Mecklenburg_Well Abandonment_20220819

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: _ WELL ABANDONMENT DETAILS
JOHNNY BURR �"' n �,' �5 --D
�. i 7a.Number of wells being abandon) 1
d
Well Contractor Name(or well owner personally abandoning well n Itns/h pr Fbr muhiple injection or non-wafer .supply wells ONLY with the saute
t I t construction/abandonment,you can.submit;on'e farm.
A - 3098 F'J — j
NC Well Contractor Certification Number ) ��,ti3u�D ;'f:L %u�:t?�Ufii�
7b.Approximate volume of water remaining in well(s): 14'0 (gal)
GEOLOGIC EXPLORATION, INC D°f �i` ' FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: GRANULAR CHLORINE
2.Well Construction Permit#: 10013296
List al/applicable well construction permits(i.e.County,State, Variance,etc.)ii known 7d.Amount of disinfectant used:
2 OUNCES
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
i
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 16.25 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description oft;he abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 07/22/22
i
5a.Well location:
CLINE RESIDENCE
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification:
6505 SOUTH TRYON STREET CHARLOTTE 28217 � 07/29/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKLENBURG 167-221-02 By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 09' 43.96" 800 54' 56.51" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple h jection or non-water supply
wells ONLY with the same consiructiomabandonntent,you can submit one farm' 10a. For All Wells' Submit this form within 30 days of completion of well
6a.Well ID#: WW-3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 100.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface: 15.0 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Suooly& Iniec ion Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit;one copy of this form within 30 days of
completion of well abandonmentito`the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
r
Fonn OW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

i
i.
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
f
I.Well Contractor Information: WELL ABANDONMENT DETAILS,
JOHNNY BURR 7a.Number of wells being abandon 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
onstruction'abandonment,you can submit otie form.
A - 3098 '� "
'% s -5 Y_. b.Approximate volume of water remaining in well(s): 24'0 (gal.)
NC Well Contractor Certification Number i
GEOLOGIC EXPLORATION, INC pier 9 2022 FOR WATER SUPPLY WELLS ONLY:
Company Name GRANULAR CHLORINE
U ,Z.Type of disinfectant used:
�t
2.Well Construction Permit#: 10013295►00fy' ;
List all applicable well construction permits(i.e.County.State.Variance,etc.)ij'known 3 OUNCES
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural ❑Municipal/Public ❑Neat Cement Grout O Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) RIResidential Water Supply(single) O Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry i ❑ Other(explain under 7g)
❑Monitoring ORecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation 37.25 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description oft'he abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMI PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 07/22/22
5a.Well location:
CORROS RESIDENCE
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification:
6431 SOUTH TRYON STREET CHARLOTTE 28217 � 07/29/22
Physical Address,City,and Zip Signature of Certified Well Contractor orVell Owner Date
MECKLENBURG 167-221-01 By signing this form, 1 hereby cerl'ify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 9.Site diagram or additional well details:
35° 09' 44.94" 800 54' 55.27" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recard(s)if available. For multiple injection or non-crater supply
welly ONLY with the.came construction.abandonntent,you can submit one form. 10a. For All Wells' Submit this form within 30 days of completion of well
6a.Well ID#: WW-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
57.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4'0 above,also submit one copy of this form within 30 days of completion of well
(in.) abandonment to the following: j
6d.Water level below ground surface: 20.0 (ft•) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
loc. For Water Supply& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
64.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
I
Fonn G W-30 North Carolina Department of Environment and Natural Resources-Division of Water QIi ality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) pbr multiple injection or non-wal'r supply wells ONLY ivith the same
construction/abandonment,you can submit one form.
C - 4421 _ E 4.5
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number �.. r
GEOLOGIC EXPLORATION R 4- E j �.dE
"E
FOR WATER SUPPLY WELLS ONLY:
Company Name AIJ `. ! _ 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County, 'tale,VpKKy1ce,t�rt ivo�n '
7d.Amount of disinfectant used: 1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: O Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 6.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/10/22
5a.Well location:
PELTON - CRANE
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
200 CLANTON ROAD CHARLOTTE 28217 "` 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MECKLENBURG By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35° 11' 46.81" 800 52' 34.18" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-waler supply
melts ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this.'form within 30 days of completion of well
6a.Well ID#:
MW-14 abandonment to the following:
Division of Water Quality,Information Processing Unit,
36.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection Wells: In addition to sending the form to the address in 10a
2 above,also submit one copy of thiss form within 30 days of completion of well
6c.Borehole diameter: '0 (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 8'0 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunaly& Iniection.Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6C Inner casing/tubing length(if known):
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

i
'WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or mtdtipie wells
I
1.Well Contractor Information: WELL ABANDQNMENT DETUt
Zach Thompson 7a.Number of wells heitng,abandoned: 1
Wdt Contractor Name o well monal atmoda well For multiple tnkK¢far or nurt-w•fer .nrppf>- wells ONLY Leah elm snob
( Pc S r�8 propertS) i
arrrstrxcfuvr?ahandrutAicnt�r�n VW? sArnlf crie fomr,
4478A
NC Well CorrtmaorCeniftrallonNmnbcr
7b.Approximate volume of water4remaining in well(s): (gat j
SAEDACCO Inc FOR WATER SUPPLY WELLS,ONLY:
Caaga y Namc s `>rJ �—_ JR 7e.Type of disinfectant used:
2.Wdi Consttvction Pe mlt l):70001119, ,
Lea all applkrrbte well permlls(f.e_Coanfk stare.l'rsrfaw-V. fin. !c f - Id.Amaant of disinfectant used:
3.Well use(checkirr lluse): ltijc�fwit"rn Pr.camnrg Used
Water Supphr Well: 7e.Scaling materials used(cheer{all that apply):
❑Agrictdtor tl ❑municipat/Pnbtic M Ncat Cement Groat ❑ 8crttonitc Chips or Pellets
❑Gcolk n al(HcarineCoolino Supply) ❑Rcsidcnrint Water Supply(single) ❑ Sand CerrotM Ctntrl ❑Dry Clay
❑Industrial/Comrnercial ❑Rcsidentint Water Supply(shared) i ❑Concrete Grout ❑Drill Cutli.dgs
❑irri •tion ❑Specialty Grout ❑Gravel
Non-Water Supply Well; ❑Bentonite Slurry i]Other(L\Tlain under 7g)
mmonliorifre ❑Recovery
Tnjection Welt: X For each material ideetcd above,provide amount of materials trued:
❑Aquifer Recharge 00mmindttalerRemediation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
❑A uifer Storage 8nd Recovery OSaliaity Barrier
❑Aquifer Test ❑Stomnvater Dtairtage
❑Experimental Technology ❑Strhsideace Contra)
Tg.Provide>t brief dinseriptioa of the abandoament pntrx�tluce:
DGeothermal(Closed Loop) (]Tracer
Grout emplaced via tremie pipe
OGeothermat(Heati I.i Return) OOd►er(explain under 7 )
4.Date svil(s)shandencd 7-2 9-2 0 2 2
52.Well location:
Domestic Laundry
Faciltty/(h%-mr Name Fac)ldy IDrr(fapplicablc) S.Ce-rdfkaatiaall:�
801 S McDowell St Charlotte, NC 28204 ?—44 //L9Mwadem- 7/29/2022
Physical Add.City.and Zip Migmare nrcert:iriod Well Contactor or Wet)On-wr Dare
Mecklenburg By:sign} this form, I/tereby certify that the wellfs)was fieere)ahandaimd ne
Coutity Paned IdendtieadmtNo.(PiN) ac rdance with 1SA XCAC 02C.0100 or 2C.02W Mull Cm trtection Randtirds
curd dral a copy of this retard has been provided to the well owner.
gh.lAtitude and longitude in degrees/minutes/seconds or decimal degrees.:
(if well field,are 67tllattg is s„mcient) 9.Site diagram or additional well details:
You tam,use the back of this page to provide additional well site details or well
35.213757 N. -80.842996 W abandonrnerudetails. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLfSI BEING ABANDONED SUBM TTAT.INSTRUCTIONS
AfNcdr nrll enmmucAm returdtsf if available. For nmkplr h#eerirm or rwn-myrier.wppl)-
n,ella ONLY with the mwe eotrstrrtc0an abmn4zrxnent.ioo can Arbmti rsrr fwm 10a. For All Wdh.- Submit this form uritbin 30 days of completion of cull
6a.We"M#•MW-6 abandonment to the following;
Division of Water Rewurces,Information Processing Unit,
6b.Totat well depth: 2 5 (et,) 1617 Mail Service Crater,Raleigh,NC 27699-1617
106.For Infection Wells: In addition to sending die fomt to the address in 10a
6c Borehole diameter.2 fin,) above,also submit one copy of this forth within 30 days of complttion of%mi
abandonment to the following:
t 14.5 Division of Water Resources;Underground injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6a Outcr cane length d Imowo)• 10 (ft) loc.For Water Satrnly&infecdon Wells: In addition to sending the form to
p ( the address(es) atwve. also submit one copy of this form within 10 days of
completion of well abandonment lo the oonmy health department of the touchy
wh=atxtndoncd.
6f.Inner cnsin�tnl►iag length(if Imawa): (E1t.j
6g,Screen length(If known):15
Fenn GW-ia North Camlim Depannrcar of Environment and Natural Resources-Division of Water Resources Revised Augnsl 2011

i
WELL ABANDONMENT RECORD For Irma=)use ONLY:
This fbmu can be used for single or multiple wells
1.WcD Contractor Infonnation: FELL ABANDONMENT DETAiL4
Zach Thompson 7a.Number of wells being abandoned: 1
%Vdl'CoolmdorNamc %8raltowner manatl abondonln well an For mnRipk kllrerta► a• aorj-%-lrer supply wer7s ONLY v11h M,r sane
( Pc Y• S tnY) ,
cz A-� cwn:trrrctuxi/abamkurwrnG ie,ncar.rwMidraieJFirvn
4478A
NC Well
7b.Approximate volume of water remaining in wells): (gel)
SAfiDACCO Inc A�J`, 2V L! FOR WATER SUPPLY WELLS ONLY:
Can pony 1 Fa►ae y,?x,p u C /►f di iiOfCtt9ttt nsell:
eil
2.We11 Canstmetion Permit M:70001119,
Ltsratl ttppltnrblr url)prrmtts il.r_C:arutt Stave,i aiarncz,iryaKflon,e1el ifkmrvro 7d Amormt of disinfectant used:
3.Well use(check well use):
Water Suppy Well: Te.Sealing materials used(check►ill that apply):
❑Agriculturll OMuu►icipal/Publbc 0 Newt Ccmcnt Grout ❑ Bcntonitc Chips or Pellets
❑Gcothcrunt(Hcatine`C000ling Supply) ❑Rcsideritial Water Supply(sin)e) ❑Sand Cement Gnnrt ❑Dry Clay
❑Intbistrial/Cgmmcrcial ❑Rcsiden dal Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑irri •tion ❑ Specialty Grout ❑Grated
Non-Water Supply Wen: 0 Bentenite Slurry ❑Other(exl)laittunder 7g)
Monitoring ❑Recovery
injection Wcll: 7f.For each material selected aboive.provide amount of nutaalals used:
❑Aquifer Recharge ❑GromndwaterRemediation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recrn ery ❑Salinity®artier
❑Aquifer Test ❑Stort►nvater Drainage
❑Experimenlal Technology ❑Subsidence Cortlml
Tg.Protsdc a brvf dtseription of the abandonment procedure:
1713veothermal(Closed Loop} ®Tracer
Grout emplaced via tremie pipe
0Geothemtal(Head oti Retum) C30thert;px0ain under 7 )
i.Date well(s)abandoned: 7-2 9-2 022
Sa.Well location:
Domestic Laundry
recilEty/Owner Nam Facility IDa(ifapplicablc) S.Certification:: ,.
801 S McDowell St Charlotte, NC 28204 7/29/2022
Physical Ad&m.City,and Zip ee rtnrCafCeniiiM WcfCoinnxiar or'Welt Owwr Doro
Mecklenburg 13y si ifigg this fame, I hereby cerdfy that the wells)wav(were)abandfoned in
County Parcel Identiffol it No.(PIN) ocwrdonce wah I SA NCAC 02C.0100 or 2C.0200[Pr11 Canowcoon Start&srds
mid that a onp,of this record has been provided to fire well owner.
Sb.Iautitude and longitude in dcgirccOminptetr/seconds or decimal degrces:
(11'weu A01d,ouc 49Ulong is solficiet%) 9.Site diagram or additional well detaffs:
You may use the(tack of this page'to provide additional well site details or well
35.213437 N,, -80.841835 W abandonment details. You may also allachaddilional pages iflnecessary.
CONSTRUCTION DETAR S ON WELDS)BEING ABANDONED SUBARn-AL I NSTFIIICTIONS
+tthuh arlf cnrrsYnuetiNt rrcvrdts/if Ovdtf(�Gtr. For muhiple tn/eaiem or wn-itw9•supple
welfaONLY witin the wrue m=*wurom'dl,arrk mmr,ivn ten s,tbnnit wte,i ppm 10a. For All Welts: Submit this;farm within 30 days of completion of well
6a.Wen M#:MW-7 abandonment to the foiioving:
Division of Water Resources,Infannatino Processing Unit,
6b.Totat weal depth: 18 A) 1617 Mail Service Center,Rale"rA.NC 276"-1617
10b.For Inleedon Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:2 above.also ubmit one copy of lhis form mithin 30 days of completion of well
(7n.) abandonntcul to the following:
12.5 Division of WanxResources,iUnderground Injection Control of Program.
6d.Water level below ground surface: (ft.) 1636 Mail Service Carter,Raleigh,NC 2769'l-1636
6c.Outer caan1:1 (if known): 3 A) 10c.For Water supply&iubecWn•wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion(if well abandonment to the county health deparumcnt of the county
where abandoned, g
6E Inner easing/tubiag length(if known): (flu)
i
6g.Screea length(if known):15 (R.)
Fonn GW-30 North CamHca Depannncot of Environment and N nuW Resou►ces-Divisbon of W'atcr R�oiuck"s Rn•i"Ar►Sus12013

