ri 9 Mom.. Lwri; a.r' ".
12. Well crinttnrctipi IIYetlimd DRIVEN
fri,I
(fl.I
cI.¢,rorger,roinn,i-0hIr,dIlrci Itielc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Vivid lrpamr of t e r
tile, bi lnf'activa ripe: 4muuut;
1.4 WAIIk 2.01,11s
RCN 11n
R!_SI'HIP I'J!1',
It.
Its
t5. OUTHR CASiliC {nrr prou141-renoil ii Ni) OR L FfER (il appJRcahkh
FROM 11-0 PR ITTFR TPPICKNFM4
0 11' j 11' O.
I 2fir LN}1R cot:1INc Iln'r_ 91ni� rlrivr.Oaki.. rrarup_.
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
61.
II,
n,
1.5" Jo.
NA
lli Isr.#lrel-Nit 1 $I;orsra
19' Ii. 1.5"
I.
NA
NATIENTAI
Steel
THIClistSi
NA
st.krIttiril,
Steel
IL
It.
Ii
iN, GROW
Ir
Nn[Eltli[. F.#TrL1C Mk4TlIIT.nomLJLAMOUNT
It.
n,
l4
ir.
IL
19. S)lNWI;RAVPL Peril, I+r dyrlicibk}
R.
Trr
II,
1JI FL HLII.
1rirEl_1(rwnr*r1'' M11.11n
{
It.
11, DRILLING LOG I nliich iddllionxl'rlxdi if memoryI
FROM
0 fl,
rt.
TO
19' fr.
IL
DP.W-REPT:OJNIBuhr,iirdhw. RIL'rKki5Rr•a'Iii4r,ef[.I
R.
14
IL
IL
ft.
Ic
IL,
It.
R-
IL,
24 artri ikRb ,
Temporary injection point through DPT tooling
2/_ Cerliiicatitrar
Brian Ewing
SitPmurg aletalGod WcitCoiiinj•rur Date
AT MT4lI1.I4 2PLY frMrl, 1 rrrr.'bl' e,r0r7I' rrlui rliz 1A-10.1 LIUTY i wars J twrurrireirra err ve.ervmmune
II'Jt •bi iirCAC .13,7C .0fr*r ry NL'.M1CL�G�.TC,ti 82i 1'y1• I Y I)Jrrrrirrnur Stalrida,i mist riilU 0
rT .11 orals rm. and ,Jii b,rrrJ prrrr'Id.W1 rrM AL. 4I1r+J1 iIwwr.
1/27/2021
23. Site dr t;r'slni or aiddlli'Jil,il well delimit?.
Ycn1 rl1Hr use Ilse tuck of fills pew to provide addilionul i ell site ddiils ur we]
construction derails. You nun also Mod acklilr4stlltt twb'is d hxwes#an .
;ii1 BRlrf7 Ai, LNb11.1C IONS
lda. ihlr All Wells. Suborn this Form w]tin 3U dale of courplehoo of nett
construction LB the fblkomrl4.
il1►iJrFra urPiimrrResources, Information Pni rsxiog Gull,
1617 hlblt Sersire Ceaolcr, Raleigh, NC 27699-1617
24b. For [u%eciilm YWIA ONLY: hi addition to aetadillg Ilse Form to Ills iiddress ui
a�eabo4'r. also suhiiii1 a copy of tills. form uiiLlui 10 dates of L:amplctiati of well
construction Irk [he reLlowiu .
Thh isiaal of Water Resources, lrndcrgrnund 1nlecrioil Cunlrol Program,
16.19 batik Service Center. Raleigh, NC 27fiyr4•.1836
2 iL Fur Wirer.5ippl} 1r 1njeisi im Wile.
Also sublr'lit sire cop). of Ali . ILA Ill u Itlhiil ;r8 trays of comf+ietiopF of
tircll cnogtrlrrttnn co tL1e cniiim Ua 111tii lleportine11 or air c iiu*i wise=;
coral -tiered
rarin trii -1
wFnnt arc'ulnFLrlrurciitmnl LIII1r5�IIJIYCIIr
mid Nmucil JtC&]Iictfi - DPE1aun1%Warr ilC{JLF
I#[h'L9Cd Aug= 1111I;I

WELL CONSITRUC CON RECORD
Thy fonrl+nn be 1lsfld rec sll gk ,lr I!l I111 t'I ii erl5
1. Wel L Curltrnctur Infornirrtiose
1F'ar frOcmill 4ic D141.V
Brian Ewing
Weft CF P ri 4L.T Hire
4240-B
NC Well Cool{,Iciar C'crllfrkLiun Nitro
SAEDACCO Inc
W'e1I 1rtmatractian Pernik Or; w10300399; 70002483
lirrrd2 opvliruhlr 0.Yirovemir4lr-r.. ( IILIIrY SLtlr_WiridlLr 1rofortrar#.
3. Weil Irse term& well MAO
Water Supply Well:
UCreotli nwI IifeatiogiCoaling 5upph1•
I' 1ledusiiia fCantreercial
❑ In3gai nn
Llhiilttil.iperllrhlic
rlFkcsfdennml Water Sunk! aSiRfJcl
I-1Rcsidenlr,ll Water Supply is]'Iarodl
M1rr:-Wake Suppl Wdl:
❑hianiIoiine 1=11 a}> '
Eiji:I/ 1tr1I WkrIk
r1Ad111ifir Recii51I [e
pAtinirer 9torm8c ald Ttecr,3ler,r
❑ AgpiF r T{6t
❑ EN rimcruR1 Ttchn togi..
❑ Ci uthernial IC'lusrd Loopr
❑ Geotherrrial iFIc iiii1 JC•noling Retltiill
. Date WeIICsI CunilPItIttI; 1/15/21
❑ u_ %fell Locution:
Qttreni dwaret Rum-1.4111w!
DSRlinit% 13arricr
❑ p' orrowsiler Erryio.2r4
❑tiIIf3GhdCIICC caul nil
❑ Traorr
®O11ier iiipiuiil under 121 Remarks)
1�'ell dime B5
Remediation Management Service Company
I. . ' I I i I ' [if rrepli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PInokuI Addrea Cit... ;Ind Zip
Mecklenburg 12710204
t'lnuntl t}leecl Ideiuifciuol, Nn (P1N1
h. 1.41ihmin iiid 1aingltnihr nr der'imil et•egrrrs;
idt rli Add Ina' LIUIativ strf,tl<Jui
35.210533 (-80.801887 '
9. l3 turd Ihi 11ur 211'mporon'
7. is this a rrpairiu an rhriodir
iowrit: 11'rs or ElN
+u
{reheat rr Ir rriNllr.•i lrii F r;FrrrIIW war l 'illfri'rl I'SrlrratJr rill' lI lrNrr IIr rJlr
rr,4drr ulaL.i'!11 rrei rJ:h set.li a LW All der hack rtr 0.116.1orJu.
S. Nuttier of welbt cniislrrueeed: 1 _
F it criatiootc OrrMAI40.11 W rire-Irxrrr J•IIf ' !WM' ONLY lI'.rh rrlr WNW enrrarnreri,r+r
satviirro )'iJnu.
9.1'001 wan depth helm lewd surface 19
for I'NIHrp1i' dl'LJr+r, thifi r'rect1'Jr{rrrtrdre- 1*. 00' a hid 2cir ;IVO
11F4. Stitic water' level below nip ofl'usiu1
i+ IV/NH k'.ri 9 Mom.. Lwri; a.r' ".
12. Well crinttnrctipi IIYetlimd DRIVEN
fri,I
(fl.I
cI.¢,rorger,roinn,i-0hIr,dIlrci Itielc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Vivid lrpamr of t e r
tile, bi lnf'activa ripe: 4muuut;
1.4 WAIIk 2.01,11s
RCN 11n
R!_SI'HIP I'J!1',
It.
Its
t5. OUTHR CASiliC {nrr prou141-renoil ii Ni) OR L FfER (il appJRcahkh
FROM 11-0 PR ITTFR TPPICKNFM4
0 11' j 11' O.
I 2fir LN}1R cot:1INc Iln'r_ 91ni� rlrivr.Oaki.. rrarup_.
k FROM TO DLk'41ESFR TDICKl§ESS MALE JAL
61.
II,
n,
1.5" Jo.
NA
lli Isr.#lrel-Nit 1 $I;orsra
19' Ii. 1.5"
I.
NA
NATIENTAI
Steel
THIClistSi
NA
st.krIttiril,
Steel
IL
It.
Ii
iN, GROW
Ir
Nn[Eltli[. F.#TrL1C Mk4TlIIT.nomLJLAMOUNT
It.
n,
l4
ir.
IL
19. S)lNWI;RAVPL Peril, I+r dyrlicibk}
R.
Trr
II,
1JI FL HLII.
1rirEl_1(rwnr*r1'' M11.11n
{
It.
11, DRILLING LOG I nliich iddllionxl'rlxdi if memoryI
FROM
0 fl,
rt.
TO
19' fr.
IL
DP.W-REPT:OJNIBuhr,iirdhw. RIL'rKki5Rr•a'Iii4r,ef[.I
R.
14
IL
IL
ft.
Ic
IL,
It.
R-
IL,
24 artri ikRb ,
Temporary injection point through DPT tooling
2/_ Cerliiicatitrar
Brian Ewing
SitPmurg aletalGod WcitCoiiinj•rur Date
AT MT4lI1.I4 2PLY frMrl, 1 rrrr.'bl' e,r0r7I' rrlui rliz 1A-10.1 LIUTY i wars J twrurrireirra err ve.ervmmune
II'Jt •bi iirCAC .13,7C .0fr*r ry NL'.M1CL�G�.TC,ti 82i 1'y1• I Y I)Jrrrrirrnur Stalrida,i mist riilU 0
rT .11 orals rm. and ,Jii b,rrrJ prrrr'Id.W1 rrM AL. 4I1r+J1 iIwwr.
1/27/2021
23. Site dr t;r'slni or aiddlli'Jil,il well delimit?.
Ycn1 rl1Hr use Ilse tuck of fills pew to provide addilionul i ell site ddiils ur we]
construction derails. You nun also Mod acklilr4stlltt twb'is d hxwes#an .
;ii1 BRlrf7 Ai, LNb11.1C IONS
lda. ihlr All Wells. Suborn this Form w]tin 3U dale of courplehoo of nett
construction LB the fblkomrl4.
il1►iJrFra urPiimrrResources, Information Pni rsxiog Gull,
1617 hlblt Sersire Ceaolcr, Raleigh, NC 27699-1617
24b. For [u%eciilm YWIA ONLY: hi addition to aetadillg Ilse Form to Ills iiddress ui
a�eabo4'r. also suhiiii1 a copy of tills. form uiiLlui 10 dates of L:amplctiati of well
construction Irk [he reLlowiu .
Thh isiaal of Water Resources, lrndcrgrnund 1nlecrioil Cunlrol Program,
16.19 batik Service Center. Raleigh, NC 27fiyr4•.1836
2 iL Fur Wirer.5ippl} 1r 1njeisi im Wile.
Also sublr'lit sire cop). of Ali . ILA Ill u Itlhiil ;r8 trays of comF+ietiopF of
tircll cnogtrlrrttnn co tL1e cniiim Ua 111tii lleportine11 or air c iiu*i wise=;
coral -tiered
rarin trii -1
wFnnt arc'ulnFLrlrurciitmnl LIII1r5�IIJIYCIIr
mid Nmucil JtC&]Iictfi - DPE1aun1%Warr ilC{JLF
I#[h'L9Cd Aug= 1111I;I

WELL CONSTRUCUON RECORD
Thy fonrl+nn be 1lsi3d rec s1'Iu;}c +Ir I!nlal l'I ii ergs
1. Welt Curllr riet[.r Il,iruririrrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
WdlCF P rl4lurNarn
4240-B
NC Well Coulr,Icior CarliiimLiun M1ii rti
SAEDACCO Inc
?. V4'e14 traristnictiun Pernik WI0300399; 70002483
lirrrdl opvllruhlr LkrirPrrmil4 lr-r.. - it th keert'Or#
3. Wr I Use trim& wall M
Water Supply VieIL-
ClAgrt,calturil
UCreolli nwI Iiiearing'Cooling 5upp]}l
I' 1lndusiria fCanuni:rcial
❑ hnt Lhnn
L1M iicipal/Plrhlic
rl RAsidellnlll Wtiror Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
M1ir:-Water S+upp1}' Well:
❑I4ioi iIoriuc ❑lea}> '
Eiji:I/arr1I V- Ik
rlAdllriCi r Rectiktrim
pArinircr 9tormc and Recr131er,r
❑ AgpirFr 7�61
❑ EN rimCllff1 TgC1rn6L13 '
❑ Jouiherm;rl iCluted Linlpt
❑ Geodleiiiial illes,uii Cnssliu Rrtuiihl
0 7recRodwalcr p.E'l1iCS{1JYa9a7
DSalini1% l arncr
❑ A'orrowsfier Erryin.2r4
❑ IILNUICllcC Cali MI
❑ 'Traorr
111O11kr iucpiuiil LIINICr 121 Renlulks)
4. RAW Wellk0 Crjilrlrlel€tl; 1/15/21 We.11 Mgr A29
5a_ %fell ".Ilrathrn:
Remediation Management Service Company
l • . ' I I i I ' of lrrpli nb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;ind Zip
Mecklenburg 12710204
VwmJ1 ?lied IlLil'iuirlciuui1 Nn fP1N?
ih. T:init ir iiid laangttmhr In lP12-prxrarinrimrtelilccnnrls nr k imil kt rrra;
ads rli Add strnekiiii.
35.210533 N-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an r xir iodiowrit: 011ie or IR ND
+
Origin lr Ir lriNll1..1%11 iNF 0.4,11.0 i1 lflcorlJ.7'IFl,frr'rI llrllJ'TJJ'rIJIJJI mod I'irlrratJ, rA„ ll,lrNrr IIr NIr
rr,4drr uldifef i r ei rk set.li a LW All [IIr hack rtr 016.1orJu.
S. PluuLbet of well tlnirlrrueeed: 1 _
iirddr Vte lrrMAullwl W rire-Irxwr .141Atift ingtr ONLY lI'.rh rllr WNW
sd1rmIlrro )'iJnu.
9. 7'Utal wail drppr helm lima surface 19
for hNllirlrfl' thifiVirect 16JGfr' ijdre- *.:1;10' Aril2cir ;IVO
11F0. SiSTIE water' level iicluw nip of lAriio1
i+ IV/NH k''.ri 9 Mom.. L iri; a.r' ".
1. I3oi#1Y4110 ilijnrelEr.1. 5"
12. Well i`riidilniZipii uwilin41: DRIVEN
(ri, t
(fl.I
c I.c rorger, rninrl, i-0hlc, dIlrci prEIL.M.F
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield Igpiiof
111r, biilnfaL ua ripe: 4muuut:
1.4 Wftiltf170f115
RCN l 1n
R!_tir'HIP rJl1',
ft.
ft.
t5, OUTHR CASiliC {nrr Prou141-renoil ii Ni) OR L N R (it amaRcahkh
FROM 1110 PIAMFTFR TPPICKNFM4
0 it. j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO Dtk41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" la,
NA
T1} pr.#lTrrl?ir J $IfirrLlls.
19' II- 1.5"
I.
NA
NA
NATIENTAI
Steel
rrl.#TI[krii,
Steel
IL
rt.
7N, GROUT
FROM.
I r7
Nn [Eltlii. F.#TFL1i> IilkwTlliLnI(IJJ Jr AMOUNT
ft.
n,
rr.
r4
rr.
IL
24, ! WGRAVPL PAC. I+r dyrlicibk}
T[r
p,
1JI FL HLII.
Lrirr'i _1( r wnr *r 1' ul_e 11.gn
{
(I.
11, DRILLING LOG I ntiich iddllionxl chi if rreemary I
FROM
0
ri.
TO
19' fi.
IL
DPW-REPT:OJN ...ahr,1'Mrdhw. Rµ'nlcki5 eJ-Inwir,Cf[.I
rt.
14
IL
rL
rt
Ic
14
Ira
R-
IL
21. gr-M.#M
Temporary injection point through DPT tooling
2/_ (crlrircatiira[
Brian Ewing
Sieshourg a Fecal God W cit Colorserur Nee
AT MT4lI1.I4 drhr frMrl, I rrrr.+b' eirr7I' r,Yw rl+r ivedi(yl u rY JI l J tY.O.V.trirelea Ire .0lre'rir2 lr
u'JtA l •bl riCAC OTC .Okra) ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)Jrrrrirrnur Standard nand
i o
rTg.1 orals rm. and AmbrrrN plrlr'If1.Wl Fa' Au 4I1r+J1 iiI wr.
1/27/2021
23. Site ditioslni or iiidtii'Jlimil well delimit?.
Yuu Flury 1k ate Lack of digs "rage to provide addilionul,rcll site details ur we]L
c8Ii Inim LLati iklails. You Hul% ulso Ara acldiirrfuut tra&ws d r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I+Iir All Wrik Suhaoi ilirs Farm wires 3U dal of courplerloo of swat
couglucttpn to the rblkohri[l
lFl►isFia ul'Wrlirrkeno rce5, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uieciiim Wedb ONLY: In addition Ie aeladitlg Ilie rofn7 to the Address ur
2-ra zikitOVd. mi1s.i Stith loll a copy of tills. try uiiLlui iLl dlks of r:ampletii ii of vcc ll
c n tructluu Iv the faL]Ohviu .
abh imam of Water Resources, lrndcrg nand 1njr:riIIalr Control Program,
1636 Halt Service Center. Raleigh, NC 27iWcr-I(136
2 it For Wif ...54RpI} IDjraion 'WOW
Also submit oire cop). of !hi . ruin, u iF[ ;8 hays of coni1leriorr uF
tire)) comonettnn co tLle crniut} U 1iItil llepplrl,lxnl or air court w it11;
conilmcicd
rarin trii -1
wFn n t arc' a Ina Lr.1imtr ii in nI EFII1r,0men
alit LIILuia1 I 0Iuctfi - l rvGlaunl'1'.11er Rinut.rcL
t#[h'L9Cd Aug= 11.1 I:I

WELL CONSTRUCUON RECORD
Thy fonrl+nn be 1lsi3d rec s1'Iu;}c +Ir I!nlal l'I ii ergs
1. Welt Curllr riet[.r Il,iruririrrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
WdlCF P rl4lurNarn
4240-B
NC Well Coulr,Icior CarliiimLiun M1ii rti
SAEDACCO Inc
?. V4'e14 traristnictiun Pernik WI0300399; 70002483
lirrrdl opvllruhlr LkrirPrrmil4 lr-r.. - it th keert'Or#
3. Wr I Use trim& wall M
Water Supply VieIL-
ClAgrt,calturil
UCreolli nwI Iiiearing'Cooling 5upp]}l
I' 1lndusiria fCanuni:rcial
❑ hnt Lhnn
L1M iicipal/Plrhlic
rl RAsidellnlll Wtiror Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
M1ir:-Water S+upp1}' Well:
❑I4ioi iIoriuc ❑lea}> '
Eiji:I/arr1I V- Ik
rlAdllriCi r Rectiktrim
pArinircr 9tormc and Recr131er,r
❑ AgpirFr 7�61
❑ EN rimCllff1 TgC1rn6L13 '
❑ Jouiherm;rl iCluted Linlpt
❑ Geodleiiiial illes,uii Cnssliu Rrtuiihl
0 7recRodwalcr p.E'l1iCS{1JYa9a7
DSalini1% l arncr
❑ A'orrowsfier Erryin.2r4
❑ IILNUICllcC Cali MI
❑ 'Traorr
111O11kr iucpiuiil LIINICr 121 Renlulks)
4. RAW WeII» Crjilrlrlel€tl; 1/15/21 We.11 Mgr A31
5a_ %fell ".Ilrathrn:
Remediation Management Service Company
l • . ' I I i I ' of lrrpli nb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;ind Zip
Mecklenburg 12710204
VwmJ1 ?lied IlLil'iuirlciuui1 Nn fP1N?
ih. T:init ir iiid laangttmhr In lP12-prxrarinrimrtelilccnnrls nr k imil kt rrra;
ads rli Add strnekiiii.
35.210533 N-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an r xir iodiowrit: 011ie or IR ND
+
Origin lr Ir lriNll1..1%11 iNF 0.4,11.0 i1 lflcorlJ.7'IFl,frr'rI llrllJ'TJJ'rIJIJJI mod I'irlrratJ, rA„ ll,lrNrr IIr NIr
rr,4drr uldifef i r ei rk set.li a LW All [IIr hack rtr 016.1orJu.
S. PluuLbet of well tlnirlrrueeed: 1 _
iirddr Vte lrrMAullwl W rire-Irxwr .141Atift ingtr ONLY lI'.rh rllr WNW
sd1rmIlrro )'iJnu.
9. 7'Utal wail drppr helm lima surface 19
for hNllirlrfl' thifiVirect 16JGfr' ijdre- *.:1;10' Aril2cir ;IVO
11F0. SiSTIE water' level iicluw nip of lAriio1
i+ IV/NH k''.ri 9 Mom.. L iri; a.r' ".
1. I3oi#1Y4110 ilijnrelEr.1. 5"
12. Well i`riidilniZipii uwilin41: DRIVEN
(ri, t
(fl.I
c I.c rorger, rninrl, i-0hlc, dIlrci prEIL.M.F
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield Igpiiof
111r, biilnfaL ua ripe: 4muuut:
1.4 Wftiltf170f115
RCN l 1n
R!_tir'HIP rJl1',
ft.
ft.
t5, OUTHR CASiliC {nrr Prou141-renoil ii Ni) OR L N R (it amaRcahkh
FROM 1110 PIAMFTFR TPPICKNFM4
0 it. j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO Dtk41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" la,
NA
T1} pr.#lTrrl?ir J $IfirrLlls.
19' II- 1.5"
I.
NA
NA
NATIENTAI
Steel
rrl.#TI[krii,
Steel
IL
rt.
7N, GROUT
FROM.
I r7
Nn [Eltlii. F.#TFL1i> IilkwTlliLnI(IJJ Jr AMOUNT
ft.
n,
rr.
r4
rr.
IL
24, ! WGRAVPL PAC. I+r dyrlicibk}
T[r
p,
1JI FL HLII.
Lrirr'i _1( r wnr *r 1' ul_e 11.gn
{
(I.
11, DRILLING LOG I ntiich iddllionxl chi if rreemary I
FROM
0
ri.
TO
19' fi.
IL
DPW-REPT:OJN ...ahr,1'Mrdhw. Rµ'nlcki5 eJ-Inwir,Cf[.I
rt.
14
IL
rL
rt
Ic
14
Ira
R-
IL
21. gr-M.#M
Temporary injection point through DPT tooling
2/_ (crlrircatiira[
Brian Ewing
Sieshourg a Fecal God W cit Colorserur Nee
AT MT4lI1.I4 drhr frMrl, I rrrr.+b' eirr7I' r,Yw rl+r ivedi(yl u rY JI l J tY.O.V.trirelea Ire .0lre'rir2 lr
u'JtA l •bl riCAC OTC .Okra) ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)Jrrrrirrnur Standard nand
i o
rTg.1 orals rm. and AmbrrrN plrlr'If1.Wl Fa' Au 4I1r+J1 iiI wr.
1/27/2021
23. Site ditioslni or iiidtii'Jlimil well delimit?.
Yuu Flury 1k ate Lack of digs "rage to provide addilionul,rcll site details ur we]L
c8Ii Inim LLati iklails. You Hul% ulso Ara acldiirrfuut tra&ws d r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I+Iir All Wrik Suhaoi ilirs Farm wires 3U dal of courplerloo of swat
couglucttpn to the rblkohri[l
lFl►isFia ul'Wrlirrkeno rce5, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uieciiim Wedb ONLY: In addition Ie aeladitlg Ilie rofn7 to the Address ur
2-ra zikitOVd. mi1s.i Stith loll a copy of tills. try uiiLlui iLl dlks of r:ampletii ii of vcc ll
c n tructluu Iv the faL]Ohviu .
abh imam of Water Resources, lrndcrg nand 1njr:riIIalr Control Program,
1636 Halt Service Center. Raleigh, NC 27iWcr-I(136
2 it For Wif ...54RpI} IDjraion 'WOW
Also submit oire cop). of !hi . ruin, u iF[ ;8 hays of coni1leriorr uF
tire)) comonettnn co tLle crniut} U 1iItil llepplrl,lxnl or air court w it11;
conilmcicd
rarin trii -1
wFn n t arc' a Ina Lr.1imtr ii in nI EFII1r,0men
alit LIILuia1 I 0Iuctfi - l rvGlaunl'1'.11er Rinut.rcL
t#[h'L9Cd Aug= 11.1 I:I

WELL CONSTRUCUON RECORD
Thy fonrl+nn be 1lsi3d rec s1'Iu;}c +Ir I!nlal l'I ii ergs
1. Welt Curllr riet[.r Il,iruririrrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
WdlCF P rl4lurNarn
4240-B
NC Well Coulr,Icior CarliiimLiun M1ii rti
SAEDACCO Inc
?. V4'e14 traristnictiun Pernik WI0300399; 70002483
lirrrdl opvllruhlr LkrirPrrmil4 lr-r.. - it th keert'Or#
3. Wr I Use trim& wall M
Water Supply VieIL-
ClAgrt,caltural
UCreolli nwI Iiiearing'Cooling 5upp]}l
I' 1lndusiria fCanuni:rcial
❑ hnt Lhnn
L1M iicipal/Plrhlic
rl RAsidellnlll Wtiror Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
M1ir:-Water S+upp1}' Well:
❑I4ioi iIoriuc ❑lea}> '
Eiji:I/arr1I V- Ik
rlAdllriCi r Rectiktrim
pArinircr 9tormc and Recr131er,r
❑ AgpirFr 7�61
❑ EN rimCllff1 TgC1rn6L13 '
❑ Jouiherm;rl iCluted Linlpt
❑ Geodleiiiial illes,uii Cnssliu Rrtuiihl
0 7recRodwalcr p.E'l1iCS{1JYa9a7
DSalini1% l arncr
❑ A'orrowsfier Erryin.2r4
❑ IILNUICllcC Cali MI
❑ 'Traorr
®O1ller iucpiuiil LIINICr /21 Renlulks)
4. RAW Wellk0 Crjilrlrlel€tl; 1/15/21 We.11 Mgr A19
5a_ %fell ".Ilrathrn:
Remediation Management Service Company
l • . ' I I i I ' of lrrpli nb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;ind Zip
Mecklenburg 12710204
VwmJ1 ?lied IlLil'iuirlciuui1 Nn fP1N?
ih. T:init ir iiid laangttmhr In lP12-prxrarinrimrtelilccnnrls nr k imil kt rrra;
ads rli Add strnekiiii.