WELL ABANDONMENT RECORD For Iraemal Use ONLY:
This tbim can be used for single or multiple yells
1.Well Contractor infor matioD: WELL ABANDONWNT DETAILS
—— - - - i
Zach Thompson 7a.Number of wells being abandoned: 1
Welt tCocime r Nam(or well as tier persanwtl)ahawtoniag%cil an bkllier ptoperrr) For mtf le &!%%Vat or iron-mafer' snippy refls ONLF with the spurt
c*w0vc"j1abar&mmeW,tan et9r.yx1mJt mcfarvn,
4478A
NC Well Cammaor CcnifiWlion Nrntsber r F 7b.Approximate miume of water i maining in well(rs): (gal,)
4 F ma/
SABDACCO Inc
" "s 6�. FOR WATER SUPPLY WILL$ONLY:
Cantyany Name
A U r '
1 9 ZRZ 7e.Type of disinfectant used:
2.Well Construction Permit#:70001119, ,
Ltsr aV1 applkahlt k e1/permtis d'.t.Co41gf1',Siam.I'urt
Id.Amo tit of disinfectant used:
3.Well use(check well rose):
Water Supph,Well: 7c,Sealing materials used(check all that apply):
❑Agricidtutal ❑ koricipal/Pirblic M Neat Ccmcnt Groin ❑ Ucirtonitc Chips or Pellets
1343mothcmwl(Hcating/Cuoline Supply) ❑Residentiat 1V+aicr$Yrpnlg(single) ❑Sand Cement Grout ❑Dry Clay
❑InudlislriaflConrmcrcial ❑Residential Water Supply(shard) ❑Concrete Grout ❑Drill Cutiingt
❑Irti •tion ❑Specialty Grout ❑Gravel
Non-Watcr Supply Wen: ❑Bentonite Slurry d Other(explain under 7g)
mmonitorhre ❑Reco%im
injection Well: 7f.For each material selected above*provide amount af.matcaials used:
❑Aquifer Recharge 043munduaterRemediation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recmvg, ❑Salinity Barrier
❑Aquifer Test ❑Stomntimer Dratimge
❑Exptximental Technology 13Subs!&4re Control
7R.Prsnide a hricf description of the abandonment procedure:
DGeotliemral(Closed hoop) OTmcer
Grout emplaced via tremie pipe
OGeothemiat(Heath ali Retum) 00ther(cylairi under 70
4.Date vsvil(s)abandoned: 7-2 9-2022
Sa.Well location:
Domestic Laundry
Facilityl(hw er Name Facility IDri Ofapplic ibte) ti.Certlllradon:
801 S McDowell St Charlotte, NC 28204 7/29/2022
Physical Addrim.City,and Zip 6Warc of Cetlilied Well Comm mr or Well On-rer Dw
Mecklenburg By:sigwgg this farm, I heriehy certify that 1/m wellps)was(mere)abandoned is
Couuty Pated Idetti imtlaa No.(PIN) atxurdaurx ivWh 15.4 NCAC 02C,0100 or 247,6200 Well C onshucuon Standt;r/s
and 1/rat a copy ofdris recurs/hay been pravided to tire well awn er.
4b.Latitude and long Wide in degreeOminutealscaindsordecimal degrees:
(if well Ctetd,one Lit(l)rig is so iciea) 9.Site diagram or additional ina Iletaffs:
35.214508 -80.843084 You may use die bark of this page to prm�ide additional well site details or well
r W abandonment details. You rosy aLso sWaeh additional pots if imcessan,-
CONSTR11CT1ON DETAILS OF WELLfSI BRNG ABANDONED SUR11ti1TAL INSTRUCTIONS
1lrmdr Mrfl mrvovelian rt[md(sr ijovaifii6la. For muhipke a0ecftrm or rwn•rvxa-supply
wells ONLY n-uh the eamr can sarhmti aw,krmt. lea. For All WdIs: Submit ibis form within 30 days of completion of hill
62.Well ED#:MW-8S abandonmcnt to the following:
Diyiiiou of Water Resources,Infor•matino Processing Unit,
6b.TOW well depth: 20 A) 1617 Mail Servicc Center,Raleigh,NC 276"-1617
10b.For Ialecdon Wdis: In addition to sending die forth to the address In 10a
6c Borehole diameter:l fin,) above,also skibi th one copy of this!,fonu widttii 30 days of completion of aril
abandonment to the following:
Division of Water Resources,Underground injection Control Program,
ftd Water kid below ground surface: 19 00 1636 Mail Service Center,Raleigh,NC 276"-1636
r
6e.Outer casin 1 if known): 10 (�) lOc.For Water Suonh•&Inhxtlon*Veils: In addition to sending the form to
> h( the addresses) above. also Submit!one Copt of this form within 30 days of
completion of well abandonment to the comity health depardmerd of the county
ii•heir abandoned,
6f.Innercasintjtuhing length(if fmtnva): (ft)
6g,Screen length(if known):10 fft)
Fora GW-10 North Camlim Dcpanmcm of Environment and Natutai Resomes-Dk ision of Watcr Rcsoiumes Revised Angusi 2013

I
WELL ABANDONMENT RECORD For Imemal Use ONLY:
This form can be used for single or multiple viells
1.Well Contractor information: WELL ABANDONMENT DETAILS
I
Zach Thompson 7s.Number of wells being ahandoned: 1
WelfCouttodm Nam W well oaMrpY:cicrwfi}abandoning well anhistlterproperty) For midapte Nlkvtar ar mn-+triter supply wefts ONLF wtth tlte sa»t
_ t 9�4"n"•' cvnzr c(hwr/abwf&ArvRjm4 pm cwr FNNn r mle firwi,
4478A r—, ,.a: )
NC Well CantmavrCCttifcalionNannber
.,+�-•�'•� '"' 7b.Approximate.+nlnme of water remaining in well(s)s (gaf)
SABDACCO Inc p, r� " FOR WATER SUPPLY WELLS ONLY:
Cc"VW Nam
�, rFy,tD;l Pro 7e.Type of disinfectant used:
2.Well Construction Permit K;7o0011i ^
Listd1 uppllruDle s,r11permlrs(s.e_CfiaraAt SI®ie,t artsuer.fir}arcfiar;rtc)Jknusrn 7d.Amount of disi ifecttutt used:
3.Well use(check well uses):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agtctltmal ❑httmicipal/Poblrc 0 Nan Cement Grout C1 Bentonitc Chips or Pellets
❑Gootherinal(Ilcadng/CoOting Supply) 131to0crtrinl Water Supply(single) ❑ Sand Central Grout ❑Dry Clay
❑Irtdlrstrial/Commercial ❑ltcsidcndat Witter Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01trigation ❑Specialty Grout ❑ Gm%d
Non-Wafer Strpgiy Well: ❑Bentonite Many ❑Other(explain under 7g)
IAMou ttoring ❑Recowsry
injection Well: Tf.For each material selected abovte,provide amount of.materials used:
❑AquilerRecharge ❑GroundwatffRentediation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recot•ety ❑Salirriry Barrier
❑Aquifer Test ❑Siomnyater Dnif tape
❑E.xperimenial Technology, ❑Subsidence Control
Tp,PrnyirM a brief description of the ahamdnmrrrcnt pn►minrr:
OGeothennal(Closed Loop) ❑Tracer
OGeothemiak(Heati Gling Return) 00theT(coggainunder7 ) Grout emplaced via tremie pipe
i.Date well(s)abandoned: 7-2 9-2 022
5a.Well location:
Domestic Laundry
Facilityl(hvr er Name Facility IDA(icapPl_icable) S.Certification:
801 S McDowell St Charlotte, NC 28204 � ` ' r'�' �� 7/29/2022
Physical Addtcs.Cits,and Zip "Ilrc of Certified wen Co+utacier or well ow wr Date
Mecklenburg B3 signing this farm, 11—by certify that the xell(sl was(mere)dimidoned in
Canary Pared Idemll'radmtNo.(PIN) aatxmlonve tvlth 15A VCAC 02C,0100 or 2C.4200 Il%ell Cons#vcaon Sfanckrrds
and Unit a clip,of this record An been provides/to the well owner.
5b.Latitude and longitude in degrcalminutcs/seconds or decimal degrees:
(if well 11W,Oise M lloag is sarifici'ent) 9.Site diagram or additional sell details:
35.214508 -80.843084 You may use the back;of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEINC ABANDONED SU13MITTA_L INSTRUCTIONS
drLoch xrll cvmramcYivn rccvrd(si if rrvattuGk. 1br tmrhlpk in Ion or run-nrtto•supply
x eNs ONLY a irA the siwm rnxsvuttlom'n6a,rrlarrtenr.ivn can arJlmtt are folios 10a. Fnr All Wells Submit this farm within 30 days of completion of well
6a.Well um:MW-8D abandonment to the following;
Division of Water Rawiucccs,Information Processing Unit,
6b.Total cavil depth: 45 00 1617 Mail Service Center,Raleigh,NC 276h9-1617
10b.For Inlecdnm Wdls: In additii n to sending die form to the address in 10a
tic Borehole diameter;l nn,) above.also submit one copy of this,form v6ddu 30 days of completion of well
abandonment to the follmving:
fid Water Iec'd below ground surface: 19 (R) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Ralco.NC 27699-16M
6r-Outer casing lend(if tmmrn): 40 NO Ift For Water Sarmly& iniect6ao Wells: in addition to sending the form t0
the address(es) above. also submit,one copy of this form within 30 days of
completion of well abmdonment to,Ac comity health department of the count'
6f.Inner casingkohing length(f known): (ft.)
w hcro abandoned.
6g.Screen length(if known):5 fft,l
Fomr GW-30 North Carodm I)c.Wmem of f?avirontncnt and Natural Resources-Dlvistan of Wmcr Rtsomrces Revised August 2013

i
I
WELL ABANDONMENT RECORD For b leml Use ONLY:
This form can be used for single or multiple wells
1.Wen Contractor Infmvnation: WELL ABANDONMENT DETAILS
zach Thompson 7a..Number of yells being abandoned: 1
Well Coitnelor Name(or well owner persoriall}aban toning well on hisll&n pwperry) For mtrtnple h!Rdfair or nau-n�w sirpph, sreils ONLY wah the sonic
cxxattrttctuwabwrckuiwaanat,yr,nreorsuMjrlralwfri n,
4478A
NC Well Comrodor Ceti ificabein Ni mber
7b.Approximate wolumic of wait remaining in n ell(sj: (gal j
SAHDACCO Inc FOR WATER SUPPLY WELLS 4l4'L'V.
Company Name Alh 1 _ 7e.Type of disinfectant used:
2.Well Construction Pet'mtt#-700 r.'; ,,- c W niTT. Uril
Ltat a�/applkrrhle utl!permits{Le.Cvuut%, rave.1�ririk+rjtc}jVmryro
7d Amotmt of disinfectant used:
3.Well use(check well use):
Water supply Well: 7c.Scaling materials used(check,all that apply):
❑Agrl.0 tutal ❑Mtmicipalftblic M Ncat Cement Grout 0 Bedonitc Chips or Pcllcts
❑Goothcmntd(11catineCooling Supply) ❑Residential Water Supply(wnglc) ❑Sand Centel Grout ❑Dry Clay
❑lodustrial/Commcn;ial ❑Rrsidentiat Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑1ni •lion ❑Specialty Grout ❑Gravel
Naa-Water Supply Welt: ❑ Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Reco%ery
Injection Well: X For each material selected abotrc,provide amount of matmists used:
❑AgmhtRech3n8e ❑Groundn-aterRemoedreuon Neat Cem.:941b ,Wtr:6gal: Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Reewery ❑Salinity Barrier
❑Aquifer Test ❑StommaterDrainage
❑E.tipe imental Technolo& ❑Subsidence Control 7g.Provide a briif description of the abandonment procedure:
OGeotbermal(Closed Loop) Mracer
Grout emplaced via tremie pipe
OGeo6hemtal(Heating/Cooling oli Return) OOther(' sin under 7
4.Date%vll(s)abandoned: 7-2 9-2 022
5a.Well location:
Domestic Laundry
Facility/Oa•ner Narrre Facility 09(ifapplxable) 8.Ceri fiCation:
801 S McDowell St Charlotte, NC 28204 Lalf� ��M- 7/29/2022
Physical Addres.City,and Zip figmvire ort`enifled Will UrAiswiar or Well Owwr Dace
Mecklenburg 13•sign}rg this firrm, 1 hereby certify that the wel1/s}was preN)ah andoned hi
County Parcel ldentl[Uca"t No.(PIN) ncrannhrncz ivith l SA NCAC 02C.0100 or 2C.02M Mecll Qnov coon&artdtmis
and Bart a Copy of/ibis remrd has beevi provided to die well owner.
Sh.Latitude and longitude in degmcstminum/scmnds or decimal d'egrem
(Irvelt yield,ooe 4itllmtg is sadfietew) 9.Site diagram or additional well det(ttfs:
35.214316 -80.842487 You may use We back of this page to provide additional well site details or bell
N W abandonment details. You may also iutach additional pages if necessary_
CONSTRUCTION DETAILS ON WELLIS)BEING ABANDONED SURM17TAL INSTRUCTIONS
Attach wrl/mmr&uetian reEwrd(t)if avai/aDk For muhiple infection ar nan•xrttar wppJ'
%vik ONLY oath The mwhr enmtnraYiadobamlru,wienr ion Con sarbmft are fiPtm. 10a. For All Wdh: Submit this form a ithin 30 days of completion of%ill
6a.Wen ID6:DMW-1 abandonmcnt to the following;
Division of Water R[sou'roks,Information Processing Unit,
6b.Total well depth: 65 (n;) 1617 Mail Service Center,Raleigh,NC 276"-1617
10h.For Inleerlon Wells: In addition to sending Use form to the address in IOa
6c.Borehole diameter,2 (in.} above.also submil one copy'of this,fbmt midiin 30 days of completion of%.tell
abandonment to the following:
24 Division of Water Resources,Underground Injm&n Control Program.
lid Water level below ground surface: (ft 1636 Mail Service Center,Raleigh.NC 27699-1636
Er-Outcr casing liangth(if known): 60 (D,) lac.For wares Su6nt<Br Iniectiml wens: In addition to sending the fort to
the address(es) above. also submit one copy of this form within 30 days of
completion of well abandonment to the county health deepartmed of the county
%� atnndoncd,
6f.Innercasinghnbing length(if hinarao): (ft)
6g.Screen length(if known):5 ilt.j
Fomn GR1-10 North Carolim Deparuncod of Emrironnncrrl and N uumt Resources-Division of Warcr Resolcroes Revised Augusn 2001