35.210533 N-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an r xir iodiowrit: 011ie or IR ND
+
Origin lr Ir lriNll1..1%11 iNF 0.4,11.0 i1 lflcorlJ.7'IFIIfrr'rI llrllJ'TJJ'rIJIJJI mod I'irlrratJr rill' llllrNrr IIr NIr
rr,4drr uIdL.i'!1i r ei rk set.li a LW All [IIr hack rtr 016.1orJu.
S. PluuLbet of well tlnirlrrueeed: 1 _
iirddr Vte lrrMAullwl W rire-Irxwr .141Atift ingtr ONLY lI'.rh rllr WNW
sd1rmIlrro )'iJnu.
9. 7'Utal wail drppr helm lima surface 19
for hNllirlrfl' thifiVirect 16JGfr' ijdre- *.:1;10' Aril2cir ;IVO
11F0. SiSTIE water' level iicluw nip of lAriio1
i+ IV/NH k''.ri 9 Mom.. L iri; a.r' ".
1. I3oi#1Y4110 ilijnrelEr.1. 5"
12. Well i`riidilniZipii uwilin41: DRIVEN
(ri, t
(fl.I
c I.c rorger, rninrl, i-0hlc, dIlrci prEIL.M.F
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield Igpiiof
111r, biilnfaL ua ripe: 4muuut:
1.4 Wftiltf170f115
RCN l 1n
R!_tir'HIP rJl1',
ft.
ft.
t5. OUTHR CASiliC {nrr Prou141-renoil ii Ni) OR L N R (it amaRcahkh
FROM 1110 PIAMFTFR TPPICKNFM4
0 it. j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO Drk41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" la,
NA
T1} pr.#lTrrl?ir J $IfirrLlls.
19' II- 1.5"
I.
NA
NA
NATIENTAI
Steel
rrl. Tl[krii,
Steel
IL
rt.
Ii
7N, GROUT
FROM.
I r7
Nn [Eltlii. F.#TFL1i> IilkwTlliLnI(IJJ Jr AMOUNT
ft.
n,
rr.
r4
rr.
IL
24, ! WGRAVPL PAC. I+r dyrlicibk}
T[r
p,
1JI FL HLII.
Lrirr'i _1( r wnr *r 1' ul_e 11.gn
{
(I.
11, DRILLING LOG I ntiich iddllionxl wbotifl if rreemary I
FROM
0 kl,
ri.
TO
19' fi.
IL
DPW-REPT:OJN ...ahr,1'Mrdhw. Rµ'nlcki5 eJ-Inwir,Cf[.I
rt.
14
IL
rL
rt
Ic
Ir,
Ira
Ft-
ReralkM
Temporary injection point through DPT tooling
2/_ (crlrircatiira[
Brian Ewing
Sieshourg a Fecal God W cit Colorserur Nee
AT MT4lI1.I4 drhr frMrl, I rrrr.+b' eirr7I' rllw rl+r ivedi(yl u rY JI l J tY.O.V.trirelea Ire .0lre'rir2 lr
u'JtA l •bl riCAC OTC .Okra) ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)Jrrrrirrnur Standard nand
i o
rTg.1 orals rm. and AmbrrrN plrlr'If1.Wl Fa' Au 4I1r+J1 iiI wr.
1/27/2021
23. Site ditioslni or iiidtii'Jlimil well delimit?.
Yuu Flury 1k ate Lack of digs "rage to provide addilionul,rcll site details ur we]L
c8Ii Inim LLati iklails. You Hul% ulso Ara acldiirrfuut tra&ws d r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I+Iir All Wrik Suhaoi ilirs Farm wires 3U dal of courplerloo of swat
couglucttpn to the rblkohri[l
lFl►isFia ul'Wrlirrkeno rce5, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uieciiim Wedb ONLY: In addition Ie aeladitlg Ilie rofn7 to the Address ur
2-ra zikitOVd. mi1s.i Stith loll a copy of tills. try uiiLlui iLl dlks of r:ampletii ii of vcc ll
c n tructluu Iv the faL]Ohviu .
abh imam of Water Resources, lrndcrg nand 1njr:riIIalr Control Program,
1636 Halt Service Center. Raleigh, NC 27iWcr-I(136
2 it For Wif ...54RpI} IDjraion 'WOW
Also submit oire cop). of !hi . ruin, u iF[ ;8 hays of coni1leriorr uF
tire)) comonettnn co tLle crniut} U 1iItil llepplrl,lxnl or air court w it11;
conilmcicd
rarin trii -1
wFn n t arc' a Ina Lr.1imtr ii in nI EFII1r,0men
alit LIILuia1 I 0Iuctfi - l rvGlaunl'1'.11er Rinut.rcL
t#[h'L9Cd Aug= 11.1 I:I

WELL CONSTRUCUON RECORD
Thy fonrl+nn be 1lsi3d rec s1'Iu;}c +Ir I!nlal l'I ii ergs
1. Welt Curllr riet[.r Il,iruririrrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
WdlCF P rl4lurNarn
4240-B
NC Well Coulr,Icior CarliiimLiun M1ii rti
SAEDACCO Inc
?. V4'e14 traristnictiun Pernik WI0300399; 70002483
lirrrdl opvllruhlr LkrirPrrmil4 lr-r.. - it th keert'Or#
3. Wr I Use trim& wall M
Water Supply VieIL-
ClAgrt,calturil
UCreolli nwI Iiiearing'Cooling 5upp]}l
I' 1lndusiria fCanuni:rcial
❑ hnt Lhnn
L1M iicipal/Plrhlic
rl RAsidellnlll Wtiror Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
M1ir:-Water S+upp1}' Well:
❑I4ioi iIoriuc ❑lea}> '
Eiji:I/arr1I V- Ik
rlAdllriCi r Rectiktrim
pArinircr 9tormc and Recr131er,r
❑ AgpirFr 7�61
❑ EN rimCllff1 TgC1rn6L13 '
❑ Jouiherm;rl iCluted Linlpt
❑ Geodleiiiial illes,uii Cnssliu Rrtuiihl
0 7recRodwalcr p.E'l1iCS{1JYa9a7
DSalini1% l arncr
❑ A'orrowsfier Erryin.2r4
❑ IILNUICllcC Cali MI
❑ 'Traorr
111O11kr iucpiuiil LIINICr 121 Renlulks)
4. RAW Wellk0 Crjilrlrlel€tl; 1/15/21 We.11 Mgr A17
5a_ %fell ".Ilrathrn:
Remediation Management Service Company
l • . ' I I i I ' of lrrpli nb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;ind Zip
Mecklenburg 12710204
VwmJ1 ?lied IlLil'iuirlciuui1 Nn fP1N?
ih. T:init ir iiid laangttmhr In lP12-prxrarinrimrtelilccnnrls nr k imil kt rrra;
ads rli Add strnekiiii.
35.210533 N-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an r xir iodiowrit: 011ie or IR ND
+
Origin lr Ir lriNll1..1%11 iNF 0.4,11.0 i1 lflcorlJ.7'IFl,frr'rI llrllJ'TJJ'rIJIJJI mod I'irlrratJ, rA„ ll,lrNrr IIr NIr
rr,4drr uldifef i r ei rk set.li a LW All [IIr hack rtr 016.1orJu.
S. PluuLbet of well tlnirlrrueeed: 1 _
iirddr Vte lrrMAullwl W rire-Irxwr .141Atift ingtr ONLY lI'.rh rllr WNW
sd1rmIlrro )'iJnu.
9. 7'Utal wail drppr helm lima surface 19
for hNllirlrfl' thifiVirect 16JGfr' ijdre- *.:1;10' Aril2cir ;IVO
11F0. SiSTIE water' level iicluw nip of lAriio1
i+ IV/NH k''.ri 9 Mom.. L iri; a.r' ".
1. I3oi#1Y4110 ilijnrelEr.1. 5"
12. Well i`riidilniZipii uwilin41: DRIVEN
(ri, t
(fl.I
c I.c rorger, rninrl, i-0hlc, dIlrci prEIL.M.F
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield Igpiiof
111r, biilnfaL ua ripe: 4muuut:
1.4 Wftiltf170f115
RCN l 1n
R!_tir'HIP rJl1',
ft.
ft.
t5, OUTHR CASiliC {nrr Prou141-renoil ii Ni) OR L N R (it amaRcahkh
FROM 1110 PIAMFTFR TPPICKNFM4
0 it. j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO Dtk41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" la,
NA
T1} pr.#lTrrl?ir J $IfirrLlls.
19' II- 1.5"
I.
NA
NA
NATIENTAI
Steel
rrl.#TI[krii,
Steel
IL
rt.
7N, GROUT
FROM.
I r7
Nn [Eltlii. F.#TFL1i> IilkwTlliLnI(IJJ Jr AMOUNT
ft.
n,
rr.
r4
rr.
IL
24, ! WGRAVPL PAC. I+r dyrlicibk}
T[r
p,
1JI FL HLII.
Lrirr'i _1( r wnr *r 1' ul_e 11.gn
{
(I.
11, DRILLING LOG I ntiich iddllionxl chi if rreemary I
FROM
0
ri.
TO
19' fi.
IL
DPW-REPT:OJN ...ahr,1'Mrdhw. Rµ'nlcki5 eJ-Inwir,Cf[.I
rt.
14
IL
rL
rt
Ic
14
Ira
R-
IL
21. gr-M.#M
Temporary injection point through DPT tooling
2/_ (crlrircatiira[
Brian Ewing
Sieshourg a Fecal God W cit Colorserur Nee
AT MT4lI1.I4 drhr frMrl, I rrrr.+b' eirr7I' r,Yw rl+r ivedi(yl u rY JI l J tY.O.V.trirelea Ire .0lre'rir2 lr
u'JtA l •bl riCAC OTC .Okra) ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)Jrrrrirrnur Standard nand
i o
rTg.1 orals rm. and AmbrrrN plrlr'If1.Wl Fa' Au 4I1r+J1 iiI wr.
1/27/2021
23. Site ditioslni or iiidtii'Jlimil well delimit?.
Yuu Flury 1k ate Lack of digs "rage to provide addilionul,rcll site details ur we]L
c8Ii Inim LLati iklails. You Hul% ulso Ara acldiirrfuut tra&ws d r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I+Iir All Wrik Suhaoi ilirs Farm wires 3U dal of courplerloo of swat
couglucttpn to the rblkohri[l
lFl►isFia ul'Wrlirrkeno rce5, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uieciiim Wedb ONLY: In addition Ie aeladitlg Ilie rofn7 to the Address ur
2-ra zikitOVd. mi1s.i Stith loll a copy of tills. try uiiLlui iLl dlks of r:ampletii ii of vcc ll
c n tructluu Iv the faL]Ohviu .
abh imam of Water Resources, lrndcrg nand 1njr:riIIalr Control Program,
1636 Halt Service Center. Raleigh, NC 27iWcr-I(136
2 it For Wif ...54RpI} IDjraion 'WOW
Also submit oire cop). of !hi . ruin, u iF[ ;8 hays of coni1leriorr uF
tire)) comonettnn co tLle crniut} U 1iItil llepplrl,lxnl or air court w it11;
conilmcicd
rarin trii -1
wFn n t arc' a Ina Lr.1imtr ii in nI EFII1r,0men
alit LIILuia1 I 0Iuctfi - l rvGlaunl'1'.11er Rinut.rcL
t#[h'L9Cd Aug= 11.1 I:I

WELL CONSITRUC CON RECORD
Thy fonrl+nu tic irscii im sl.imk +Iw coral rk ii errs
1. Wel L Curltrect[.r Inform/aline
1F'ar ftlicmill USe D141.V
Brian Ewing
CF P ri 4LTNarnC
4240-B
NC Well Coulr,Icior Carliihmtiul1 t:iirti
SAEDACCO Inc
V41I 1 oostrl,ctiun Pernik 1:; w10300399; 70002483
liuul2 opvllruhlr 0.YirPrrmir4lLt. G iltnty SLtlr_Y'aridlLr 1rofortrar#. h-.1
3. Well Ilse term& well MA
Water Supply Well:
UCJeol i nwI IifeatiogrCoaling Stipp]}l
I' lledusiiia fCanunercial
❑ hngai nn
Lllsinnicipal/Public
rlFktsfdennml Water Sunk! aSiRfJcl
I-lRcsidentrml Water Supply is]'Iarodl
M1rr:-Wake Suppl Wall:
❑hianiloiine 1=11 a;Ct]_
Eiji:I/aIr11 WkrIk
El A:741u Recii51Ir
pAtinirer 9torm8c ald Ttecr135er,r
❑ AgpiF r 7�6I
❑ EN rimCruR1 Ttchn togi..