i
i
WELL ABANDONMENT RECORD For Irt ffirial Ilse ONLY:
This form can be used for single or nuiltiple Rrells
1.We"Contmettr information: ABANDONMENT DETAM
I
Zach Thompson 7a.Number of wells being abandoned: 1
Weil Coutmetm Nam for well o-A anpcwmllyabandrming%ellanhilltt:rpropeuv) For mttlnpte ro}eafrbf or unit-wq'1rw srrmh, setts ONLY rfdt lire Haute
cmurmcfrnahm6otn_hutwertf,7„rt GYDr.sNhVlydlare,jtirvn
4478A
NC Welt CoatlaciorED
f^
Cenifi fin Nm*cr
k^�3 , " 71r.Approximate vnlnmc M water mttiniut~in nell(s}: {gaf)
SAEDACCO Inc FOR WATIRR SUPPLY WELLS ONLY-.
Carnpatty Nam a _ 7e.Type of disinfectant used:
2.Wet ICast a met Permit#-70001119, - C`1I Pre.";4 aS�itA U�'
o
11sraJt nlrrythYtAle ttrlt�ermtfa ft.e_Cretrtir•Statute,liarlrlme.btfetiinr�jl j#. ?d Amount Of disinfectant Used:
3.Well nee(check well use):
Witter Suppn,Welt: 7e.Soling tutorials used(check All that apply):
❑Agrkidtnml ❑Tut ik-iprtiftblic 10 Nett Cement Griner ❑ 13catonitc Chips or Pcilets
13(7wl ermad(HcatineCootin;Supply) ❑Residmdat Water SSrpph'(single) ❑Sand Caned Grout ❑Dry Clay
❑I K1nstrial/Commcn:ial ❑ltesideutiat Water Supply(shared) ❑Concrete Grout ❑ Drill Ci"ngs
❑irrf •tion ❑Specialty Grote ❑ Gravel
Non-Water Supr►h Wen; ❑Beatoaite Slurry ❑Other(explain under 7g)
F9Molittorine ❑Recm*ty
injection Welt: 7f.For each material selected abos+e,provide amount of.nrateirials treed:
❑AquillerRecharge ❑GrotndwaterRemt iwion ' Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
❑Attu fer Storage Bid Rtm ertt ❑Salinity Barrier
❑Apnifer Test ❑Stomm'ata Drainage
OF-xpe imental Technology ❑Subsidence Control 7R,Pride a brill dteseription of thee abandonment pnrcoilure:
OGeolhemnrl(Closed hoop) ®Tracer
Grout emplaced via tremie pipe
OG�altertnel(lieati all Return) OOtber(explain under 7 )
4.DAte%VH(s)abandoned: 7-2 9-2 022
SM..Well location:
Domestic Laundry
F=1410-iv-mr Name Facilily UP(ifitpplicable) 8.Celtitkation:
801 S McDowell St Charlotte, NC 28204 1!� 7/29/2022
Physical Addrm.Cih.and Zip rm of Ccaified Well Coumcior or%i Ifl thsrttr Dmee
Mecklenburg fii.•sipiAg this forum. I fwmby certify that the well(c)was pvw-,e)abaudoried M
Caoaty Panel Identiff6timt No.(PIN) aawrrlanee with 15A VCAC 02C.0100 or 2C.0200 reel Cunstrucaon SUr m*irds
and drat a copy ofdris record has bear provided 10 fire well owner.
ft.Latitude and done itrde in degrcestadoutea/sle odsordecimal degimm
<ifa:n 6 t4,olio 4104118 is aatificiellf) 9.Site diagram or additional well detalke:
3s.213186 -80.842426 YOU real''use the back,of this page to provide addrlional Well site details or still
N W to abandonttteett details. You may alsottttrch atdtii►ional pates if necessary.
CONS"t][ TON DETAILS OF WELDS)BEING ABANDONED SURMTTi`AL INSTRUCTIONS
!trfQ[tf nxll CTIrLYlrLClfrilt/LLLF[ft�:I 1jOvdlteGtr_ Fw•m„hlpk iitleteYlrJn eV•rrM•nxrto.sttppll '.
w,elk ONLY woth die aaittr tithmit onefi�rr tGa. For All Weld: Submit this limn -aithin 30 days of completion of well
6m.Well ED4.MW-12 abandontocat to the fallowing:
Dkyision of Water Remurm,Information Processing Unit,
6b.Total arIl depth: 25 {n,) 1617 Mail Service Cmtrr,Radeit;h,NC 276"-16t7
10b.E2r Itttecdon Wells: fit addition to sending the fornt to the address Ln 10a
6e Borehole diameter:2 (in.) above.also subunit one copy of this form within 30 days of comptetion of well
abandanmeUt to the A111MViug:
L is.s Diviston of Water Resou mes,Underground Injection Control Pingratu,
6d.Water level belaw ground surface: at.) 1636 Mail Service Center.Ralcip,NC 27699-1636
6e.Outer casin le if known• 10 Hic.For W�P Slimly R intection BM. In addition to sending the font to
rw n { )' - - Vt) the address(es) abate. also submit I one-copy of this font within 30 daps of
cotmpledoa of well abandonment tolthe county health department of the county
6f.Inner e8sinyp'tnlring length(if tara+nn):-(ft.) svhcre abandoned.
6g.Screen length(if ImoWa).15 (fit)
Fern GW-10 NonhCamOm Deparntrat ofEattiroatneot and Naeumt Acsomccs-Division of WatcrRcsotucts Revised Aiigwsi 20B

f
f
'WELL ABANDONMENT RECORD For Irnema)usc ONLY:
This fbnn can be used for single or multiple wells
1.Well Contractor Information: WfiLL ABANDONMENT DETAILz4
zach Thompson 7m Number oi wells being abandoried: 1
WdtCoonactor Naar(or overt owmi pe-ma llp abandoning well an hiller property) For wtdpplr tnkafar or notj-"%6e supp, veffs ONLY with tie rauie
M7J°r/ftCfKA7�lIbtiJKli//tAJCPJl,lnN GtiBr.PJJIAJtJr fNJL'fANJI,
4478A
NC Well CvmraaorCegifrcattotr Nrrmbp +'r• - °- $ 7b.Appmximatt,riltmw of water r emainin8 in wtll(x)-
SABDACCO Inc Q I(� 2�2� FOR WAITR. StJPPLV Witt tS ONLY-,
Carrpatng Name 7c.Type of disinfectant used:
1r 7�L'17'l is uL'1 ari':F:'!.Ra UM .
2.Weil ConJtmction Permit#:70001119, r�t� b��;ji,.aon
Last s4 JrprJlhVb1e We11 perrailtr r]',e.CiartM- ,91Ak,b'rrrtaJx.lJy a oN,e1c:t jkJtowre 7d Amotutt of disinfectant used
3.Well U.-&(ehtc Lwdl wit):
Water Supply Well: 7e.Sealing tmakntials used(check all that apply):
l7Agrict itoral ❑tNtmicipal/Pnblic 0 Neat Cement Grout 0 acntonitc Chips or Pellets
❑Gcathermal(Hcating/Cooling Supply) 131kcsickntial,Water Supply,(single) ❑Said Ctnrew Gmnt ❑Dry Clay
❑hrrttrslrial/Coprummial ❑RMidentiat Writer Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑irti leer ❑Specially Grout ❑Gravel
Non-Water Soplilly Wan: ❑Hentonite Stony ® OBrer(pTlaut under 7g)
l9Monitoring ❑Recomy
Injection Well: 7f,For each maternal selected abmic.provide amount our materials used:
❑AquiferReclauge ❑GmurdwaterRcmedialion Neat Cem.:941b ,Wtr:6gal Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recovery ❑Salinity Harrier
❑mait'er Tea ❑swninvaterDrainage
❑Experimental Technology 08obsiderice Control Tr,Peth4de a brief•description of the abAndnomcnt primmeduri
OGeotbetmat(Closed Loop) OTracer
'. Grout emplaced via tremiea pipe
CGeothermat(Healj&2qhng Return) 00ther(exWaia under 7 )
4.Dar¢w•eli(s)ahandoned: 7-2 9-2 0 22
Sa.Wen Iscation:
Domestic Laundry
Fdcr1ily/4rvtkr Name Facility IDA ffappl-kzbie) 8.Certification:
801 S McDowell St Charlotte, NC 28204 d� "'•"�� 7/29/2022
Physical Address.City,w d Zip rrJ tyre ore eniftsd Wei t pnt4tctar or Well()hVMr Date
Mecklenburg 13r Agning this fornt, f her,eby certify 1hm 1he weft(q) ivas firem)abaudaned at
Conuty Parcel IdcntditcatkHt No.(Pill) amordance with ISA hCAC DIC,0100 or 2C.0200 Wi dl CoLoruvUen S m&irds
arrd that a copy,ofdris r+ecard has been provided to tire well owner.
Sh.Latitude and longitude in dcgr+meattrdteutalseconds or decimal dgpv
(irwell fnetd,ow Livions is tatificict* 9.Site diagram or additional well.details:
35.214474 r -80.842625 You may use the back:of this page to provide additional well site dietads or uvll
i\ W abandonment details. You may also;utach additional pages if necessary
CONSTRIkC'I ION DETAILS OF WELDS)BEttVf:A13ANDONED SUIMIi'ITAL INSTRUCTIONS
:lfJYJde kill mmYlnrtclM.ue trcvrdl;J if aN5i7fefll�. 1"rir JtnrBlryle illjecfiolr cv-hen-xxNrr sJrpply
Welk ONLY with the slsme i-a care mibmtr ate,jrntr. 10a. For An WctLi: Submit this form within 30 daD:s of completion of well
6a.Weil ED#.DMW-2 4andonntcrrt to the following:
Dipiiion.of Water Resouroes,Information Processing Unit,
66.Total w•dl depth: 9 8 (,fY.) 1617 Mail Service Center,Raleigh,XC 276"-1617
10b.For Inleedon Wells: In addition to sending ttte form to the address.in 10a
6e.Borehole diameter.2 (In.) eve.also subnW out copy of this
foal uit hin 30 days of completion of tech
abandonmept to the follotiving:
Division of Water Resou rces,Underground Injection Coulml Program,
fd Water iced heinw grvmnd surface: 21 (fo 1636 Mail Service Center,Raleigh.NC 2709-.16M
6e Autry easing �le (rf Immrn) (ft) l0c.For Water Supply& iniectirtn Wells Jn addition to sending the form to
the addresses) above, also submit]one copy of this form within 30 daps of
courpWion of Well abandonment to the vourny health deparuacrd of the county
when;at nndoncd,
6f.Inner rasinpjMirint;ImtNh(if known): (ftl
i
6g.Screen length(if known):5 (Il.)
Farm G-W-10 North Carobm Dcpannlcot ofEnviromncat and Natural Resources-Divislan of Watcr Res.twee Revised Angpa 2001