❑ Ci uihermal iClused Levi.
❑ Geothefhial illesirflatoollmn Retlfiift
. Dute WeIICxl CuilglItIttI 1/15/21
❑ u_ %Veil Locution:
Q 7ronoJdwarer 1{e1m-1.4111w!
I SRlinii3 13arricr
❑ p' orrowsiler ErRig2ga
❑tillr3GhdC11CC C'ailmi
❑ Traorr
®O11mt Icitp11iiii Birder 12I Remarks)
1�'eal ill`mr A9
Remediation Management Service Company
I. • [if rwepli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PInokui Aifdrea Cit... ;md Zip
Mecklenburg 12710204
I'lnua ll t ii 1 I[ feiuiFicauol, Nn fP1N?
ih. T:1nil11irend laingltnrhr nr derimol et•egrrrs;
d t ali Add Ina' Li'loj Js str ekm
35.210533 (-80.801887 '
9. 13 Imri) Ihh!1+I rIPIji. ❑Perillanrnl Li 211 'moron'
7. Is this a rrpair iu an r w(ioll writ: D't'rs or El Nu
irilrr; rr Ir rriNlrr.•i l ii F �Tr+rIIW war l 'ili frl'r1 I'SrlrflrJ' r211' lI lrNrr Ire rJlr
rr,4drr ulaL. i' 2111 rrei r2t5 Y[ eJrnrr 1Jr All der hack rtr Mrs form.
S. Number of well cniillirveeed: 1 _
F it urietionte Orrjai'uilmll W rire-Irxwr .141Atq ' Ira'r' ONLY rr.r11 rlIr WNW enrrarnreri,r+r
_5dI�5'Ilrr RAC fiJnu.
9.1'001 welt depth helm lewd surface 19
for I'NIHrp11' rii'LJr+r, tld+JPheart1e'JGfr' ijdle- 7f.:00' a hid 7 ;IVO
11F4. SUSTIE water' level below nip ofcuitu1
i+ IV/NH k'.ri 9 Mom.. L iri; a.r' "*
11•• lSai ale ilijnreltr 1. 5"
12. Well criretinrctipi inielliont DRIVEN
fri,I
(fl.I
cLe. Airger, roinn, i-0hlc, dlTeclelkEILerc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Vicki %rpamt nit e r
111r, M.9ifectiva ripe: 4muuut;
14. Wail 201,11s
RCN 11n
R!_tir'HIP rJl1,,
It.
Its
t5. {MJT R CASF NC «llr rani 111-mail nab) OR L 7PiRR (il amaRcahkh
FROM I IT; PRMFTFR TPPICKNFM4
0 11' j 11' O.
I 2fir IN}10 C#L1INC Iln'r_t)91niirivr.r4rir[I�[rarup_.
k FROM TO DLk'41ESFR TDICKf4ESS MALE JAL
6.
II,
n,
1.5" Jo.
NA
lli Morel-Pla 1 $I,tFrLlls
19' Ii. 1.5"
I.
NA
NATF•RTAI
Steel
THIClistSi
NA
�rl Tllkril,
Steel
IL
It.
Ii
7111. t7111.017
RAOi1
I h7
Nn[Eltlii. F.#TrL1C Mk4Tlllr.nomLaAMOUNT
It.
n,
I4-
ir.
11.
19. ! WI;RAVPL Peril. I+r dyllicibk}
T[r
II,
1JI FE Hd II.
Irirr'i -1( r rn *r l' ulm a 11.gn
{
II.
11, DRILLING LOG I nliich iddllionxl rbotifl if riecousry I
FROM
0 kl,
r.
TO
19' fr.
IL
DP.WrltEPT:OJNi IBuhr.iirdhi. RIL'rKk hh pr. a'Iii 4r, Cfi.I
rt.
IL
IL
It
if -
FL.
It.
R-
IL,
24 artnl
Temporary injection point through DPT tooling
2/_ ('crlificationf
Brian Ewing
Sieshourg a Fecal red W c8 Comb:rim Dtec
AT MT*111.4 dfar )Fran,) rrcr.+b' ei0105' rMw rliz ived { u rY a 1.m J twrl5rrireirra Ire ve.erimavire
II'Jt •bi rirCAC .13,7C .0fr*r ry NL'.11CL�G�.TC,(1V8Il lrk I C I- um-ei rmur S errk a,{ii mist riilU 0
rT .11 orals rm. and ,Jii bPr*J prrrl'If1.Wl rrF JIIW 4I5:41 rrrwwr.
1/27/2021
23. Site dat:rslni or aidwell delimit?.
Yuu Fluky use die hick of drla pew to provide addiliisl,ul viell site ddiils ur we]
construction derails. You nun also Mod ;E[ldiirfuut twb'cs d hxwcs#an .
;1.11 BRlrf7 Al. LNb11.1C IONS
lda. Len( All Wr,ik Suborn ilus Form within 3U dale of courplerloo of nett
construction to the fblkomrl4.
1F1►ilrFra i rPiimrrResources, Information Poi rsxiog Gull,
1617 hlblt Sersire Ce Llcr, Raleigh, NC 27699-1617
24b. Fier [ukciiim YWIA ONLY: hi addition to aeladitlg Ilse Form to the iiddress ni
a�eabo4'e. also suhiiii1 a copy of tills. form uiiLlui 10 dates of COmpluticith of well
construction Iv [he reLlowiu .
T1'h iilrwi of Water Resources, lrndcrgrnond 1nji rlioll Cunlrol Program,
16.19 Hair Service Center. Raleigh, NC 27fi'f4•.1836
2.3L Fair Were:F.54mAA} 1Dj1FEt pi WOW
Also sublr'lli[ owe cop). of Ali . fl,in, u IHliu ;8 Heys of comFilelieni of
tircll cnoglrlrrttnn co IL1e crmiim U 1iItil Ileppin,lxnl or air c iiu*i wise=
corarniicd
rarin tali -I
'win n Iarc' II II:r L'Ictmii iiE III bp, lase IIJIICIII
alai 4aurml itesaiactfi - DPE10111 n1%Warr klimarm
Kelaged ALVA 11.11:1

WELL CONSTRUCUON RECORD
Thy fonrl+nn be 1lsi3d rec s1'Iu;}c +Ir I!nlal l'I ii ergs
1. Welt Curllr riet[.r Il,iruririrrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
WdlCF P rl4lurNarn
4240-B
NC Well Coulr,Icior CarliiimLiun M1ii rti
SAEDACCO Inc
?. V4'e14 traristnictiun Pernik WI0300399; 70002483
lirrrdl opvllruhlr LkrirPrrmil4 lr-r.. - it th keert'Or#
3. Wr I Use trim& wall M
Water Supply VieIL-
ClAgrt,calturil
UCreolli nwI Iiiearing'Cooling 5upp]}l
I' 1lndusiria fCanuni:rcial
❑ hnt Lhnn
L1M iicipal/Plrhlic
rl RAsidellnlll Wtiror Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
M1ir:-Water S+upp1}' Well:
❑I4ioi iIoriuc ❑lea}> '
Eiji:I/arr1I V- Ik
rlAdllriCi r Rectiktrim
pArinircr 9tormc and Recr131er,r
❑ AgpirFr 7�61
❑ EN rimCllff1 TgC1rn6L13 '
❑ Jouiherm;rl iCluted Linlpt
❑ Geodleiiiial illes,uii Cnssliu Rrtuiihl
0 7recRodwalcr p.E'l1iCS{1JYa9a7
DSalini1% l arncr
❑ A'orrowsfier Erryin.2r4
❑ IILNUICllcC Cali MI
❑ 'Traorr
111O11kr iucpiuiil LIINICr 121 Renlulks)
4. RAW WeII» Crjilrlrlel€tl; 1/15/21 We.11 Mgr A13
5a_ %fell ".Ilrathrn:
Remediation Management Service Company
l • . ' I I i I ' of lrrpli nb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;ind Zip
Mecklenburg 12710204
VwmJ1 ?lied IlLil'iuirlciuui1 Nn fP1N?
ih. T:init ir iiid laangttmhr In lP12-prxrarinrimrtelilccnnrls nr k imil kt rrra;
ads rli Add strnekiiii.
35.210533 N-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an r xir iodiowrit: 011ie or IR ND
+
Origin lr Ir lriNll1..1%11 iNF 0.4,11.0 i1 lflcorlJ.7'IFl,frr'rI llrllJ'TJJ'rIJIJJI mod I'irlrratJ, rA„ ll,lrNrr IIr NIr
rr,4drr uldifef i r ei rk set.li a LW All [IIr hack rtr 016.1orJu.
S. PluuLbet of well tlnirlrrueeed: 1 _
iirddr Vte lrrMAullwl W rire-Irxwr .141Atift ingtr ONLY lI'.rh rllr WNW
sd1rmIlrro )'iJnu.
9. 7'Utal wail drppr helm lima surface 19
for hNllirlrfl' thifiVirect 16JGfr' ijdre- *.:1;10' Aril2cir ;IVO
11F0. SiSTIE water' level iicluw nip of lAriio1
i+ IV/NH k''.ri 9 Mom.. L iri; a.r' ".
1. I3oi#1Y4110 ilijnrelEr.1. 5"
12. Well i`riidilniZipii uwilin41: DRIVEN
(ri, t
(fl.I
c I.c rorger, rninrl, i-0hlc, dIlrci prEIL.M.F
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield Igpiiof
111r, biilnfaL ua ripe: 4muuut:
1.4 Wftiltf170f115
RCN l 1n
R!_tir'HIP rJl1',
ft.
ft.
t5, OUTHR CASiliC {nrr Prou141-renoil ii Ni) OR L N R (it amaRcahkh
FROM 1110 PIAMFTFR TPPICKNFM4
0 it. j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO Dtk41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" la,
NA
T1} pr.#lTrrl?ir J $IfirrLlls.
19' II- 1.5"
I.
NA
NA
NATIENTAI
Steel
rrl.#TI[krii,
Steel
IL
rt.
7N, GROUT
FROM.
I r7
Nn [Eltlii. F.#TFL1i> IilkwTlliLnI(IJJ Jr AMOUNT
ft.
n,
rr.
r4
rr.
IL
24, ! WGRAVPL PAC. I+r dyrlicibk}
T[r
p,
1JI FL HLII.
Lrirr'i _1( r wnr *r 1' ul_e 11.gn
{
(I.
11, DRILLING LOG I ntiich iddllionxl chi if rreemary I
FROM
0
ri.
TO
19' fi.
IL
DPW-REPT:OJN ...ahr,1'Mrdhw. Rµ'nlcki5 eJ-Inwir,Cf[.I
rt.
14
IL
rL
rt
Ic
14
Ira
R-
IL
21. gr-M.#M
Temporary injection point through DPT tooling
2/_ (crlrircatiira[
Brian Ewing
Sieshourg a Fecal God W cit Colorserur Nee
AT MT4lI1.I4 drhr frMrl, I rrrr.+b' eirr7I' r,Yw rl+r ivedi(yl u rY JI l J tY.O.V.trirelea Ire .0lre'rir2 lr
u'JtA l •bl riCAC OTC .Okra) ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)Jrrrrirrnur Standard nand
i o
rTg.1 orals rm. and AmbrrrN plrlr'If1.Wl Fa' Au 4I1r+J1 iiI wr.
1/27/2021
23. Site ditioslni or iiidtii'Jlimil well delimit?.
Yuu Flury 1k ate Lack of digs "rage to provide addilionul,rcll site details ur we]L
c8Ii Inim LLati iklails. You Hul% ulso Ara acldiirrfuut tra&ws d r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I+Iir All Wrik Suhaoi ilirs Farm wires 3U dal of courplerloo of swat
couglucttpn to the rblkohri[l
lFl►isFia ul'Wrlirrkeno rce5, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uieciiim Wedb ONLY: In addition Ie aeladitlg Ilie rofn7 to the Address ur
2-ra zikitOVd. mi1s.i Stith loll a copy of tills. try uiiLlui iLl dlks of r:ampletii ii of vcc ll
c n tructluu Iv the faL]Ohviu .
abh imam of Water Resources, lrndcrg nand 1njr:riIIalr Control Program,
1636 Halt Service Center. Raleigh, NC 27iWcr-I(136
2 it For Wif ...54RpI} IDjraion 'WOW
Also submit oire cop). of !hi . ruin, u iF[ ;8 hays of coni1leriorr uF
tire)) comonettnn co tLle crniut} U 1iItil llepplrl,lxnl or air court w it11;
conilmcicd
rarin trii -1
wFn n t arc' a Ina Lr.1imtr ii in nI EFII1r,0men
alit LIILuia1 I 0Iuctfi - l rvGlaunl'1'.11er Rinut.rcL
t#[h'L9Cd Aug= 11.1 I:I

WELL CONSITRUC CON RECORD
Thy fonrl+nu tic ascii rec sal gk ,lr milli trk hw ell5
1. Welt Contractor lamination:
:
1F'ar rnicsnill sic DN1.V
Brian Ewing
WillCrotm l['rNarrnC
4240-B
NC Well Coal{,Icior Car[IfrkLiun riled
SAEDACCO Inc
?. WeLI #mister, ian Pernik O; m10300399; 70002483
tinuL2 opvlfruhlr kr/rPrrnlir$ ILi.. ( It th 1 eertea}
W'rdl Isar trim& well MAO
Water Supply Weil:
UCreolli nwI IJiaalin3iCaaling Stipp]}l
I' 1lndusifla fCorurlerciak
❑ hngairnn
EffsloinicipaliPublic
CJ Rtsidenaul Water Sunk. a Si n fJcl
I-lRcsidentnil Water Supply is]'Iarodi
NrrP-Water S1upp1}' Wd1:
❑kloniloriuc 1=11 a'ar]_
Eiji:I/alrll WkrIk
r1Ad111ifir Rech51rire
pArinircr 9tonr8c sail Ttecr131er,r
❑ Agpircr 7�61
❑ EN rlmcruRl Ttchnoto
❑ Geothermal iClused Loopt
❑ Gtodleitiial iFleoui1 JC•nolinn Retutift
DSRlinits $arnc r
❑ orrowsfier Erryig2r4
❑ IILN kilcC Cali MI
❑ Tratier
®O11mt i i i plluil wider. /21 Remarks)
. D:rtiV Viellk0 CrinipliIttI; 1/15/21 We.11 Mgr B11
i.L. %Veil Locution:
Remediation Management Service Company
I. . ' I I i I ' [if rq'pli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI A dlse Cite_ ;md Zip
Mecklenburg 12710204
Cnua[ll Prldecl Idleiuiticiuoll Nn fP1N?
ih. Lollhasintind IJngltntir in ilrgrxrailmim;te1Isecnnils nr decimal et•egrrra;
idsrliBrad Int'Lil21Rt¢lsJIrITJC�Jur
35.210533 (-80.801887 '
fr. Is lmre) the l+rIPIji. ❑Pernt>rnrnl ur 211'moron'
7. Is this a rrpair iu an rxiodioil writ: 't'rs or IR ND
+
{rrlr2i Ii Ii rriNllr. •i rrii F �TrrrIIW i1 lfI cor l 'ill f2o'rI rlrilJ'TJJ'rIJIJJI llrl'i I'SrlrrrtJ. rill' rllrrNr r Ile rrlr
rr,4drr aldL.i'!1i r ei rk Y[eJrnri LW tYl der hack rd Mrs form!.
R. Plumber of well roniiirueeed: 1 _
F it codrostc rreMArilmll W are-Irxwr .1.113.04 ingtr ONLY lr.rll rrlr WNW ivarrnreri,Nr
2.0tvIllr RAC fiJnu.
9.7001 wail drppr helm land surface 19
for I'NIHrr[II' dlq rlrl rfti+jpAroit 16.ter' ijdre- Tf .'U(r' aril2cir ;IVO
11F0. SUStIE wrter' Ie►r1 iicluw nip of cusiu1
i+ IV/NH kiri 14 ar2'rlua' L iri,; a.r' "*
1. liertraule iIIjnicicr: 1. 5"
tJrul �,.IN
12. Well tlretnretipti mletlirul: DRIVEN
(ri, t
frl.l
c I.c rirger, roAnr►, i-0hlc, dllecielkEILerc.r
FOIl WATER sUPPJ.YWELLS ONLY;
Oa. Vivid Want 11A4.11104 of t er:
1.111, Lliilnfar ua ripe: 4muuut:
1.4 WAIIk V..01,11s
Iraviw l 11;
R!_tir'HIP rJl1',
h.
ft.
t5. OF THR CASFNC {nrr Inu11I-F ieil webs) OR um ER Of amaRcahkh
FROM 11-0 PRMFTFR TPPI€'KNFM4
0 11' j 11' O.
I 2Er LN}1R cot:SINc Its'r_ 91ni� rlrivr.r4rir[I�[rarup_.
k FROM TO Drk'41ESFR TDICl:r4ESS MAIEILLtiL
6.1.
n,
1.5" Jo.
NA
T1} otoreilit J ljl,frrtstirs'
19' ri. 1.5"
I.
NA
IIATIENTAI
Steel
THIr j; spv4
NA
u. Talked,
Steel
IL
rt.
Ii
it GROUT
FROM.
I it
Nn [Eltlii. EMPLNVEMK.NTlllr.nI(IL JL AMOUNT
tt.
n,
ft,
r4
rr.
IL
29. 5,4.Nbr4;RAVPL Peril, I+r dywlicibk}
R.
To
II,
,JI FE Hd II.
KSIVi-1( r'wnr*r1' u1-e11.gn
{
(I.
'IC DRILLING LOG I cinch iddllionxl wbotifl if iceman!
FROM
0 fl,
t{.
TO
19' ft.
IL
DP.W-REPT1(J Ni I [uhr, imninn+, witnr(k hh Rr• criln 4r, OK. I
rt.
14
IL
tL
it..
if -
FL.
It.
IR-
rt.
altriLlsRbA
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a Fecal rod W c8 Comb rue Dtec
AT MT4lI1.I4 drhr frM[I. I rrrr.'b1' tMrr7I' trial rliY 11ed{ 14rd ik rs'J twusrrirelea ire zweeir2 lrie
Huth •Il rhrCAC J,7C .r)rr*r ry NC.11[L�G�.TC..0001'y1• I Y l7Jrrrririnur Sta near[ rrilt� Norio
vim orals rm. and Am b,rrrJ prrrr'Id.W1 rrF JIIW 4I1:01 riIwwr.
1/27/2021
23. Site dr rani or,iddlti'Jil,il well delimit?.
Yuu Awry iLie ate hick of ilia, puw to provide addilicsl,ul ,:.cal site details or welt
construction details. You nuts also Mod ;aildilrfdml Iwb'cs d rxwes#an .
$G BMirf7 Al. LNb11.1CTIoNS.
ails I iir All Wells: Sohaol this Form within 3U da2s of L+ampkerloo of welt
construction to the rblkomrl4.
i h Nblla lily Winter Resources, Information Processing Gull,
1617 hlbll Sersire CeLter, Raleigh, NC 27699-1617
24b. Fir [uiiectillu Wedl9 ONLY: hi addiliorl CO aeladitlg ON foal to the :Idd nzsul
a�eakhlo4e. a1s.i Stith loll a copy of tills fury uiiLlui iLl dates of COmplutii ii of well
construction Iv [he faLlowiu .
Filet islatt of Water Resources, lfndetgrnund 1njr:elIIon Control Program,
1636 Halt Seance Center. Raleigh, NC 27fi'f4..1(136
2.3L Fur Witri° Srrppl). Iojeit1). WOW
Also snblr1it sire cop). of ihi, ruin, u Itltiu ;r8 slays of CQntpletiopF uF
tircll cnosinrrttnn co talc criiiim Ur*•idlil depvinim in or air county w icm
cotton...led
rarin trii -I
e'fln t.fn' a lnr Lmictrii ii[III LII51r5r IIJIYa'lll
sari NaLuial itesalucts - >7rvrs 1011 nl' Warr ilC{JLrcL
Ctielaged Aug= h1l;l

WELL CONSTRUCUON RECORD
Thy fonrf+nu tic rlscii roc 5Iiiirk mI111EIrk hlell5
1. Welt Curllr'rieti.r II,Irur>widrliont
1F'ar FrOcsoil" 4ic D141.V
Brian Ewing
W dl Cnnirl4i r'T NarrnC
4240-B
NC Well Coui{,icior CarllfrkLiun Niirti
SAEDACCO Inc
V41I 1raoatrswctiun Perrpk WI0300399; 70002483
liu uli oglilruhlr wv/f vrmil4 !Lt. - it th SLtlr_ Y'yridlL 1.9ferteriri
3. Wr I Use trim& wall M
Water Supply Vied:
flt r'clEltural
UCJeorllc'TnwI IiiaariogrCoaling Stipp]}l
I' 1lndusi,ia fCanunercial
❑ hnipi nn
L1M iicipal/Plrhlic
rl fk:sidellnlll WtiECF Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
NOP-Water S+upp1}' Well:
❑I4ioi iIoriuc 1=11 a}> '
I [1j4`ri9iii V- Ik
rlAdlllifir Recti51rire
pArinircr 9tormc and Ttecn� cn
❑ AgpirFr 7�61
❑ EN rlmcruRl TgC1rn6Lw3 '
❑ Jouiherm;rl iCluted Lin]pF
❑ Geodreitrial illes,uii Cnssliu Rrtuilll
DSalini1% l arncr
❑ A' orrn5lrrler Erryin.2r4
❑N1lhGhdClrCC Cali MI
❑ 'soar
®O11rer LIINICr 121 RenIUIiks)
. D:It WeII» Crjrlilrlel€tl; 1/15/21 1t'e41 gm- B1
5a_ %fell t.rlrLthrn:
Remediation Management Service Company
I'. tiflrr'pli:nt71e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI . ddrea . Cirt _ ;end Zip
Mecklenburg 12710204
CVwmJ1 t31eec1 ILiriuifleiuoli Nn fP1N?
ih. T:inibuirold Iaangttntir In lP12-prxrarinlimlteiilccnnrls nr drtimol kt rrra;
ids rli Add Int' LIVIativ rrmcl<JUE
35.210533 (-80.801887 '
9. I3 lure) Ihi 11eIII Y. ❑I eim rnrnl ur 211'moron'
7. Is thin a rrpair iu an rxiodioil writ: 11'rs or IR ND
irirrfh it Ir iriNllr•,f+ll,Nlr �TNrIIW oqu'l 4r l 'illffi'rI ilrllJ'TJJ'rIJIJJI iIN'i I'tirlrrldJ' fA" ill" Nrr II rilr
rr,4drr uIdL.i'!1i remark.. Y[eJrnri LW All [I1r hack ri? Mrs form!.
S. PlutrLbet of well tnirlrrueeed: 1 _
iirddr Vte oreMArilal W rire-Irxrrr l ONLY n'.rh rllr WNW enirarnreri,r+r
_5dI�5'Ilrr RAC fiJnu.
9. Tuts" wall depth helm lima surface 19
for I'NIHI'p1I' lfifiArlrfi(e.terlrtrdre- 7 ' Aril2cir ;IVO
11l0. SUSTIE water' level iicluw nip ofcusiu1
if IV/NH k''.ri it all'om... ire,; a.L' ".
1. 13or r1lt iIIjnrcicr: 1. 5"
12. Well i`riidilniZipii militia; DRIVEN
(ri, t
(fl.I
cI.c airger, roinn, i-0hlc, dlTecl Itierc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa Yield IRpiRP oft er:
111r, biilnfai ua rapt: 4muuut:
1.4 WAIIk 70 115
RCN l 1n
R!_tir'HIP IJl1',
ft.
t5. OLITHR CASiliC «llr Prou141-renoil ii Ni) OR um ER (it amaRcahkh
FROM 11-0 PR ITTFR TPP11(1 F5'4
0 11' j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirivr.r4rir[I�[rarup_.
k FROM TO Drk'41ESFR TDICKl§ESS MAIERLtiL
Cm.
n,
1.5" Jo,
NA
T1} pr.#lTrrllt J $IfirrLlls.
19' II- 1.5"
I.
NA
THIr 1,1
NA
IIATIENTAI
Steel
mATlckrsl,
Steel
IL
rt.
7N, GROUT
FROM.
I r7
NATE'Itni. nI(IJJ & AMOUNT
It.
n,
rt+
r4
rr.
IL
24, ! WI;RAVPL PAC. I+r dyllicibk}
T[r
,JI FL HLII.
10rEH_1( Fwnr*r1''dlmehgr1
{
II.
11, DRILLING LOG I nlrach iddllionxl wbotifl if rreemary I
FROM
0 fl,
TO
19' fi.
IL
nP.WrltlPT:OJNIFl.r.i irdhn., RIIµ'nKkh5 Rr cril.n ,OS.I
rt.
14
IL
rL
it
Ic.