WELL ABANDONMENT RECORD For Irdemal Use ONLY:
This form can be used for single or multipbe wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
zach Thompson 7a.Number of wells being abandoned! 1
Well Caotmanr Near(orNellaNctcr personally abor&ning well anhiallterproperiy) Far n¢trltrple M!A?&tcur err nnrinertecr sirpph rolls ONLY with the same
c»n rrtrcnavi•m6amMnment,iron tawr salrrnit cxaeJFim
4478A
� D 76.Approximate vnlamc of watrr mainim8 in wells): (AOL)
NC Well Coilraetor Cortifirrc anon Nin*cr +�- �� • .e
SABDACCO Inc (� ( �()�� FOR WATER SUPPLY WIZLLS ONLY:
Corfa:v Nam 7e.TY,W M difilinfeetant vied:
2.Well Construction Permit ik70001119;ni UN I,
Ltst all o*tmble well permlo r.e_Coon("Stair.VarfaftV.byaai�rir,^ c crown 7d Atnonat of disinfectant usW:
3.Well use(cleat well use):
Water Suppy,Well: 7e.Scaling materials used(check all that apply):
ElAgriculturtl 17MlmieipaltPablic W Ncat Ccmcnt Grout O Bentonite Chips or Pellets
❑Geothemvit(Hcatine poling Supply) ❑Residentiat Water Strpph,(singlet ❑Sand Cement Grout ❑Dry CLry
❑btdnstrwItcommcn;ial ❑Rasidendal Water Supp4,(shared) ! ❑Concrete Grout ❑ Drill Cuttings
❑Irri lion ❑Spedally Grout ❑Gravel
Non-Witter Supply Well: a Betdonile Slurry O Other(ex-plain under 7g)
Monitoring ❑Recovery
Injection Wctt: 7f.For each material selected abot+e,provide amount of materials used:
❑AquiferRechmW ❑GmundwnlcrRemediation Neat Cem.:941b ,Wtr:6gal., Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Red vcry ❑Salinity Barrier
❑Aquifer Pest ❑Stotrmiter Drainage
❑Espeximernal Tecbnotogy ❑Sttbsiddtce Control
7R.Plrmfde a brief description of the abandonment pnncalnre:
DGeothermai(Closed Loop) ®Tracer
' Grout emplaced via tremie pipe
Meotherlmat(HeatinglCooling Return) ®Other(explain under 7 )
4.Datewcll(s)abandone(L 7-29-2022
Sa.Well location:
Domestic Laundry
Facilit•/Owrar Name Facility IDN(iNppli able) S.Cettlfkation:
801 S McDowell St Charlotte, NC 28204 Z44 7/29/2022
Physical Adamcs.City,wd Zip ore of Ceti Wed worcolarx1of or We"Onver Date
Mecklenburg Qy.8"J"g this farm, I hereby terrify that the xelift)was(were)abandoned in
Loamy Pared Identificatldnt No.(PIN) amvnhmce with 13A VCAC 02C.0100 or 2C.02001Fell ConstritUion Sfaltrkirds
and drat a copy oftlris record has been provided to the well owner.
Sh.Latitude and longitude in degreesWiniteslseconds or decimal degrees:
(if wen A04 otte 4rviott&is sufficient) 9.Site diagram or additional well detafbs:
35.214003 -80.841484 You may use the bat);of this page to provide additional vvell site details or well
I1 W abandotunm details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEI C;ABANDONED SURMMAL INSTRUCTIONC
:trlludr aril cvrnariac7iem rz•cvr[fIs/if nval/able. Fw mnhrplr Ltjacfiaa err rxm.xvrar�pah• .
x+ells ONLY with ibe Cato srrbmtr uarr form. 1.0a. For All Wdh Submit lira form within 30 days of completion of well
6a.Well M9-MW-9 abandonment to the follow-ing:
Division of Water Resttirees,Information Processing Unit,
6b.Total well depth: 30 00 1617 Alail Service Center,Ralengb,NC 276R9-1617
10b.For Ittlecrion Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter.2 �n,) above.also submit one copy of Illis'fowl ttidthi 30 days of completion of well
abandonment to the fatlotiVing:
64.Water level below ground surface: 23 ( ) Diviston of Water Resou fees,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6ts Outer cadn I of Immrn): 15 ( ) toc.For Water Supply& Inkxtboir Wells: In addition to sending the form to
S e�( the address(es) above. also submit iorie copy of this form within 30 days of
completion of well abardornrtcot to the county health department of the minty
whin abandoned.
6f lmttreminWtubing kmgtb(if known): ( )
I
6A.Screen length(if known):15
Faun GW-30 Nonh Carolim Depanntcat of Environmeal and N:uuml Resmuces-Division of Water Resootocs Revised Augtg 20 t3

WELL ABANDONMENT RECORD For Itsenml Use ONLY:
This form can be used for single or ntaitiple wells
i
1.Well Contractor information WELL ABANDONMENT DETAU S
Zach Thompson 7a.Number of wells being abando I eth 1
WellCodractorName(orvvello%acr personally abandoning well an W er properly) For mduple h1fawor or rein-ncner supph we O,YLY with rlre swie
�,-„ --�: --�, g- � cauhrrcfk+nrnbrunhurn,cnf,�r,n cror.skM,rjr aie/F,rvrr,
4478A .,%.. s a D
NC Well Cordmctor Ceti orwtion Number ?h.Approximate wninme of water i maining io well(s): (gal)
AUG 1 9 202Z FOR WATER SUPPLY WitLLS ONLY:
SAEDACCO Inc
Coaparty Nam
C.� fit:�ti° `l i?_ UfC3 7e.Tppe of disinfectant used:
rfl$ii± :i:
2.WdI Construction Permit q:7 0 0 o i 119, ,
>VQ 0G
List all applkvrhle well permtty(Ke Coernty.State,i ariam:,e,faft Tarr,etcl tfbwwH 7d.Amount of disinfectant used:
3.Well use(check wen use):
Water Supphy Well: 7e.Sealing materials used(cheep all that apply):
❑Agricudhual ❑MunicipaVPublic 0 Ncat Ccmcnt GroW ❑Bcntonitc Chips or Fclicts
04310011cmytl(Ilt:aonglCooling Snppty) ❑Residential Water Supply(single) ❑Sand Cemend Grout ❑Dry Ctay
❑IrdustriailCommcnial ❑Residential Water Supp4,(shrived) ❑Concrete Grout ❑ Drill Cuttings
❑Itti •tiou ❑ Specially Grout ❑ Gravel
Non-Water Supply Well: O Bentonite Slurry O Other(explain under 7g)
Imma"Horing ❑Recovim
injection Well: 7f.For each tuaterial selected above,provide amount of.materials used;
❑Aquifer Rerharge ❑GrntnadwatterReme"on Neat Cem.:941b ,Wtr:6ga1: Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Reecrs`ery []Salinity Barrier
❑Aquifer Test ❑Stonmvater drainage
OF-Verimental Technology ❑Subsidence Contra!
7g.Pro-vide a brief description of the abandonment pra►eoduce:
C Geolhennal(Closed Loop) ❑Tracer
Grout emplaced via tremie pipe
OGeothertnal(Head oli Return) ❑Other( win olden 7 )
L.Date well(s)abandoned: 7-2 9-2 022
51t.Well location:
Domestic Laundry
Foeil-ctyA)wner Nam Facility 1DA(ifappliwble) 8.Cel IillCalio�uj,
801 S McDowell St Charlotte, NC 28204 7/29/2022
Physical Ad&m.City,and Zip 66igmvirc of Certified W Cmuractnr or Well Ow wr Dme
Mecklenburg 13y.-sighing this fame. I hereby certify that the wellfs)was(irere)abandoned br
County Parcel Idemi[irrtkm No.(Pill) aeorrrd ante tnflh 15A?VCAC 02C.0100 or 2C.0200[Fell C4n.+7 vdion S7nrrckirds
and drat a cxrpY of this r omrd has been provided to the well owner.
ft.Latitude and longitude in degnecolminutes/second,:or decimal degrees:
(irwell told,o+,e Mrlkr,rg is sufflcterl) 9.Site diagram or additional wdl details:
35.215196 a -80.843994 You awy'use the back of Ibis page io provide additional%ell site details or tell
A W abandonment details" You may also Affach additional pages if necessaw-
CONSTRUCTTON DETAILS OF WELL(S)BEING ABANDONED SUl3NLTTAL iNSTRUCTIONS
A4fkwh well eonvvucltam raenrd(s)if avajWk. For nwhipk myetriom or,an•wentr supply
wells ONLY with the,name tv rals M L W o reiG»rn- 10a. For All Wept: Submit this form within 30 days of completion of«ell
6a.Well IDg•MW-10 abandonment to ale following;
Division of Water Resources,information Promsing Unit,
3 0
6b.Total well depth: (ft.)
1617!!fail Service Center Raletgh,NC 276"-1617
10b.Bor Inledlton Wells: in addition to sending the fotnt to the address In 10a
6c Borehole diameter,2 ()u,) above,also submit one copy of this;form within 30 days of completion of well
aba ndonmew to the falloning:
Division of Water Resources.Underground injection Control Program,
lint Water level below ground surface: 16 (ft.) 1636(!fail Service Center,Raleigh,NC 2 7 699-1 636
6c Outer casing length(if known): 15 (D) 10c.For Water Supply&lnlectltn Wells: In addition to sending the font to
- -- the address(es) above. also submitione copy of this font within 30 days of
completion of well abandanmeml to the county health department of the cotittty
a.Inner easingltnbitrg length(if known): (ft.) w,h=abnndoncd„
f
6g.Screen lenob(if Imowm):15 (ft.)
Faro Mr-10 North Carolina Depsament of EnOronr ocnt and Natural Resmuccs-Division of Watcr Resorw-s Revised August 2013
i

'WELL ABANDONMENT RECORD ^ / For Internal Use ONLY:
This fort can be used for single or multiple wells ' X`
I
1,Well Contractor i"ormg0on: e
WELL ABANDONMENT DETAR.S
zach Tho son 7a.Numberofwellsbeingabandon
med: l
WeltCoatndorName(or acLloamrpesarwtl)almndordtt8xct14Ptiis/Irgl ) For molaple IVifiemm or alm-wafer •mrpj*- wtlis ONLY anh tt,e samr
�+:'_ i � cxaixrrtrcruwi'nbrurchA,A,enf.}an titer.rxhanlr wuJ6rm.
4478A r t,,l��'' s
NC Well t;oMmaor Certifa:ation Nmnbcr i ! 2z2� 71►.Appmximatc.nlnmc at vratcr itemaining in well(s): (gal)
SABDACCO Inc FOR WATER SUPPLY WFLLS ON LY-
sPR'r�U11t1
-fg?yW
Cantpart}Name �3' 0133- 7e.Type of disinfectant used:
2.WellConstructlonPermitp,700o1119, ,
11st a/f a}rytlkr,bft urll parmidr(1':N Ctiarnly,S&v/t,i aridrn[t,ltt�ttitan rtr i tfkaruvrt 7d.Amount of disinfectant used-
3.Well use(cheek wen use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
C]Ag ipiltural ❑Mtmicipatl/Pohioc M Ncat Ccmcnt Grout ❑ Bentonitc Chips or Pellets
❑GooihCrmal(Hcatinrr,jCo9)ing Supply) ❑Rcsirlctrtinl%v cr Sttgph'(single) ❑ Sand Ctmn►1 Gmut ❑Dry Clap
0hxfu5trial/Cnzun=i4l ❑Residential%Varcr Supply(shared) ❑(Concrete Grout ❑Drill Cnitings
❑hti •tion ❑Specialty Grout ❑Grand
Non-Waiter Supply Well; O Bentonite Slutly ❑Other(explaat under 7g)
Immouitorine ❑Recmjcn
injection Well: 7f,For each material selected above,provide amount of materials used:
❑Aqutferitccharge 0Gt31tnda7AterRentaGatd011 Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
17Aquifet Storage and Rem env ❑Salinity Bander
❑Aquifer Test ❑Storm Aver Drainage
❑Expetdmeaial Technologe ❑Subsddenct Cotum!
7g.Provide a hrnf description of the abandonment pr+Twodutc
DGeothemtal(Closed Loop) 17Tracer
DGeothenual(Heatd fi Retum) ®Other( lainunder7 ) Grout emplaced via tremie pipe
4.Date well(s)abandoned: 7-29-202 2
52.Well location:
Domestic Laundry
Factltty/Owmt Nmw iwilft TDO(ifappl-=bic) 8.Ccrlifdcutlon:
801 S McDowell St Charlotte, NC 28204 ?""4 //Z9/4?'JO<ZBI1i 7/29/2022
Physical Addmm.Cih•,and Zip "tmluro 0M."lfied W .cenaraetnr Or Well(hrcaer Dme
Mecklenburg M xignlnR this form, I hemby certify that the welifs)was(irer,e)abandoned in
County Pared Idemittmtinn No.(PIN) acwrdance wth i 5A NCAC 02C.0100 or 2C.0200 ltdl Construction SYandrrr ds
and thaf a coptr ofthis t mard has been provided to tire well owner.
Sh.Latitude and longittstic in degmcsfminutes/seconds or decimal degrem
(if yell C,etd,one L100,tg is SatftlNotrp 9.Site diagram or additional well detalls:
You may use the bads of this page in provide additional well site details or till
35.215165 Tr -8a.842247 W abandomnerudeutils. You may also itttacltadditiottalpages il'necessanv_
CONSTRUCTION DETAILS OF WELLS)BF.INt:ABANDONED SURMITTAL INSTRUCTIONS
lttach nrt!crirrvtructktip rtcvrtka!if oval/oGtt• For nwhipfe rA tcrimr or mm-wxrtir supph-
u,elk ONLY iot11 Jvo can tithwit orte f,>.m" 10a. For All Wells: Submit this form within 30 days of completion of nrll
6a.Well Dg•MW-I abandonmcntto the following;
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30.5 (n•) 1617 Mail Service Center,Raleigh,NC 276"4617
10b.For Inlettlon,Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter.2 po,) above,also stibinh one copy of this,form aiihin 30 days of completion of well
abandonment to the follonirig:
6d.Water Irrd bch"m•ground surface: N/A ( ) Division of Water Resources,Underground injection Control Program,
1636 Mail Service C'cmrr,Raleigh.NC 276994636
6r-fluter casin le if knownl: 15.5 (�) IOc.For Water Supply& iulectigh Wells: in addition to sending the fort to
R ( the address(es) abode. also submit one copy of this form iiidtin 30 days of
completion of n-ell sbandarunent tolthc comity health depattrncrd of the county
where abandoned.
6E Inuer casinghnbing length Of known): (ft)
6g.Screen length(if known):15 (ft.)
i
Form G1W-30 North Camiim Depaninece of Endroameal and Natural Resources-Division of Water Rcsoafm Revised August 20 t3