Ir,
Ira
R-
IL
21. BCMAttRbA
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a Fecal red W c8 Caurrserur Nee
AT MT41lI1.I4 Au. fatal, I rrrroiry eMrr I' rllw r♦+Y 1A-10i 4rrY JI,l J t111115 ireira Ire.0ItY'rimavir
u'JtA l •bl riCAC OTC .Warr" ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)JrrIIrNi rmur Siorida,i mist riLU o
r' n orals rm. and Ambr,rN plrlVlfl.Wl Fa' Au 4I1LJ1 iiI wr.
1/27/2021
23. Site ditioslni or iiidt1i'J1u1I well delimit?.
Ycn1 rllal 1k ate L ac6 of digs "rage to provide addilicsnul Ii.e111 site details ur we]
L'8IiSIrur;Llali tkrails. You Hun ulst5 8tildi ;E[1diirmiut tkJ ws rI r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I iir All Wr,ik Suhaoi ilus Farm wires 3U dale of courplermoo of swat
coogructtpa to the rblkohrltl
ii1►:isfua ul'V4'rrirrkeno rce5, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uiectiim We3b ONLY: In addition Ie aeladitlg Ilie rofn7 to the itddmss Pik
a�ezibo4's:. miles+ Stith loll a copy of tills. try uiiLlui iLl dlks of I:ampletii it of vcc ll
c n tructluu ILl (he rind riu .
I"h imam of Water Resources, lrndcrg nand 1njr:riIoll Control Program,
1636 Malt Service Center. Raleigh, NC 27iWcr-I(136
24r For Veir ...54ppl} Iojraion 'WOW
Also submit ogre cop). of phi& ruin, u Itlhru ;8 hays of COritpieliopF uF
tire"" cnoglrlrrttnn co ILle cnlrut} 1101101 rleppfrlimN1I or air c iiu*i w it=,;
conilmcicd
rarin trii -1
wFnnh an'ulnFL'.lktnii instil LII51r5rIIJIYCIIr
slag LIILur 1l itesoluctfi - 3)1kr5I011*f' W.nicr aC{JLrc
CtiChlgt 4J hrl;I

WELL CONSITRUC CON RECORD
Thy fonrl+nu be ascii rec sllll;k +lr Irlllll llk hs ell5
1. %V 1 Contractor inform/Milne
1F'ar frOcmill 4ic D141.V
Brian Ewing
▪ pelt Crotmo ur H irn
4240-B
NC Well Co cr1i k Liun rKii rti
SAEDACCO Inc
? . V4'e14 t aDatr,e ieu Pernik O; w10300399; 70002483
lkJ-din pvlicuhlr 0.YirPrrmil4lr-r.. G IUnty Slap_WiridlLr Pea -Um .11-.1
3. Well Ilse tetrad well MAO
Water Supply Weil:
IJCreolli nwI Iiitaliog''Coalirig Stipp]}l
I' Ilndusiria fCantrllercial
❑ hngai nn
Llhililiil.ipctlllhlic
0 R{Sfdr:Ilnlll Water Sunk l Si RLICl
I-1Rcsidenlr,ll Water Supply ls]vamdf
• :-Water Suppl Wd1:
❑h ioniloriuc ❑lea}>'
Eij4`r1kr1I V- IL,
r1Ad111ifir Recii51r re
pAtinircr 9tormc mild Ttecr135er,r
❑ AgpirFr 7�61
❑ EN rimcnfRl Trc11n€1Gaet'
❑ Ci ulhermal iClused Loopr
❑ Gradicltrial iFlciiiii Cnssliu Rutuiil}
4. Date Wetkst Cunilli It d; 1/15/21
i.L. %fell [alrathln:
DSRlinits 13arritr
❑ A' orrnytilrl r ErRig2ga
Cl5i9bRickilCC cailmi
❑ Trour'r
®O1lier Iexplain outlet. /21 Remarks)
Well JTir B3
Remediation Management Service Company
I. . ' I I i I ' [if rr1'pli:irble6
2650 Shenandoah Ave., Charlotte, NC, 28205
Plonk li Addrea Cit... ;md Zip
Mecklenburg 12710204
tjnwlnt� Prieecl Il1l'IuiEltiu ii Nn rP1N1
h. LoIlbasintod IJngltnnPL' In rIL`pl+ceSrinlilrµte1Ili4 pnlrrls nr der'imol st•egro2s;
i d t rli Add Int' Li '10 r¢ lx strlT,tkiu i
35.210533 (-80.801887 W
fr. Is lmre) Ihh! 1+rII1&Y. ❑i'erillanral Li 211'moron'
7. Is this a rrpair iu an rhriodll iowait: 11'rs or MIND
+
{rill ri Ii Ir lriNllr. •i rrii F �TNrIIW 14J'fl r4r•'J.7'ili rr'rl llrll J'TlJ'fl Jlkl iiri I'SrlrfldJ' rA I' llllrNrl' IIr rilr
rr,4drr ulaL.i'!11 remark.. wear a ur r41 der hack rtr Mrs form.
S. Number of well consiruceed: 1 _
i r DartljvJ* Orr MA14 mll W rive-IrNfYr .1•11AtiOelpotir UNfl' ar.r11 roar inNWivrrarnrethilr
_5d1�5'llrf RAC fiJnu.
9. 7'utai won depth hei m lewd surface 19
r,rr I'NIHrp1i' N'f1�1 �rlr irrl rilq rlr7 thifiVirect 16.terrrtldre- *ND' aAIr17 ;IVO
10. Stitic water level below mitt 11f l'usiu1
▪ I141.1I'r k''.ri 14 Mom.. Lwri; a.r' "*
11. Flee ule rlijnreltr 1. 5"
12. Well eurstIntslipu IPYetlirlii: DRIVEN
iri.
(fLI
cI.¢, Forger, rotor►', i-0hlr, din: 0 elkEILeK.1
FOIl WATER sUPPJ.YWELLS ONLY;
1.7,1. Vicki IRpiiP i IIIid nit err
1313, biilnfad ua raper 4muuut;
. WAIXas V..01,11s
FaDiw 111r
D!_tir HIP IJl1,,
R.
t5. {MJT R CASFNC {nrr Inu141-mail nab) OR L FfER lit appJRcahkh
FROM 11TI PIAMFTFR TIIICKNFM4
0 11' j 11' ti,
I 2fir LN}1R cot:1INc Ian'r_ 91niirlrkr.r4rirr rrarup_.
k FROM TO DLk'IESFR TDICKl§ESS MALE JAL
to
n,
1.5" Jo,
NA
ntoreillt ;or sin'
19' 11, 1.5"
I.
NA
Steel
TFllr lk!rPy4
NA
Sri. rooked,
Steel
IL
rt.
I.
7111. C1R01T
RAOi1
Isl
Nn[Eltli[. F. trL1i> Mk4TAIL nomLaAMOUNT
tt.
n,
r4-
rr.
IL
24, S)lNbt1:RAVPL Peril, I+r dyllicibk
rpirir
R.
Trr
IJI FE HLII.
Irirr'1.1( F %IF,i 1''dame1.1.111.1
{
(I.
11, DRILLING LOG I march iddllion it wbotifl if ricecoory I
FROM
0 II.
rt.
TO
19' fi.
IL
DP.Wrltlen:OJ Ni I k hh Rr• a'Iii 4r, ef[.I
r1.
rL
tL
It
Ic
It.
R-
IL,
24 altriLlkWb ,
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a Fecal led Wcrt Cauurk'rur Decc
AT MTQVI1.I4 drhr frMrl, 1 rrrr.+b' erM0r7I' rllul rNAY im di(yl u rY a1.mJ tyietwlreirtL 4r vre'rimavi e
u'Jrr1 1 •bl rifCAC OTC .Ofrrrl nJ. i Tel NL'r1CL�u�.TC,(V8f1 WI Y I>+rrrrrrrrrmur Stajpdards nand NMI o
r'rJl1 r l', lis rm. and lli:h brrr J plrlurfl.Wl FFF JIIW 4I1r+J1 iiI wr.
1/27/2021
23. Site diiK;r'slni or addlti'Jil,il well delimit?.
Yuu Fluky ,Lie illr Ll;icL of ilia. IIe2' to provide addiliol,ul ,yell site ddiils ur we]
construction i1m LuEr. You nun also Mod ;acklilrftlut tritLxs11. hxses#an .
$LI BRICf I Ai. LNb7 tJcrIoN5
Na. ihlr All Wr,ik Sohaoi this Form wiles 3U dal. of L+amplerloo of nett
construction to the rblkomrl .
ii11: sflla lir Wafer Resources, Int11rmmiluu Pni rs ing Gull,
1617 blab Semler CeLlcr, Raleigh, NC 276911-1617
21b. For [uiiectillu Wedl9 ONLY: In addition to sending Ilie faun to floe :address ui
a�eakrOVd. mils,+ Stith !oil a copy of tills. tint uiiLlui i0 dales of r:ompletii ii of well
construction ILl [he faLlowiu .
Iih ialrm of Water Resources, lrndcrgrnund luleciIan Cunrrol Program,
1.8.16 Halt Seance Center. Raleigh, NC 27694463e
2 iL Fur Wafer.5ipPI} Fojetsips Wile.
Also stllrlliit sire cop). of Ali. 11.4111 u ICL1iil ;r8 days of co111 1eIiop1 uF
tircll cno9Il1Irttnn co tL1e cniwO 1101101 Ileportine1I or air county Isla.=
coral -lured
rarin trii -1
'win n t an' II II:r Lour ii iiE III LI II mum!"
mid 1LIILWi11 ILcs0lucts - ] 1kr5I6I1r1I W.11Cr 11CiJLr9L
t#[h'Lged Aug= 11AI:I

WELL CONSITRUC CON RECORD
Thy fonrl+nu tic !mil cog 5Illl;k'Iw echo rk,serl5
1. Wo11 Curltrnctur inform/dime
1F'ar frOctrill USe D141.V
Brian Ewing
Crotnwrur NarrnC
4240-B
NC Well Coui ,icior cr1IfrJLiun r:iirti
SAEDACCO Inc
V41I (wis rrictiun Pernik O; wi0300399; 70002483
liuul2 opvllruhlr 0.YirPrrmir4lr-r.. G iltnty SLtlr_Y'yri+lLr 1rofortrar#. h-.1
Wril Ilse trim& well iIr
Water Supply Weil:
ri€tlltLlril
IJCreo bcfmal IliaaliogiCoaling 5upph1•
I' 1ledusiria fCantrllercial
❑ hnipi nn
EffsinnicipaliPulslic
CJFktsfdennlll Water' Sunk! aSiRfJcl
I-1Rcsidenu,ll Water Supply ts]'Iarodf
NOP-Water Supply Well:
❑hioi iIorine ❑lea}> '
Eiji:I/aIr1I WkrIk
r1Ad111ifir Reci151r [e
pAtinircr 9tormc ald Ttecr135er,r
❑ AgpirFr 7�61
❑ El p rimCluR1 Ttclin log
❑ Ci ulhermal iClused Loopr
❑ Geother ial iFlenuii JC'nolinn Rutuiill
4. Date Welikst CunillItIttl; 1/15/21
i.L. %fell lalrathrn:
Qttrolatbdwaler Renlcduulw!
DSalinits 13ar ricr
❑ A' orrn5rlller ErRig2gc
❑51ILNUICIICC C'ahyr{ll
❑ Traorr
l O11Ler �ucpluiil Louder /21 Remarks)
Well JTii<B7
Remediation Management Service Company
I. • [if rq'pli:iiblei
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;md Zip
Mecklenburg 12710204
Cnu1111 l' Itee11rieiuirlciuul, Nn fP1N?
h. T:lnilasinind laingltnti In Ilcpncearinrirrµte1Ili4 nnrls nr der'imol st•egro2s;
t rli Add Int' LiSnativ s strnekmi
35.210533 (-80.801887 W
9. I3Imri) the l+IrIPIji. ❑i'erillanral Li 211'moron'
7. Is this a rrpair iu an r7riodll iowait: ®hlu 011ie or
+
{tilt ri lr Ir lriNllr. •i lrii F �TrrrIIW war corlJ.Irill. f ?ow r lrrl J.TJJ.rIJIJJI mod I'irlrratJ. pJ.' ll.rrNr r Ire NIr
rr,4drr ulaLN 2t11 rrei r2t5 Y[ eJrari 1Jr tYl der hack rtr Mrs form.
S. Number of welbt cnrirrrrueeed: 1 _
f r uw2rljV.rc Orrjavuilmll W rire-Irxwr J•IIf ' !WM' LIMA rr.r11 rrlr WNW carrarnreri,r+r
_SdI�r.II2r RAC fiJnu.
9.1'0101 Fell depth beim land surface 19
for I.0.10p1I' 1fifiReed 16Jrrrrrtrdre- 7*: 17' aAIr+ 7 ;IVO
11F0. SUStIE water' level below nip of cusiu1
i+ IV/NH kiri 14 Mom.. L iri; rr.r' "*
tJrul �,.IN
12. Well i`uestIntctipir IPYetlimd DRIVEN
fri,t
(fLI
cLe. rorger, roinr►, i-0hIr, dIlres Is.elc.r
FOIl WATER sUPPJ.Y WELLS ONLY;
I.la. Yield Want Viiclllad of t e r
1313, biilnfar ua rapt: 4muuut;
1.4 WAIIk 2.0141s
FaDid 111r
D!_tir HIP IJl11,
1.
Its
t5. {MJT R CASFNC «llr prou141-tenoil ii Ni) OR L FfER lit apOlcahkh
FROM 11Tr PRMFTFR TIIICKNFM4
0 11' j 11' f1,
I 2fir 0.40 C.#1INC Lln'r_ 91ni� rivr.r4rirr rrarup_.
k FROM TO DLk'41ESFR TDICKl§ESS MATE.III.9i
6.
n,
1.5" Jo,
NA
71) PlArkTlr'I-I?ir J $I,tF'rSWF
19' 11. 1.5"
Ir.
NA
IIATIENTAI
Steel
THIr lk!rPy4
NA
m. rllprsl,
Steel
IL
It.
Im.
it C7R01T
RAOi1
1st
Rik [Eltli[. F. tFL1C Mk 4TAIL nomL JL AMOUNT
ft.
n,
r4
l4
Ir.
IL
19. ! WI;RAVPL PAC. I+r dyrlicibk}
rpsl�I
R.
Trr
II,
1JI FL
Irirr'1.1( F %Ir *i 1' u1-e11,4n
{
II.
11, DRILLING LOG I Attach iddllionxl chi if memory I
FROM
0 fl.
rt.
TO
19' 11.
IL
DPW-RIF l(JNi Iml.r.i.ir1Fw,., .tI'nrikhh Rr• a'In 4r, OK.I
R.
IL
IL
IL
It
Ic.
IL
It.
R-
IL
IleriLlatbA
Temporary injection point through DPT tooling
2/_ Certification..
Brian Ewing
Sieshourg a fetal God W c8 Coiiinj rur Nee
AT MTlr'JI1.4 drhr frrFnll. I rrer.'b.' erM0r7I' Phil rliz i1'rd{ 14rrY aI l J twrl5rrireirra err.0.ra'rvmmlr
!Nth l •bl riCAC OTC .0fr fr ry ?rt Nt','CL�i�LTC, V8I1 l44 I Y I>+rrrrNi rmur Sramok ds reeled
i o
rT .11 orals rm. and ,Jii brrrIu prrrr'Id.W1 rrF JIIW 4I1r+J1 iIwwr.
1/27/2021
23. Site diiK;r'slni or additi'Jiim1I well delimit?.
Yuu rl1H1 1k 111re Ll;icL of fills pow to provide addiliol,ul i ell site ddiils or well
construction Ilelails. You nun also Mood ackiilrfrmt twb'cs r1 rxscs#an .
;il; u trf7 AI, LNb1 tJc IONS
lda. lhl( All Wr,ik Suhaml this Fran wiles 3U dale of courplerloo of welt
construction to the rblkomrl4.
;IMAMS ul'Wafer Resources, Intlrrmmiluu Pni rs log Gull,
1617 Malt Semler CeLlcr, Raleigh, NC 27699-1617
For [uiiectillu Wedl9 ONLY: Ili addition to aeladitlg the faun to floe :Idd tees ui
a�ealro4e. slew+ suhiiii1 a copy of tills. form uiiLlui 101 dates of Llampluticish of well
construction ILl the faLlowiu .
Iih ialrm of Water Resources, lrndcrgrnund lwleclIoiu Control Program,
1.8.16 Halt Service Center. Raleigh, NC 27694•.1639
2.3L Fur War °.54ppl} 1DJrEips WOW
Also submit sire cop). of ihi . fuln, u Itliiu ;8 1IAys of ccMFi•1eiion uF
tircll cnoglrlrrttnn co tL1e criiiim lIt1IIlii sleppinimN11 or air courtly Is'la.=
coral -tiered
rarin trii -I
'win n Iarc' II Ina Lmiar ii iiL III bp, II 1r5I IIJIICII1
a lrl LIILuck.1 JtC&]IQctfi - DPSS 1011 f1.1% Warr 11.m.c.nrcm
t#[h'L9Cd Alva 111I;I

WELL CONSTRUCUON RECORD
Thy fonrl+nn be 1lsi3d rec s1'Iu;}c +Ir I!nlal l'I ii ergs
1. Welt Curllr riet[.r Il,iruririrrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
WdlCF P rl4lurNarn
4240-B
NC Well Coulr,Icior CarliiimLiun M1ii rti
SAEDACCO Inc
?. V4'e14 traristnictiun Pernik WI0300399; 70002483
lirrrdl opvllruhlr LkrirPrrmil4 lr-r.. - it th keert'Or#
3. Wr I Use trim& wall M
Water Supply VieIL-
ClAgrt,calturil
UCreolli nwI Iiiearing'Cooling 5upp]}l
I' 1lndusiria fCanuni:rcial
❑ hnt Lhnn
L1M iicipal/Plrhlic
rl RAsidellnlll Wtiror Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
M1ir:-Water S+upp1}' Well:
❑I4ioi iIoriuc ❑lea}> '
Eiji:I/arr1I V- Ik
rlAdllriCi r Rectiktrim
pArinircr 9tormc and Recr131er,r
❑ AgpirFr 7�61
❑ EN rimCllff1 TgC1rn6L13 '
❑ Jouiherm;rl iCluted Linlpt
❑ Geodleiiiial illes,uii Cnssliu Rrtuiihl
0 7recRodwalcr p.E'l1iCS{1JYa9a7
DSalini1% l arncr
❑ A'orrowsfier Erryin.2r4
❑ IILNUICllcC Cali MI
❑ 'Traorr
111O11kr iucpiuiil LIINICr 121 Renlulks)
4. RAW Wellk0 Crjilrlrlel€tl; 1/15/21 We.11 Mgr A25
5a_ %fell ".Ilrathrn:
Remediation Management Service Company
l • . ' I I i I ' of lrrpli nb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea City_ ;ind Zip
Mecklenburg 12710204
VwmJ1 ?lied IlLil'iuirlciuui1 Nn fP1N?
ih. T:init ir iiid laangttmhr In lP12-prxrarinrimrtelilccnnrls nr k imil kt rrra;
ads rli Add strnekiiii.
35.210533 N-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an r xir iodiowrit: 011ie or IR ND
+
Origin lr Ir lriNll1..1%11 iNF 0.4,11.0 i1 lflcorlJ.7'IFl,frr'rI llrllJ'TJJ'rIJIJJI mod I'irlrratJ, rA„ ll,lrNrr IIr NIr
rr,4drr uldifef i r ei rk set.li a LW All [IIr hack rtr 016.1orJu.
S. PluuLbet of well tlnirlrrueeed: 1 _
iirddr Vte lrrMAullwl W rire-Irxwr .141Atift ingtr ONLY lI'.rh rllr WNW
sd1rmIlrro )'iJnu.
9. 7'Utal wail drppr helm lima surface 19
for hNllirlrfl' thifiVirect 16JGfr' ijdre- *.:1;10' Aril2cir ;IVO
11F0. SiSTIE water' level iicluw nip of lAriio1
i+ IV/NH k''.ri 9 Mom.. L iri; a.r' ".
1. I3oi#1Y4110 ilijnrelEr.1. 5"
12. Well i`riidilniZipii uwilin41: DRIVEN
(ri, t
(fl.I
c I.c rorger, rninrl, i-0hlc, dIlrci prEIL.M.F
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield Igpiiof
111r, biilnfaL ua ripe: 4muuut:
1.4 Wftiltf170f115
RCN l 1n
R!_tir'HIP rJl1',
ft.
ft.
t5, OUTHR CASiliC {nrr Prou141-renoil ii Ni) OR L N R (it amaRcahkh
FROM 1110 PIAMFTFR TPPICKNFM4
0 it. j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO Dtk41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" la,
NA
T1} pr.#lTrrl?ir J $IfirrLlls.
19' II- 1.5"
I.
NA
NA
NATIENTAI
Steel
rrl.#TI[krii,
Steel
IL
rt.
7N, GROUT
FROM.
I r7
Nn [Eltlii. F.#TFL1i> IilkwTlliLnI(IJJ Jr AMOUNT
ft.
n,
rr.
r4
rr.
IL
24, ! WGRAVPL PAC. I+r dyrlicibk}
T[r
p,
1JI FL HLII.
Lrirr'i _1( r wnr *r 1' ul_e 11.gn
{
(I.
11, DRILLING LOG I ntiich iddllionxl chi if rreemary I
FROM
0
ri.
TO
19' fi.
IL
DPW-REPT:OJN ...ahr,1'Mrdhw. Rµ'nlcki5 eJ-Inwir,Cf[.I
rt.
14
IL
rL
rt
Ic
14
Ira
R-
IL
21. gr-M.#M
Temporary injection point through DPT tooling
2/_ (crlrircatiira[
Brian Ewing
Sieshourg a Fecal God W cit Colorserur Nee
AT MT4lI1.I4 drhr frMrl, I rrrr.+b' eirr7I' r,Yw rl+r ivedi(yl u rY JI l J tY.O.V.trirelea Ire .0lre'rir2 lr
u'JtA l •bl riCAC OTC .Okra) ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)Jrrrrirrnur Standard nand
i o
rTg.1 orals rm. and AmbrrrN plrlr'If1.Wl Fa' Au 4I1r+J1 iiI wr.
1/27/2021
23. Site ditioslni or iiidtii'Jlimil well delimit?.
Yuu Flury 1k ate Lack of digs "rage to provide addilionul,rcll site details ur we]L
c8Ii Inim LLati iklails. You Hul% ulso Ara acldiirrfuut tra&ws d r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I+Iir All Wrik Suhaoi ilirs Farm wires 3U dal of courplerloo of swat
couglucttpn to the rblkohri[l
lFl►isFia ul'Wrlirrkeno rce5, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uieciiim Wedb ONLY: In addition Ie aeladitlg Ilie rofn7 to the Address ur
2-ra zikitOVd. mi1s.i Stith loll a copy of tills. try uiiLlui iLl dlks of r:ampletii ii of vcc ll
c n tructluu Iv the faL]Ohviu .
abh imam of Water Resources, lrndcrg nand 1njr:riIIalr Control Program,
1636 Halt Service Center. Raleigh, NC 27iWcr-I(136
2 it For Wif ...54RpI} IDjraion 'WOW
Also submit oire cop). of !hi . ruin, u iF[ ;8 hays of coni1leriorr uF
tire)) comonettnn co tLle crniut} U 1iItil llepplrl,lxnl or air court w it11;
conilmcicd
rarin trii -1
wFn n t arc' a Ina Lr.1imtr ii in nI EFII1r,0men
alit LIILuia1 I 0Iuctfi - l rvGlaunl'1'.11er Rinut.rcL
t#[h'L9Cd Aug= 11.1 I:I

WELL CONSTRUCUON RECORD
Thy fonrl+nn be 1lsfld rec s1'Iu;}c +Ir I!nlal l'I ii ergs
1. Welt Curllr riet[.r II,Irurlrirrliont
1F'ar FrOcsoil) 4ic D141.V
Brian Ewing
WdlCF P rl4lurNarn
4240-B
NC Well Coulr,Icior CarlifrkLiun M1ii rti
SAEDACCO Inc
traristnictiun Pernik WI0300399; 70002483
lirrrdl opvllruhlr LkrirPrrmil4 lr-r.. - it th keert'Or#
3. Wr I Use trim& wall M
Water Supply VieIL-
ClAgrt.calturil
UCreolli nwI Iiiearing'Cooling 5upp]}l
I' 1lndusiiia fCanuni:rcial
❑ hnt Lhnn
L1M iicipal/Plrhlic
rl fk:sidellnlll Wtiror Sunk! I Si RL:1Icl
I-lRcsidentr,ll Water Supply .s]'Iaredl
M1ir:-Water S+upp1}' Well:
❑I4ioi iIoriuc ❑lea}> '
I L1jCr11rr1I V- Ik
rlAdlllifir Rectiktrim
pArinircr 9tor.gc and Recr131er,r
❑ AgpirFr 7�61
❑ EN rimCllff1 TgC1rn6L13 '
❑ Jouiherm;rl iCluted Linlpt
❑ Geodleitrial illes,uii Cnssliu Rrtuilll
0 7recRodwalcr p.E'l1iCS{1JYa9a7
DSalini1% l arncr
❑ A'orrowsfier Erryin.2r4
DNIILNUICICC Cali MI
❑ 'Traorr
®O1ller lucpiuiil tiirdrt /21 Renlulks)
4. RAW WeII» Crjrlrlrlel€tl; 1/15/21 We.11 Mgr A23
5a_ %fell t.rlrathrn:
Remediation Management Service Company
l • . ' I I i I ' of lrrpli nb1e6
2650 Shenandoah Ave., Charlotte, NC, 28205
PIM IcIiI Addrea Citr_ ;ind Zip
Mecklenburg 12710204
VwmJ1 P1dee11deiuirlciuol4 Nn fP1N?
ih. T:init ir iiid laangttmhr In lP12-prxrarinrimrtelilccnnrls nr k imil kt rrra;
ads rli Add strnekiiii.