9
'WELL ABANDONMENT RECORD For lrserrrnl use ONLY: j
This form can be used for single or midtipte vivUs.
I
1.Well Contractor tnformstiow. DONM NT DUA—"
zach Thompson 7a.Number of wells heft ahandoloed: 1
WdtCodndorNaine(urn+elloKrcr personally abaadaningKellonhisiiriprQpertt For nurlople rolALVdon or rnrin er supply wells ONLY vtlh doe enure
4478Ar 5 �'
7b.Approximate volume of watirtimaining in vtell(s): (mil)
TiCWetlContmaorCcnifrc.�l3onNrrmba k
SAEDACCO Inc FOR WATER SUPPLY WRLtS ONLY-
Can pang NamC r� e�'c 7e.Type of disinfeetaurt used:
2.Well Construction Permit t1:70o01119, ,
Lest a/11krrDfe well perrklls(i.e-Ccwnttt Staue.)�riarrax.lrrcYinry etc)Jknuwra
7d Amount of disinfectant used:
3.Well use(check well use):
Witter Supply Well: 7e.Scaling materials used(dteel;all that apply*):
❑Agrncuhmal ❑Mtmicipal/Poblirr ®Neat Cement Grout ❑ 13cwonitc Chips orPcilcts
❑Gcothcmgd(HcatineCooling Supply) ❑ftesidentiai Witter Supply(sin$(c) ❑Sand Cement Grout ❑Dry Clay
❑Irtdlistnal/Commercial ❑Residemial Water Supply(shared) ❑Concrele Grout ❑ Drill Cutdogsa
011rdeation ❑Sped(k1ty Grout ❑Gravel
Non-water supply Wen: d Bentonire Slurry O Other(ex•plain under 7g)
19Mouhoring ❑Reem ety
trajection Well: 7f.For each material selected above.provide amount of materials used:
❑AcliiferRcchaige ❑GnnmdnuterRentediation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Slorage and Rem,ery ❑Salinity Barrier
❑Atiuifer Test OStorm%%Ver Drahwge
❑Experimental Tecbnotog-v ❑SubsiMice Control
Tg.Provide a brief dtscrit►tion of the abandonment prvtccdurc:
❑Geothennal(Closed Loop) ®Tracer
Grout emplaced via tremie pipe
DGeothennal(HatinglCooling.Return) OOdterl-m ain under 7 )
4.Doc well(s)abandoned: 7-2 9-2 0 2 2
51.Well location:
Domestic Laundry
Faclliiy/OwncT Norte Facility lDN(ifapplxable) 8.Ce►Tifirntlon�:jam,
801 S McDowell St Charlotte, NC 28204 rr� 7/29/2022
Physical Addmss.Cin,and Zip rareorCeti led Well ontrxior or Well Other D;ae
Mecklenburg )3y signing Phis farm. I hereby cerri,/y that the wells)was(irerq)abandoned in
Cooaty Parcel idemil'dailmr No.(PIN) accvrrhrnce with ISA NCAC 02C.0100 or 2C,0200(Bell C insnurlion Standards
and drat a cvptr ofdais record has becif provided to pre well owner.
glt.Latitude and longitude in dtgreea/mimatea/seconds,or decimal degre:s:.
(if-well cold,ortc LIVUItg is Sartttttcrrt) 9.Site diagram or additional well details:
35.215110 q -80.842315 You may use the back:of this page to provide additional hell site details or well
11 W abandonment details. You may also attach additional pages if necesm,-
CONSTRUCi'ION DETAILS OF WELDS)B61NC ABANDONED SUBMITTAL M. TRUCTIONS
AfAmh well cmaYlrLction recvrdt.TJ if nwilabk. For nwhipk injeeYiam or rwnrnrxar supply
wills ONLY,with the mmw�,r r„�rw,r abdrrkurmeru.j.m taro arhmit wreFbnn. 10a. For All Weft; Submit this lrami within 30 days of completion of n-ell
6a.Well Mg.MW-2S abandonincitto the following:
Division of Water Resources,Information Processing Unit,
6b.Total%A depth: 30 fft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For InIgglon Wells: In addition to sending the form to the add.mss in l0a
6e Borehole diameter,l �n,y above,also submit one copy of this forms mithin 30 days of completion of well
abandonment to the fallowing:
6d.Water kvd below ground Surface: N/A (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,N-C 27699-1636
6e.Outer casin le now )
if known): 15 ({t) loc.For Water Supply&Inketio Wells: In addition to standing the fort to
g ( the address(es) above. also submitioue copy of this fort within 30 days of
completion of well abardormirm to the tawny health department of the county
61%tuner easingkni ft length(if known): (ft)
where Anndoned,
6g.Serven length(if Imovm):15
E
Fom GW-10 North Carotim Depanrnem of Entiroamcnt and Natural Resomccs-Divis6an of Water Resorcmcs Revised At"a 2013

f
' WELL ABANDONMENT RECORD For Irsem d Use ONLY:
This fbrm can be used Par single or multiple wells C'
1.Well Contractor Information: WELL ABA ftDONMF_NT DETAILS
Zach Thompson 71t.Number of wells being abandfned: 1
%VcllCoulmerm Name(or well owner pusortally abandarriag well on hist r propeny) For mulrok fgRtwon or mm-m6i r ,atN)ty wells ONLY vtrb the snuje
cwnrtrtrctuut!m5arclrurwmat,ynn evur.rt+hwiir areJFirnr.
4478A ,..
NC Well Comraaor Gtniferation Nnm6« { w m ``' a 7b.Approximate volume of wattrl remaining in well(K): (gal.)
�s,
SAEDACCO Inc FOR WATTR SUPPLY WELLS ONLY:
Canpany Name - } - 7e.Type of disinfectant usal:
2.Well Construction Permit M:70001119 UrVA
flat dl applkm6le well permits q.e.Cmo—,SMO, ariomie,lrr 1`FJZ{d!Y kmurn 7d Amount of disinfectant Used:
3.Well use(cherkwtm nst):
Water Supph,Well: 7e.Sealing materials used(check all that apply):
❑Agniniftpral ❑Mmridpallisnbiic M Neat Cement Grout D Qcntonite Corps or Pciiets
❑Gcollic n al Wcslinr�,JCooting Snppty) ❑Rcsidprrtial Water Supply(single) ❑ Sand Cement Grout l7 Dry Clay
❑hrdlnslriallCommcrcial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri •tion ❑Specialty Gtoul ❑Gravel
Non-Water Supply Well: ©Bentonite Slurry 0 Other(exc-plaut under 7g)
IAMonitorittg ❑Recovery
Injection Well: X For each material selected above,provide amount of materials used:
❑AquiferRecharge ❑GmuidsusiterRemediation Neat Cem.:941b ,Wtr:6gal'. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recrn'eay ❑Salinity Barrier
❑Aquifer Test ❑Stomnvater Drrtitage
❑E.epMmenlal Technology ❑3ubsidence Control 7g.Provide a brief dcuriptian of the abandonment p"medurm
DGeothennal(Closed Loop) OTracer
t]Geothermal(lieati ling Retum) OOtfter(explain udder 7g) Grout emplaced via tremie pipe
4.Datcwell(s)sbandone4b 7-29-2022
So.Well location:
Domestic Laundry
Facility/Orener Nwnc Facildc 1Ds f fappligblt:)
8.Certification:
801 S McDowell St Charlotte, NC 28204 7/29/2022
Physical Adilmss.QV,and Zip 6gtcrtnre Af CRttfied Well Coarr»eior ar!Well ot%t er Date
Mecklenburg BY-signing this form. I hereby certify drat the well(s)was(were)abandoned irr
Camay Parcel Idcmll'int Mk No.(PIN) acwrdlanve with 15,E,NCAC 02C.0100 or 2C.0200 rEdl Conshvclion&a►&rds
and drat a coplr of tlris record h4u berm provided to floe well owner.
Sib,.Latitude and longittrdc in degrees/minutes/seeondsordecimal degrees:
(if well fieltt,Arne 13tltotis is hdre m) 9.Site diagram or additional well details:
35.215110 ? -80.842315 You may use the back of this page to prm•ide additional aeil site details or well
i\ W abandonment details. You may also attach additional pages if necessary_
CONSTRUCTION D>~TAU S OF WELLfSI BEING ABANDONED SUBMITTAL INSTRUC7ION5
Rrtach aril cvrtroacttun rccurdla!if ovniln6k_ For multiple htpecatm or non-unier supply
w,elk ONLY with the arum van submit ate form_ 10a. For All Wells: Summit dais dorm within 30 days of completion of well
6a.Well ED#:MW-2D abandonment to the fallaivinr:
Division of Water Resources,Information Processing Unit,
6b.Total atll depth: 50 ffr)
1617 Mail Service Center,Raleigh,NC 27699-1617
10h.For Inleetian Wells: III addition to sending die fort to the address It 10a
6c.Borehole diameter..1 .(In,) eve.also submit one copy of this;fort wtiWio 30 days of completion of svell
abandonment to the following:
Division of WaterResourees,Underground Injection Control Program,
6d,Water level below ground surface: 33 (ft) 1636 bail Service C•cinter,Raleigh,NC 17699-1636
6e.Outer casin 1 if Immrn): 45 (R) lot.For Water supply& Inbecdon Wells: In addition to sending the fort to
F e ( the address(es) above. also submit j one copy- of this form within 30 daps of
completion of well abandonment to!the county health department of the oaunly
6L Inner easingltubing length(if known): (tit)
wh rcabanndoned.
I
6g.Screen length(it lmoav):5 (lt.l
i
Foml MI-30 NenhCamlim Depamirrd ofEavironrneni aW NatumlRcsowccs-D10swnof WamrResalmes Revised AnLpsi 20t3
0

f
'WELL ABANDONMENT RECORD For lrocmalUsoONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAIL
Zach Thompson 7a.Number of wells being abandoned: 1
WdI Cod maw Nantc(or aril owner personatl)aLmndoning%ell an hislirr properiy) For trardrlple filpEvon or mjn tr sttppA, rP[is ONLY with the crone
: u_._ `' .a•9 eonVmcrton!abomitstiwenr,ran cwr stmMiur atefornt.
4478A hi
t4C Well Cortteaeaor Cenificsalion Nnmbea 7b.Approximate�nlume of w i remaining m tWll(ae} (gal)
SASDACCO Inc AUG ! 9 202Z FOR WATFR SUPPLY WELLS M1ONLY:
Canipnny Natne '�;;�^ow
Irtic�r.�:a::c� ` �,B Una 7e.Type M disinfectant used•
2.Well Construction Permit q;70001119, r-)%A1Qi30G
LW all applkrehte well permits p'.$.Cairene State,i'drfaftV,/ty k0fon,etc:)rfktmwn 7d Amonat of dlsi fectant used:
3.Well use(check well use):
Wader Suppy,Well: 7e.Sealing materials used(chock all that apply):
❑AgriietdturAl gMonicipolftbibc M Neat Ccmcnt Grout 0 Bcnitonitc Chips or Pellets
❑Geothennot(Hcating rCoolin;Supply) ❑Residcnrial Water Supply(single) Cl Sand C=L'm Grout ❑Dry Clay
❑IrtdttstriallCornntercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Intl •tion ❑Specialty Grout ❑Gravel
Non-Water Supply Well; O Benntonite Slurry C3 Other(explain under 7g)
ImMouttoring ❑Rero%vw
Injection Welt: 7f.For each material selected above,proAde amount of materials used:
❑Aquifer Recharge ❑Gnnmd%vterRemediation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtz:gal.
[]Aquifer Storage and Recm,eq, ❑Salinify Bartier
❑Aquifer Teat ❑Storrmvater Dtatrwge
❑Experimental Tochnotogv ❑Subsidence Control 7g,Psmidk a brief description of the abandonment i rocedurm
DGeothermtl(Closed Loop) OTracer
Grout emplaced via tremie pipe
OGeoihertral(fieafi alin Return) aOther( aiauttdee7 )
4.Date wa(s)abandoned: 7-2 9-2022
5a.Well location:
Domestic Laundry
Facilit)•Mwrar Name Facility lDN Omplkable) 8.Certification:
801 S McDowell St Charlotte, NC 28204 7t:�C.:/L �� BJ7ii 7/29/2022
Physical Address.Chy,and Zip m -arc of(;,en Wed Welltmarxior or!Well Owner time
Mecklenburg BY signing this firm. I hereby certify that the well(s)was twem)abandoned in
Canny Parcel Iden d im tnrNo.(PIN) ac wrdancc itrfth ISA NCAC 02C.0100 or 2C.0200 IIWI Construction Stawknrls
and drat a copy of this retard has beivr provided to due well owner.
ML Iattitude and longitude in degmcilmfnutealseconds or decimal degrees:
(if well fWd,olte LiUlong is sdfit ieaa) 9.Site diagram or additional well details:
You may use the back of(his page to provide additonal%ell site details or well
35.214754 N -80.842844 W abandontnerttdetails. You may also altaehaddilsonal pages ifnecesm,-
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMMAL INSTRUCTIONS
Atk h well cowwuclian recurd/sl if dvW14k Fur muhipM tiryeetiair or wa-uxm r juppty
it-elk ONLY with the mme cdxsmrrooar dDomkurrtetu.i.m can ssrbmft ate fwm_ 10a. For Ali Wdh Submit dtis font within 30 days of completion of%tell
6a.Well M#:MW-3S abandonment to the following;
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft,) 1617 Mail Service CcI%ter,Raleigh,NC 27699-1617
"b.For Injectinn Wells: In addition to seudin4g the form to the address in 10a
6c.Borehole diameter.1 nn,) eve.also subtrdt one cope,of this form crdWin 30 days of completion of uell
abandonment to the fh lawing:
Division of Water Resources,Underground Injection Control Program,
6d.Water kvd below ground surface: 28 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-I&M
i
6c.Outer caan le if known): 15 ( ) 10c.For Water Sunnix•&Infection Wells: In addition to sending the form to
S ( - the address(es) above. also submittone copy of this form within 30 days of
eamptetion of well abandonment to the comd3 health department of the ominty
6t Wier easinl!/tnbiug length(if lmotivn): (ft.)
whcrc abandoned.
6g.Scheer lend(if known):Is (�)
Fame Mr-30 North CaroHm Depannrcra of L'neirontncnt aid Nartml Resm=es-Division of Water Rcsottrms Revised Attprsi 20 t3
P
4