35.210533 (-80.801887 '
9. l3 lure) Ini 11r 211rInporon'
7. Is thin a rrpair iu an r xir iodiowrit: 011ie or IR ND
+
Origin lr Ir lriNll1..1%11 iNF 0.4,11.0 i1 lflcor l'IFI,frr'rI llrilJ'TJJ'rIJIJJI mod I'irlrritJ, rA„ ll,lrNrr IIr NIr
rr,4drr uldifef i r ei rk set.li a LW All [Ilr hack rtr 016.1orJu.
S. PluirLbet of well tlnirlrrueeed: 1 _
iirddr Vte lrrMAullwl W rime-Irxwr l411tgr' ingtr ONLY lI'.rh rllr WNW
sarmilrro )'iJnu.
9. 7Yital wail drppr helm lima surface 19
for h0i0p11' thifi erect 16JGfr' ijdre- 7 ' Aril2cir ;IVO
11F0. SUSTIE water' level iicluw nip ofc,riio1
i+ IV/NH k''.ri 9 arl'rlua' L ire; a.r' ".
1. I3oi#1Y4110 ilijnrelEr.1. 5"
tJrul �,.IN
12. Well i`riidilniZipii uwilin41: DRIVEN
(ri, t
(fl.I
c I.c arrger, rninrl, i-0hlc, dllecl prEIL.M.F
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield Igpiiof
111r, biilnfaL ua ,ripe: 4muuut:
14 Wftiltf170115
RCN l 1n
R!_tir'HIP rJl1',
ft.
ft.
t5, OUTHR CASiliC {nrr Prou141-renoil ii Ni) OR L N R (it amaRcahkh
FROM 1110 PIAMFTFR TPPICKNFM4
0 it. j 11' fi,
I 2fir LN}1R cot:SINc Its'r_t)91niirlrivr.r4rir[I�[rarup_.
k FROM TO Dtk41ESFR TDICKl§ESS MALE JAL
to
n,
1.5" la,
NA
T1} pr.#lTrrl?ir J ljl,frrtdrrr+'
19' II- 1.5"
I.
NA
NA
NATIENTAI
Steel
mATlckrsl,
Steel
IL
rt.
7N, GROUT
FROM.
I r7
Nn [Eltlii. F.#TFL1i> �ilkwTlliL nI(IJJ Jr AMOUNT
ft.
n,
rr.
r4
rr.
IL
24, 5.3.4.1,4W4:RAVPL PA€ k. I+r dyllicibk}
T[r
p,
1JI FL HLII.
Lrirr'i _1( F wnr *r 1' .1.1M11.113.1
{
(I.
11, DRILLING LOG I nliich iddllionxl chi if rreemary I
FROM
0 fI,
TO
19' fi.
IL
DPW-REPT:OJN ...ahr.iirdhw. Rµ'nlcki5 eJ-Inwir,Cf[.I
rt.
14
IL
rL
rt
Ic
14
Ira
R-
IL
21. gr-M.#M
Temporary injection point through DPT tooling
2/_ (crlrircatiira[
Brian Ewing
Sieshourg a Fecal God W cit Colorserur Nee
AT MT4lI1.I4 drhr frMrr, I rrrr.+b' eirr7I' r,Yw rl+r 1A-1 Y'l 14rd iI J tY.O.V.trirelea rn.0ke'rimavir
u'JtA l •bl riCAC r?SC .Warr) ru. i TA rvt',1CL�(�L'C A.041 %'W Y I)Jrrrrirrnur Standard nand
i o
rTg.1 orals rm. and AmbrrrN plrlr'If1.Wl ha' Au 4I1LJ1 iiI wr.
1/27/2021
23. Site ditioslni or iiidt1i'Jlimil well delimit?.
Yuu Fluky 1k ate Lack of digs "rage to provide addilionul ,rcll site details ur we] L
c8Ii Inim LLali iklails. You Hul% ulso Ara acldiirrfuut tra&ws d r,ewcssan .
;iu' BRICf I•Ai. LNs1 .1C"rfoNS.
lda. I+Iir All Wrik Suhaoi ilirs Farm wires 3U dal of courplerloo of swat
couglucttpn to the rblkhri[l
lFl►isFia ul'Wrlirrkeno rce5, Intlrrmmiluu Poi rss.iog Gull,
1617 MAO Sersire Ctmier, Raleigh, NC 21699-1611
241. Firr [uiectiim Wedb ONLY: In addition Ie aeladitlg Ilie rofn7 to the :Iddress ur
2-ra zikitOVd. mils.i Stith loll a copy of tills. try uiiLlui iLl dlks of r:ampletii ii of vcc ll
c n tructluu Iv the faL]Ohviu .
I"h imam of Water Resources, lrndcrg nand 1njr:riIall Control Program,
1636 Halt Service Center. Raleigh, NC 27iWcr-I(136
2 it Fur Wif ...54RpI} IDj1FEt pi 'WOW
Also submit ogre cop). of ihi& ruin, u iF[ ;8 Bays of coniFiieliopF uF
tire)) comonettnn co tLle criliut} U 1iItil ilepplrllrxnl or air c iiu*i w it11;
coniInlcicd
rarin trii -1
wFn n t arc' a Ina Lr t mtr ii ilr nI EFII1r,0men
mid LIILuia1 I 0Iuctfi - DPE10I1f1.1% nicr Rinut.rcL
t#[h'L9Cd Aug= 11.1 I:I

WELL CONSITRUC CON RECORD
Thy fonrl+nu tic 1Iscii roc sll gk +1r mIr11 Elrk hs etl5
1. %V t Curttrocti.r Inform/dime
1F'ar frOcmill USe D1,11.V
Brian Ewing
WOLCFP ri 4L.TNarrnC
4240-B
N C Well Coulr,lcior Carliihmtiul1 Niirti
SAEDACCO Inc
? . V4'e14 traoatrl,ctiun Pernik O; w10300399; 70002483
liuul2 opvllruhlr 0.YirPrrmir4lr-r.. G iltnty SLtlr_Y'aridice 1.9f9rtrar#. h-.1
3. Well Ilse tehcidc well iI�
Water Supply Weil:
UCJeolh "natal lifealiog'Coaling 5upphl•
I' llndusitia fCantreereial
❑ Imgalrnn
EffsloinicipaliPublic
rl R sidr:llnitl Water Sunk! a Si n fJcl
I-lRcsidenbml Water Supply ts]'Iarodf
ewer: -Wake Supply Well:
❑hianilotion 1=11 a'1rr]_
Eiji:I/atr11 WkrIk
El Ad1141u Recii51I re
pAtinircr 9torm8c ald Ttecrrr5er,r
❑ AgpirFr 7�61
❑ EN rimCtuR1 Ttchn€ loge..
❑ Ci uthermal iClused Luo i
❑ Geodtcitual iFIciiiii Cnsslim Retliiill
I SRlinii3 13artacr
❑ p' orrowsiler ErRig2ga
❑N1lhGhdC11CC C'aryr{ll
❑ Traor'r
®011oer ur�tiutu Iiimkt /21 Remarks)
4. D:It WepI» Crjfrlrlel€tl; 1/15/21 Weal Mgr A16
i.L. %fell Location:
Remediation Management Service Company
I. • I i 1 ! [if rq'pli:irblet
2650 Shenandoah Ave., Charlotte, NC, 28205
PIi v.cIiI Addrea City _ ;urd Zip
Mecklenburg 12710204
CoNmall Prldecl Ire iuiE'uciuoll Nn rR1N1
ih. T:aeilisinwid laa.gttnrhr In nr der'imil et•egro2s;
dtrliIkId Ink' LIA2Lr strnekmt
35.210533 N-80.801887 '
9. Is rare) Ihh! 1+rIPIji. ❑Perilla M111 Li 211'mporon'
7. Is this a rrpair iu an r siodil iotrait: D 11'rs or El Nip
+
{rrlrri Ii Ir 11,p91.1.,f+2lriir rFNr111N war r4rlJ.7riHlf?pm lIri1J'TJJrrIJIk1 mod 1. 1110.11.044rr Ire rJlr
rr,4drr ulaLN 2r11 rrei r2t5 Y[ eJrari ar Ali der hack rtr Mrs form.
S. Number of well cnitrrrrueeed: 1 _
t er uwitionre .1r0 uHa1 W Nre-Irxwr lultift !WM' ONLY 11'.rh role WNW cMrrrnrethilr
_51!I�5'Ilrr RAC fiJnu.
9.7001 well depth helm lewd surface 20
fire 1'0irprl' rtlgJrll, thifiVirect(e'Jr{rrrtrdre- 1 ' a61r17 ;IVO
1♦0. SUStIE carter level below nip of cuiiu1
fI I141+I'1. k'o-r•i 9 Mom.. Luiri; rl.r' •'
tJrul �,.IN
12. Well curetinrctipu inielliert DRIVEN
Aria
(rl.I
c 1.c Auger, roinn. i-0hlc, dllecl Itietc.r
FOIl WATER SUPPJ.YWELLS ONLY;
Oa. Yield IRpaml elf t err
I.113, bisiorectiva ripe: 4muuut;
14. WAI R tONL
RCN 11n
DEld'HIP IJl1'
rt.
t5. {MJT R CASiliC {nrr rnu11I-F ieil nab) OR L FfER (il amaRcahkh
FROM I TD PR IrFTFR TPPI€'KNFFt4
0 rL. j 12' tr.
I ik LN}itS coLSINc Ion'r_ 91niirlrivr.r4rirr rrarup_.
k FROM TO DLk'41ESFR TOIrlifiESS MALE JAL
to
n,
1.5" Jo,
NA
TD Pr.oTF?YR J Jiifirrstirs'
20' ft. 1.5"
..
NA
NATIENTAI
Steel
THILIk!�Py4
NA
m.krIttirsl .
Steel
IL
rt.
Ii
ell, GROUT
RAOi1
I At
RnTE1tPM. ! F.#tFL C Mk4TllMT.nomLJkAMOUNT
re.
n,
i4-
rr.
IL
19. ! W .RAVPL PA€ /. I+r dytlicibk}
rt.
TES
II,
1JI FE HLl1.
I[irEH _1( r %Ir *r 1' u1=me 11•gn
{
(I.
11, DRILLING LOG Ranch iddlliorod 4 otifl if merman
r I
FROM
0 kl,
ri.
TO
20' fr.
IL
DP.W-REPllilN1Buhr,1'trdhw. RIL'n1ckhhRr.a'In4r,OK. I
rt.
IL
rL
it
Ic
n,
It.
R-
IL,
24 arrilA. 4
Temporary injection point through DPT tooling
2/_ Cerliiicatittar
Brian Ewing
Sieshourg a Fecal red W cat Couurb'rur Dtec
AT ST*111.4 diLY frrFnll, I rrrr.'bi' e,r0r75' rrlul rliz 1A-10.1 14rd aI l J tClrlsrrireirrL err vre'rimmlr
1rjtA 1 •bl rirCAC 07C .0frYr ry ?ri rvc','CL�u�.TC,AV8I1 W Y I I)Jrrrrirptur ShINe♦ari rrrld riLU o
rT .11 orals rm. and ,Jii br,r J prrluld.wl r� AL. 4I1r+J1 iiI wr.
1/27/2021
23. Site dr rani or riddtti'Jirut well delimit?.
Yuu Fluky use Ile hick .uf fills page ro provide addilicsl,ul ,4.ell site ddails or well
construction derails. You nun also Milo 11;xldiinqutt Iwb'c Al rexcssan .
;il; BRICf I Ai. LNs1 .1CTIONS.
2da. Ihnr Ali Wells] S11haoi itus Fran with 3U da3s of z uipletloo of well
construction to the rblkomrl4.
ll1►ilrFra ul'Wafer Resources, Information Pi -Hemming Gull,
1A17 Malt Sersire CeLIcr, Raleigh, NC 27699-1617
24h.. Fier [ukciiim We319 ONLY: hi addition to aeladitlg Ilse farm to floe iiddress Pik
a�eab04•e. alsar suhlui1 a copy of tlllk form uiiLlui i0 dates of CaanIpluticith of well
construction to (he faLlirhviu .
IT iilrwi of Water Resources, lrndctgrnund lwleclIoir Control Program,
1.8.16 Malt Service Center. Raleigh, NC 2 7tW9-1 I36
2.3L For Wir °.54RPl} ! Ioj1Et1). Wile.
Also submit sire cop). of ilia. FLAW, u 1FLuil ;o days of coniF+ietiOrt uF
mkt cnogtrltrttnn co IL1e cniiit} him iItil llep rover rl or air cpiu*i wise=:
corarniicd
rarin trii -I
'win Iarc' II II:t LmIumiitiiE III bp, 1r5r IIIIIcu1
sore NaLuiml itesaiactfi - DPE1011. n1%Warr ilC{JLF
KeirLSCA1 Aug= 11.1I;1