i
'WELL ABANDONMENT RECORD For Irderal Use UNZY:
This forth can be used for singte or antdtipte wells
I
I.Well Contractor information: WELL ABANDONMENT DETAILS
Zach Thompson 7a,Number of wells being abandLed: 1
Well Coolrador Now( %viloarcrpemnallyabandoningxellanhisllerprvpcny) For muMple HIAXWmt or mm-11'ar6r mrpply veffs ONLY with Uw_ swe
oaa¢trttctuw abamicwmeNt)nn ceur.rHluirtr arefornr,
4478A _ f
NC Wei)Controdnrt enifrcation Nrnm6er e ti F,� 7b.Approximate volume of water,remaining in well(x): Sol-)
r� s.��, E
SAEDACCO Inc FOR WATTR SUPPLY WELLS ONLY:
Convam Name 7c.Type of disinfectant used:
2.Well Construction Permit#-7000111 g;,j Wu AiC1 �'ry 'Y �.`tb�Unit
L[rt oil applkvrble well permile p'.e_cuafttl',Sarre,l artnmr,I T wn 7d Amount of dlsl nfe"outt used:
3.Well use(check well oft):
Water supply Wdl: 7e.Sealing materials used(checl,All that apply):
l7Agrec►ltural DMtmicipttl/Public ®Ncat Ccmcnt Grout O Rentonitc Chips or Pellets
❑Geolhermmtat(HcatingglCooling Supply) ❑Residcnhatl Water$Sappy(single) ❑Sand Cenmert Grant ❑Dry Cla}'
❑industrial/Commercial ❑Residential Water Supply(shamed) ❑Concrete Grout ❑Drill Cuttings
❑frti •tion ❑ Specially Grout ❑Gravel
Non-Wafter Supply Well: ❑Bentonite Slurry O Other(expiain under 7g)
19MonitorLrg ❑Recovtry
injection Well: 7G For each material sdeeted abovC4 provide amount of.matcriats used:
❑AgrdkrRecharge ❑GroundnalerRenOxliation Neat Cem.:941b ,Wtr:6gal:. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Slontge and Rem-en, ❑Salinity Barrier
❑Aquifer Test ❑Stoma ater Dmimtage
❑Experimental Technology ❑Subsiddtce Control
7g.Prratith:a brief description of the abandonment pnrecdnre:
OGeothertml(Closed Loop) OTmcer
Mvothermal(HeatingCooling Return) 00thcr(eWain under 7 )
Grout emplaced via tremie pipe
i.Datc w•cll(s)abandoned: 7-2 9-2022
51.Well location:
Domestic Laundry
Facility/Owmr Nit= Facility lt)N ffappl cable) S.Cerili Ttitiion:
801 S McDowell St Charlotte, NC 28204 A�4 ' " ! 7/29/2022
Physical Add=.City.and Zip romore of(cemfied Well Commwor or Wen Ow r• 13-W
Mecklenburg Hy sigtrit{g this femur, l Iremby certify that the well v)was(were)abandoned hr
Conroy Parcel Ideniffi tthm No.(PIN) ac wrrhrnce Wth 15A NCAC 02C.0100 or 2C.0200 ti'cll Construction&andrm/s
and Chart a cop),of this rmorrd has been provided in the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrem
(if well field,one 41001g is sltmciew) 9.Site diagram or additional well demos•
You 35.214754 N -80.842844 W abandonmeentdetails You m use the back of ay yalsoge tattachadditiong pages
site derails or tcell
H)' pages If tICCtSS•drV_
CONSTRUCTION DETAILS OF WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Afrudr w-ell anurne ion vLvrd(,,of evwWk. Fur mahipie hyevjwr or wn.nwo-smrpp4-
weldrONLY voth the arNm rnnrarhmtt arrfrm. Mo.For All Wdh Submit this limn within 30 days of completion of well
6a.Well Mg.MW-3D tab•mdonmcntto the following;
Di ision of Water Resatirces,Information Prom dng Unit,
6b.Total well depth: so Cn,) 1617 Mail Service Celtttr,Raleigh,NC 276994617
lob.For Inleellon Wells: In addition to sending the form to the address In 10a
1 mi above,also subt one copy of this form within 30 days of eomptetiou of trail
6c Borehole diameter. (in.) abandonnnem to the follmving:
fit Water Iced below grtmnd surface 29' (tt) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh.NC 27699-16M
6e.OutercA.smg Icnpth(if known): 451 (D) Itt-For Water Supply&inicetirn Wells in addition to sending the form to
the address(es) above, also submil�oie copy of this form within 30 days of
completion of well abandonment tol the county health department of the county
6f.Loner easinghubing kynglh Cs known): (tit.)
whorc abandoned,
6g.Screen length(if Itnmt•m):5. (ft.)
F
Form GW-7n North Camlim Dcpariarrt of Emironrcnt and Natural Resowccs-Division of Watcr Rcsolaces Revi"Aug"2013

i
'WELL ABANDONMENT RECORD For Irflerml t)sc ONLY:
This form can be used for single or multiple wells
I.Wen Contractor information: WELL ARAN5(3N'MENT DETAl10
zach Thompson 7a.Number of wells being;abandoloed: 1
%VdI Coanacror Name(or w-eU ow tw pcmamUy abandoadng well on hietlrr property) Far widelpte ni/ecVlmr or non- 4r mrpnly wells ONLY vlllr fire scene
_ canstrttcfrcni!abmrchurnicnt,}rrn ceor.rrrluriit araJFirvn
4478A
NC Well Conlmgor Certifruitaon Nnmbcr
71).Approximate solnme of watw remaining in well(s): (gaL)
SABDACCO Inc 4 U G 1 9 2022 FOR WATTR SUPPLY WRLLS ONLY:
I
Cor nyName
Unt 7c Type of disinfectant used:
2.Well Construction Permit#:700o1119, ;;a�10JuOC
L(atell app(krrble u�fl permftr(i.e.Ciwniv,Sre,L'arfnnir.In�4Yilon,ah.t ffkmrvn 7d.Amount of disinfectant used:
3.Well use(check Well use):
Water Supply Welt: 7e.Sealing materials used(check.all that apply):
❑Agriaiftnr:al ❑Mnnieipn.VPnblic M Neat Ccmcnt Oran 0 Hcrntonitc Chips or Pellets
❑Cac+othcrmat(11catinglCooling Suppty) ❑rzesldcniial Water Supply(single) ❑Sand Cement Grout ❑Dry My
❑wrstrwilcommer¢ial ❑Residential Water SSrpnly,(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri tion ❑Specialty Grout ❑Gravel
Non-Water Supply Well: G Bentonite Slurry 0 Other(exTlain under 7g)
It9Mordt0dng ❑Recm+tn_•
Injection Well: 7f.For each material selected above.prmide amount of.matmiats need:
❑AgnWcrRecharge ❑GmurdvmterRemedtation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recwen, ❑Salinity Barrier
❑Aquifer Test ❑Stornm2ter Drainage
❑Experimental Technotogy ❑Subsideire Coniml 7g.Prmide a brief description of the abandonment p"Krdum:
OGeothennal(Closed Loop) OTmcer
Grout emplaced via tremie pipe
OGeothemral(He:tti all Return) DOther( sin under 7 )
t,Date w•clt(s)abandoned: 7-2 9-2022
51L Well location:
Domestic Laundry
r=r1 ty/0%-mt Numc Facility ME Gfappi able) 8.Certification:
801 S McDowell St Charlotte, NC 28204 � �'. 7/29/2022
Physical Address.Ciro.and Zip sfhMom of Cenil3ed Well Co/warder or Well(laver Dare
Mecklenburg B3v.signing this fern• I hereby cerdo that the we11 fct tiros(mere)abandoned in
Count} Pared Identification No.(PIN) acratrtrhrnce with 15.4 CAC 02C,0100 or 2C.0200 frill Cvtkyhvction Rano$trds
and that a ropy of this record has becir provided to the well owner.
gb.Latitude and longlWde in degneeslminutes/smrids or decimal degrees:
(if well(old,one Lationg is s11111cJca) 9.Site diagram or additional well details:
35.214316 -80.842487 You may use the back of this page to prm•ide additional well site details or well
1\ W abandonment details. You may also attach additional pages if necessary_
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMtITAL INSTRUCTIONS
Attach N'eIl CYI2rr171etkrn rcCvrdl$r lj 6wilu6k For nrahiple irftcf!it or wnoixthr.wpp4,
x,elk ONLY with tine sanM rnn arbor t ww .itmn. 10a. For All Wctts: Submit this form uiddn 30 days of completion of sand
6a.Well M#:MW-4S abandonment to the following:
Division of Water Resonre s,Information Processing Unit,
6b.Total wrll depth: 25 (n,) 1617 Stail Service Center,Men+. ,NC 27699-1617
10h.For Inlecdan W-dis: In addition to sending the font to the address is 10a
above,also salbrnit one bopy of this form►6thin 30 days of completion of well
6c.Borehole diameter.1 (in.) abandonment to the following:
22 Division of Water Resou fees,Underground Injection Control Program.
fid Water Icrel beloR grs►nnd surface: (It) 1636 Mail Scrsicc Ccuter,Raleigh,NC 27699-1636
I
6e.Outer casingle if tmawn): 10 (ft) 10c.For War Sus►lv& Iniecth►' Mils: in addition to sending the fora to
( the address(es) above. also submit hone copy of this form within 10 days of
completion of nett abandonment to the rnnnty health department of the county
elf.Inner cbsinl!ftnbing length(if[maa•n): (ft:)
urh=abandoned.
6g.Screen length(if known):Is (ft.)
r
i
Fenn G`Al-10 NonhCamilm Deparuncoa of1?attiroanxni and Naamxi Resowecs-Dhisbon of Watcr Rcsowres Revised Aug"20t3

i
' WELL ABANDONMENT RECORD For Irder ml Use ONLY:
This form can be used for single or multipte wells
1.Wcn Contractor Information: WELL ABAMOMMENT DUAppU
Zach Thompson 7a.Number of`cells being abandakned: 1
N'ell'CotilradmNaarc(orhettaamrpeaonatlyahaodoningxetlonh�llrrpropcAy) For mdopfe Niyewon or inn-%#6 r supph, wells ONLY with the Haute
_D cnnrnrrcnovi!arhomMuruaetof,yr,n cr�r ashaaitf aieJS,rv,t,
NiG Well
7b.Approximate snlium of wrahrirei"ning in well(m)- (aLj
t;ordrogor r..enifrcalfon Nrrntbw t
SAEDACCO Inc Q• 1 9 2022 FOR WATER SUPPLY WELLSiONLY:
Company Name
Unit 7e.Type adisinftttant used:
2.Well Construction Permit 4:70001119,
Lim till appl'kwAh wellpermfty fle.Coa*,Shiie,Yortarrcv,htJ&11an,ett)rowwn 741 Amount of disinfectant used:
3.Well use(check tt4M use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
Q ftricidtttml ❑Manicipnlfiublic 0 Ncmt Ccmcnt Grout 4 Bcotonitc Chips or Pellets
OCcothcmuil ftatinWCooling Supply) Oltcsidential Water Suppb,(single) ❑ Said CtnreM Grout ❑Dry CLky
0In105tri01/CDmi1=i21l ❑Rcsidcndal Watcr Supply(shared) ❑Concrete Groin ❑ Drill Cuttings
❑lrtt •tion ❑Specialty Grout ❑Gravel
Non-Water Supply Well: G Bentonire Slurry E3 Other(explain under 7g)
®Monitoring ❑Recover
Injection Wctl: 7f.For each material selected Amy,provide amount of.tnatcAtits and:
❑Aquifer Recharge ❑GmundnnlerRemediation Neat Cem.:941b ,Wtr:6ga1.. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Rtcoven• ❑Salinity Barrier
❑Aquifer Test ❑Storrntvater Drainage
❑Experimental Technology ❑Subsil&x:e Contml Tr,Proiti:de a brief description of the abandonmentprimmdure:
DGeolhermal(Closed Loop) ®Tracer
OGeathemtal(Heating/Coating Retum) OOdrer(explain under 7 ) Grout emplaced via tremie pipe
4.Date vsvB(s)abandoned: 7-2 9-2 022
Sa.Well location,
Domestic Laundry
Fuciliy/Owmt Now Facility IDN(l applicable) S.Certiticaliort:
801 S McDowell St Charlotte, NC 28204 ��"�'V //!.[Yt'11�tL9IL; 7/29/2022
Physical Addrm.City.and Zip um orCedifisd Wttl tartaric of Well Onrser DIM
Mecklenburg IAy sWnq this form, I fie-by cerejA that the wells)was(were)abandoned in
County PAW d IdeNiticaihmt No.(PIN) accordance with 15A VC4C 02C.n1t7/1 or 2C.0200 W-ell Gmstruction Standards
and drat a copy of dris ruwrd has been provided to dre well owner.
ft.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(itudl fiptd,o+,e t-10MIS is suit *oi) 9.Site diagnin or additionat well details:
35.214316 -80.842487 You may use the back of this page Ca provide additional uv l site details or well
11 W abandomnem details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELUSI BEING ABANDONED SURMMAL INSTRUCTIONS
411a6 wekk arena velffm rreurd(tt if avdilahk- For m,rhlple niyedanm or man-m%fw supple
it elks ONLY with the.%mte ewrsvmrrwacvalarrrkanvneru ion rnn s rbmft pure fwm 10a. For All Wd%: Submit this form within 30 days of completion of tiuell
6m.Well @d:MW-4D abandonmeM to tht fallowing:
Division of Water Resources,s,Information Processing Unit,
6b.Totat%a depth: 45 (pt,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Inlectirm Wells: In addition to sending the fome to the address to 10a
tic.Borehole diameter.1 (in.) eve.also submit one copy of tl is I rin within 30 days of completion of well
abandonment to the rallm%ing:
6d.Water lewd below ground surface: 23 ( ) Division of Water Resort ices,[Underground Injection Control Program.
1636 Mail Service Cc Frter,Raleigh.NC 27699-I&M
6c.fluter Basin le if known): 40 (fL) 10c.For Water Simooh•&hilectl Wen
s:ns: In addition to sending the foot to
8 ( the address(es) above. also submit!one copy of this form Mthin 30 daps of
completion of well abaneloament to,i the county health deparnneta of the county
6L WntrcusinWtnl►ing kngtM(if tasar,•n): (tit.j
«fine abandoned,
6g.Street[length(If known)-5
s
Famu GW-10 Noah Carolim Depannicm of Enviroornent and Natural Resources-DIviston of Wavcr Rcsoiums Revised August 2013

WELL ABANDONMENT RECORD For Irflerrml Use MY:
This form can be used for single or mnttiph:wells
1.Well Contractor Information: WELL ARANDONMENT DETIL4
Zach Thompson 7:.Number of wells behni,abandoned: 1
Welt tCotttracim Name(or well owner persanatly abandanlrtg well an hlstier praperly) For mi daple AgpWon or mwa barer suppN weiVs ONLY with the srvrte
axr:rrncanviiabornhurorerrG inn trmr.rxiArUf wit!,1etr»r,
4478A
�' '' v?.k ,i 7b.Appmrrimate,vrinmc of wa I remaining in well K
NC Well CoolvaclorCcnlf Ation Namber ` a a # I }
SAEDACCO Inc '�n�� ONLY:
FOR WATER SUPPI;V WFtLL.
Company Name 7c.T�%Ve of disinfectant used:
2.Well Conte 700011 �,1
Construction Permit tM: ..--•-r�ait•-
Ltst 0/1 applkriblt rrkld lxrvndtr(;:e_C.aralst.Stair, ariantie, erf.t Jkmiwn 7d.Amyl of disllifeetant used:
3.Well use(check Well use):
Water Supply Well: 7e.Scaling materials used(Occh'all that apply):
❑Agricutt%aI ❑Municipalftbloc H Neat Cement Grout ® Qcntonitc Chips or Pcllcts
❑Geolkwnat WcatinglCooting Supply) ❑Residentiat Water Snippy!single) ❑Sand Cemend Gmut ❑Dry Clay
❑bdushiallCommercial ❑Rctiderdatwater Supply(shared) ❑Concnele Grout ❑ Drill Cutlin—es
❑frri •tion ❑Spedally Grout ❑ Gravel
Noa-water Supply Well; O Bentouite Slurry O Other(explairt under 7g)
Monitoring ❑Recovery
Injection Well: X For each matrrial selected above,proiride amount of materials used:
❑AquifctRecharge ❑GroundutterRenuxtiation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
[]Aquifer Storage and Mcm-ery ❑Saf,rrity Barrier
❑Aquifer Test ❑Stomn%ite:r Dratnage
❑Experimental Technology ❑Subsidence Contiel Tg Protide a brief description of the abandonment pnKrdurm
OGeothetiml(Closed Loop] OTtacer
Grout emplaced via tremi'e pipe
OGeothemtal(Head li Return) OOtlter(explain under 7 )
t.Data nd1(s)abandoned: 7-2 9-2 022
5a.Well location:
Domestic Laundry
Facility/04mer Name Facility)Deli(ifapplt ble) $•A Cerrtatiffiication::�
801 S McDowell St Charlotte, NC 28204 � ' rr-�!� M� 7/29/2022
Physical Adams.Qi-,and Zip grsmvmorc�ronod Wcll CMarwwr orWiell 0"ver !Tn¢
Mecklenburg By signing this font, d hereby eerlify that the ivelljst war(irere)abandoned in
Caaoty Pared IdeaaitimurntNo.(P[N) accordance ittlth 15A NCAC 02C,0100 or 217,0200(Moll Construction&aytci4rrds
and that a cup),of this record haw been provided to the well owner.
Sh.Latitude:and longitude in dcgr+cca/minutcrlscamda or docimaF dega+c�:
(ifnee field,One 410o,ts is sufficient) 9.Site diagram or additional well detyaffs:
35.214474 �? -80.842625 W You natty use the back of this page to provide additional ntell site details or well
abandomtteat details. You may also attach additional pages if necesm,-
CON$TRUCTION DETAILS OF WELLfSI BEING ABANDONED SUFIAWffAL INSTRUCTIONS
Alkwh well t»tuaarctirxt aaord(s)if avarinDk. far=hinfe InfWiuir or wnm mx eo•augoh.
welk ONLY with the&vane eoxssnuesam'aM1atHMmlenr,ism cats xrrbwo wte fi)fm 10a. For All Welts: Submit this form nithin 30 d of co days. tnnpletnon of uril
6a.Well m#:MW-5S abandonment to the following-,
Ph-hion of Water Resources,Information Processing Unit,
6b.Total well depth: 25 1617 Mail Service Cc iter,Raleigh,NC 276"-1617
(fY.)
10b.For Injection Wills: In addition to seeding We form to the address in 10a
1 above_also submit one bopy of this form ttithio 30 days of completion of taell
6e Borehole diameter. (in.) abandonment to the following:
Division of Water Resources,Underground Injwftn Contmi Program,
64L Water Level below ground surface: 21 (ft.) 1636 Mail Service Crater,Raleigh,NC 276r19-1636
6a Outer Basin le of hnmrn)• 10 (�) 10c.For Water Supph,h Iniexthm Wells: In addition to sending the fort to
g ° ( the address(es) above. also submit lobe copy of this form sAthin 30 days of
courptetion of sell abandonment to the county health deparuncid of the county
6f.WiercasiaglMbing kugth(if lmownj: (ft)
where abandoned,
6g.Screen length(if Itnown):15
Form GW-10 North Carothn Dcpanrtners of Environment and Natural Resmuces-Divistart of Water Resottrous Revised Atigusa 2013

k
'WELL ABANDONMENT RECORD For Internal Usc ONLY:
Tlds tbmi can be used for single or multiple wells
i
1.Well Contractor fufornration: WELL ABANDONMENT DETAiIS
zach Thompson 7a.Number of wells being abandlned: 1
Wdl Contractor Name W weil o"au penally abandoning well an Wirr grope l- For mtd(4 rk mparrar or rParr4ar& srrppA, vWls ONLY with the snare
�`" ,,rr _, } A �I c»aa.:trrrcpata/abrumkuaaucraf,Iran crcar.rxlunlraaelSaamr,
4478A -,.,f
NC Wcll CarttrlAor Ctnifacation Nurrabcr 7b.Approximate+nln=of aatcr remaining in well(s): Aga(-)
SABDACCO Inc
AiJ�� i 2�22 FOR WATER SUPPLY WELLS,ONLY:
CompanyNams Jtl zm±^.1
P:� 7e M Type disiufeetaut used:
2.Wdl Construction permit o:70001119, ,
Last all applAwhh-aatll permlty p'.e.Cc na -,Sane.I ariarote.InjiWinm,elr t tfknvrm 7d.AmonnI of disinfectant used:
3.Well use(check well use):
Water supple Well: 7e.Sealing materials used(checlt Ill that apply):
❑Agricathural ❑Mtmicipa.11Ptrhlic M Neat Cement Grout ❑ilcrtonite Chips or Pcllets
❑GpothermRt(Hcatinj#Cooling Supply) ❑itCsidcrnial Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Iradtrsfriat/Cc)mmer¢ial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑itli •tion ❑Specialty Grout ❑Gravel
Nott Water Sapgly Well: O Bentonite Slurry O Other(exTiain under 7g)
®Mailtoring ❑Recovery
injection Weft: X For each material selected above,provide amount of materials mod:
❑Aquifer Recharge ❑GroundnulerRen"ation Neat Cem.:941b ,Wtr:6gal. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Stotage and Rem ery ❑Salinity Barrier
❑Aquifer Tat ❑Stornnvater Drainage
OE.Verimental Technology ❑Stdnsidmxe Cottml
7g.Partsitk a brief description of the abandonment pnreuducr:
OGeotbetm al(Closed Loop) OTracer
OGeothemlal(HeatinglCoGling Return) 00ther(explain under 7 ) Grout emplaced via tremie pipe
4.Date a•etl(s)abandoned: 7-29-2022
5a.Well location:
Domestic Laundry
Facildy/Owncr Nam Facttdy TDs Gfapplicabtc)
801 S McDowell St Charlotte, NC 28204 �"'�"'� """ ' 7/29/2022
Physical Address.Cily,aid Zip t mnrc orceri:wed Wot Courrxror or'Wen on-ftr Dace
Mecklenburg B)yt siptlnp, this form. I hereby cert fy that the xellfsl Has prere)abandoned in
Calmly Parcel Idenll5aadmi No.(PiN) acwr>awx with 13A NCAC 02C.0100 or 2C.0200 Midi Gonshvcuan Stan&rds
and d/rat a copy ofdris record has•abeen prodded to the well owner.
Sh.r atilude and longitude in dcgmcs1mbrutestseconds or decimal dew
(ifwcll nett otr lat11rrrrr is sufftcietA) 9.Site diagram or additional well detail:
35.214474 .-80 842625 You may use Ilse back of this page to provide additional well site details or well
A W abandonment details. You may also:,altach additional pages if necessan,-
CONSTRIICTION DETAILS OF WELLfS)MINC ABANDONED SUBMITTAL INSTRUCTIONS
Atkmh rrll cmirararcllart ecevrd(ta if avatlablz For multiple inocam or wn•nffrter supply
wells ONLY with the avim cam whmii oite fimm 10s. For All Wells: Submit this;from within 30 days of completion of will
6a.Well M#:MW-SD ab•andonmcni to the following:
Division of Water Resrturces,information Processing Unit,
6b.Totat well depth: 45 (n,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10h.For Inleellon Wells: In addition to sending the fort to the address in 10a
6¢ Borehole diameter.l (in.j above,also submit one copy of this fort w�ilhin 30 days of completion of Will
8bandmiam to the following: li
Division of Water Resou Underground Injection Control Program,
6d Water level below ground surface: 21 (tt.) 1636 Mail Service Ccm ,Raleigh,NC 27699-1636
6c.Outer casing length(if known): 40 ( ) 10c.For Water Strmrh•& rnjection Wells; In addition to sending the form to
the address(es) above, also subrnif one copy of this form within 30 days of
completion of nx4l abardamneat tot the county health department of the county
6t Inneremingitubing length(if known): (ft)
%,Iwc atbondoncd.
6g.Screen length(if Imow•n):5
Farr GW-10 North Carom Dcpannrced of Em ioanment and Natural Resoruces-Division of Wamr Resorc¢a:s Revised August 2013
Y

WELL ABANDONMENT RECORD For Inlerrud Use ONLY:
This fort can be used for single or multiple wells
I
1.Well Contmelor information: WELL ABANDONMENT DETAU
Zach Thompson 72.Number of welts being abandoned: l
Well Couuactor Name(or hell owner an hE�AVT
rty L For m1daple filkM n or nnu�'a ter M(PPA' �redis ONLY WOO ft&e some
.—�'t ca�rhrrcatar/trbatrdrsrmcrn,yancenr.rNMnlrate �i,
�
4478A r,,t �.� "
14C Well Camraaor Ceniftation Nrnnbcr n 7b.Approximate-,"lame of via remaining in nell(z):
SABDACCO Inc
A U G � 9 20 2Z FOR WATER SUPPLY WELLS ONLY:
Company Nam S�r^ 444411 rw
In+osr,:ass "� 7e.Tape of disinfectant used:
2.Will Construction Permit#:70001119, ,
Liar all applkroR&welt permits 0.e_C"f&(%SIMO,i'adaftV.iiyrit on,etc)ffktntvn 7d.Amount of disinfectant used:
3.Weil use(check well use):
Water Supply Well: 7e.Sealing materials used(check,all that apply):
❑Agricuhnral ❑MtmtciWftblic M Neat Ccmcnt Ormn ❑ Bcatonitc Chips or Pellets
❑Goothcrmal(Ilcati4Cooling Supply) ❑Rcsidcnrial Water Supply(single) ❑ Send Cement Grout ❑Dry Clay
❑IndttstriallCvmmcMial ❑Residential Water Supply(shared) ❑Concrete Gmul ❑Drill Cuttings
DMigation ❑Specialty Groat ❑Graves
Nort-Water Supply Well; d Bentonite Slurry 0 Other(explain under 7g)
mmoutioring ❑Reeovee»,
Injection Well: X For each material selected above,provide amount of.mataials used:
❑AgrriferRScharge ❑Groundt4wlterRenediation Neat Cem.:941b ,Wtr:6gal'. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Remo m, ❑Salinity Barrier
❑Agnifeir Test ❑Stomnvater Drainage
❑Experimental Tecbnotogy ❑St"dertee Cotiml
7g.Prvrvide a hevcf dcscripfioa of the alnaneMament prr►adure:
MmIliennal(Closed Loop) ❑Tracer
Grout emplaced via tremi;e pipe
OGeodlermal(HeatinglCooling Return) 00ther(cqAain under 7 )
S.Date well(s)abandoned: 7-2 9-2022
52.Well location:
Domestic Laundry
racr10y/(weer Nam factlity iDN Ofapplimbld 8.Cerdfkatlon:
801 S McDowell St Charlotte, NC 28204 yl�_4 7/29/2022
Physical Adams.City.and Zip igmnrt of ccin HW well-Cootrxiar or Well On•ar Dae
Mecklenburg B).•.rig ft this form: I hereby certify that the xell/s)was prere)abandoned in
Conoty Pared IdertlttkotlanNo.(PIN) awordance with IS.I MCAC 02C,010b.or 2C,0200 Well C4mvtrucnon SPancknds
and drat a capf,of Otis record has beeir provided to the well owner,
Sh.i,.atitude and longitude in dcgirccOminutes/sceonds or decimal degrees:
(ifwcll field,one I.70ong is xtdll*ro 4.Site diagram or additional well letalis:
35.215227 -80.842742 You may use the back of this page�to provide additional veil site details or well
N W abandonment derails. You may also'attach additional pages if necessan,-
CONSTRUCTION DETAILS OF WELL(S)BRING ABANDONED SUBAi17TALL_iNSTRUCTiONS
1tLatlr nett cr�nraactfan n�twdf3!if awtirJ»lc_ Fiv muhipM injecfirm r,r rmn.Hiaarr.wpply
xelk ONLY Loth the sent ewiso eutlr u'obrurthnrrienr.rent can srrbnry wee form. [On. For All WcVs: Submit this i foam within 30 days of completion of well
6a.Wen M#:P-1 abandonment to the fotlowirm;
Division of Water Resources,Information Processing Unit,
6b.Totat well depth: 22 (n•) 1617 Mail Service Center,RalriRli,NC 27699-1617
101>.For In1=11firt Wells: In addition to sending flee form to the address to 10a
6e Borehole diameter,1 above,also submit one copy of this form wvilbin 30 days of comptetion of well(ln.) abandonment to rite following:
Gel Water level below ground sterface N/A (R 1 Division of Water Resou noes,Underground injection Contmi Program,
1636 Mail Service Center,Raleigh,NC 27619-1636
6c.Outer casing length(if known): 12 (ft) rn�da west a upphalsoisuectiln Wens. in addition to sending the form to
one copy of this form within 30 days of
completion of well abandonment to the ooumy health department of the cmmit
6f.Inner casinoubing length(if known):
where:abandoned.
6g.Screen length(if known):10
I
i
Ferro mr-lo North Carolina Dep nrucm of EmOroomcal aid Natural Resources-D10sion of water Rcs�onmcs Revised Angosl 2013

i
J.
- ' WELL ABANDONMENT RECORD r, .113roppl,ti•;
This form can be used Or single or multiple wells
1.wen Contractor information: ` ♦�T%L ABANDONMENT DETAILS
John Miller 7a.Number of wells being sba nJuned: 2
WellCoutrador Name(or tell owner pemaxill)aharrloniu;well on hissfher propen)) F'W nrfrlfrpfr hVerfitur cv v ri-d nfer si pph' wells ONLY wlrh 11 .unie
crxfsfnwfrre�aabamhxirnend wifr rxur,sr lvnrf wie farm,
4337-8
""� 76.Approximate iiilunre of Water nernaining in well(s): (gat)
NC WcllCorAmctorCcrlif=1ionNtrnkcr >;- }�! '' y t ^° '
SAEDACCO Inc FOR WATIF R SUPPLY WF.(IS(NNLY-
Convany Kime - lc.Type of diwnfixtant used'
2.Well Construction Fcrmit#,WR0300117 Unr
11Vrdlupytltwbkurltprrirftr(i.c Cfwnrr,Sf/NN,1JriWitY.!!r(Yc rlr;' .t' a4rr Id.Amount ofd➢sinfedautmk4j:__
3.Well use(check-well use):
Water Supply Well: 7c,Sealing matcdals-uscd(Check all that apply)*
DAgrfculturtI ❑MtmicipllltPgblic ❑ Not Cement Grout ❑Bentonitc Chips or Pellets
OGcothcrinal(1-1catingtoolino Supply) ❑Rcsidentiaal Water Supply(single) ❑Sand Centeill Grout ❑Dry Clay
❑Industr6l,Commercial ❑Residential Water Supply(slmrod) ❑Concrete Grout ❑ Drill Cntliup
131trigation ❑ Specialty Grout ❑Gravel
Non water Supply Yell: M Benlouite Slurq 0 Other(explain under 7g)
NN10.111torime ❑Rn:oim
injection Well: Tf,For each material selected'above,provide amount of materials used:
❑Aquifer Recharge ❑Groundstwer Renwdiation
OAquifcr Stoniee and Rmovery ❑Salinity harrier
❑Aquifci Test ❑Slommvatcr Drainage Portland cement Amount:25 ga
❑Experimental Technology ❑Subsiderx.-e Control 7g.Prawide r bricf denctiption4the abandonment procedurc
DGeothennal(Closed Loop) OTmcer
©GeothemtatLHeatinjVCoolil Remni) ©Other(ex-plain under 7g) Grout pump with tremie pipe
4.Date wcll(s)abandoned: 6-23-2022
52.Well location:
McAlpine Creek WWTP
Faciiftyt0%ncr Name Facility tDli(if appticablo) S.CCrd /,,/o
12701Lancaster Hwy, Pineville, NC 28134 6/23/2022
PlLysical Adits.City,and Zip Si nn Af(Crliticd Weil Ciamruiani or W01 fhvwr Mae
Mecklenburg B),sfbgffng this form, I hereby certify rhrn the ieell(s) n'ar ttaere)ahemdoned or
Couttlt Parce1 ldsailfieatlou No.MlNi atwonioncc frith 11.4 XCAC 02C•0100 or 2C.0200 Jf%ell Consiiuction Sfondcfnls
and that a cvp}•of Phis record has bear prmtided to the well miner.
Sit.latitude and Longitude in dtTrccsAufnutcs1iccoud5 or decimal defaces:
(if W01 rk-1d,otw Kekiug is sidlicicri) 9.Site diagram or additional vi-en details:
You may we the bade of this page to pwvide addilionat hell site details or bell
I\ abandonment details. You may also attach additional pages if necessary.
CONSTRVI TION DETAILS OF WEI.Il51 BEING ABANDONED SUIMUTTAi.TNSTRTTCTIM
:ttlurh px•11 crumrfvclFUrt ntvrehlsr if arnllta(ilr, Feu•mnitlplr rrt}refion al•rain-HYrr�r wooly
>.elta ONLY with rlre log. For All Wens• Submit this form within 30 dn}s of completion of well
6a.VNcll ID#:PZ-2 6 PZ-4 obandomucul to the followin;:
Division of WnteeRe taurcLs,information Processing Unit,
61).Total will delodr: 20 {IY.) 1617 Ntail Service Center,Ralcigli,NC 27699-1617
lob.For inlcctinn tt�h: In addition to sending die form.to the address in 10a
6c.Borehole diameter.8 (iti.) above.also subutit one copy of this loran within 30 days of completion of well
abandonauent to the following.
6tR Water level below ground gtrface• S' Division of Water Resources,Underground injection Control Program.
1636 NCO Ser ,ick.entcr,Raleigh.NC 27699-1636
6e.Outcr easing iengtb(i(lanolin): 0 to 5 (ft) loC.For MICE lbw1•A fit fkS jl in MIN; Io addition to wMing the form to
the address(es) abffe. also submit one copy of this fonn within .10 days of
completion of will ahandonmrnt`to the county health departnicut of the county,
6L Inner casinWhilting length(if known): (ft.) where atmndoncd, ff
I
6g.Screcu lengtb(if knoll n):5 to 20

WELL ABANDONMENT RECORD fin lrAcrn:tivsaONLY:
This forin can be used for single or multiple wells
I
1.Well Contractor lurormation: yj'ELL ARANDON&TENT DFTAIIS
. _,..-
John Miller 7a.Number of wt.41S being.al►i nduoed:
t1'cll'CodranorCr'ante(or well owtrr p tsonalt)rbarrlattttte wotl on hWher proper)) Far wirlople tryecftar to rivia-water atrpph• wells ONLY rah mw awne
wasrrrremkl 4- a1ft&w,,?.,r,y,n wlr:sr twur twee form.
4337-B
NC tVdl Cordtahor CctlifGtlion Nnn bcr - 71).Appn►xhnatc vrdnme of tratrr remaining in nell(n): (gaL)
SAEDACCO Inc AUGy 2Q?� FORNVATFi SUPPLYIVELISON X.
CanTany Name 1 1nk 7c.Type ordisiActant used:
2.WellCoastruditln Permit N-WR0300117, :s�A/Qf�QG
Lst�r11 tlpptkvAl�•ueNlarm�tr ry:e_Cwrut,Sfufa,J itrl,llYY.1Jrjecvinfi,t[c:t jklrclwq 7d.Amottnt of d6lafeetattt used:
3.Well use(check-well use):
Water Supply Well: 7c.Scaling materials used(check all that Apply):
❑ASmi�c-Tic QMtmicfp tttPtfblic Q Neat Cement Grout Q 13monitc Chips or Picllcts
(]Geothermal(HcatingIC.aolino Supply) QResid,ntial Water Supply(single) ❑Solid Ccincnt Grout Q Dry Clay
Qbaiustrial/Comntercial QResidential Water Sup*(shartid) ❑Conercte Grout ❑Drill Cultiap
❑Irri Lion 0 Specially Grout ❑Gravel
Non-\Voter Suppl)'Well: 19 Bentoni(e Slurry d Other(explain under 7g)
ROManitorine ❑Ra-overy
injection Well; X For cads material selected iboe,provide amount of materials used:
❑Aquifer Rccbarge ❑Groundiw ter Rcntediadon
OAquifer Storage sixf Recovery ❑Salinity Bawler
❑Aquifer Test 051omn1mmter Drainage
Portland cement Amount:38 ga:
❑Exile-imental TechnoloLm ❑Subsidence Control 7g.Provide a brief dr:•scriptiorr'nf the shandonment procetlurc:
(Geothermal(Closed Loop) ClTracer
OGoothealtal(Heating'Coolin;a Return) OOtltcr(explain under 7g)
Grout pump with tremie pipe
4.Date acU(s)sbandned: 6-24-2022
c
5a.Well(ucafion:
McAlpine Creek WWTP
FaGilifyiOt�ncrNutnc F.T,ilhyID:!)ifappticiblc) R.Certificit Ott:
12701 Lancaster Hwy, Pineville, NC 28134 % 6/22/2022
Physical Address.Citr•:and Zip Sisr n orCen A el nt=tor or Well pwcur D ae
Mecklenburg fay.sisntng this Jbrua, f hereby cord&that the well(#was(were)abandoned in
Count)' ftfUl l&'116 'rtadOtl No.(PIN) auwrihoice irah ISA AUAC 02C,0100 or 2C,0200 Well Cunslntato s Ron4trmis
and this a ropv of tMa record Ims been pro ided to the well owner.
510,Latitude and hmgitade Ili dcgrceshnfnutcslfdcnnds or decimal dq!rccs:
(if well rkkI.ow ktt(kttts iss dreietil) 9.Site diagram or additional vrell details:
You may use the bad of Utis page to provide additional well site details or well
t\ ��' abandonment details. You may also attach w1litional pages if necessary.
CONSTRUCT104N DETAi15 OF W>;LUS)BKIN(:ABANDONED SUFMITTTAT.iNSTR1iCTi0M1
AfkT!well ebrcvlruc•Irda mwnl('st lt'avoiMle. Fur miJriple bVectlrin or rxJnmtitev wpplr
Mtil'?ONLY iswli ilk RU)jIt C7%Jt14/7/Yt/wt'UJiUr![e-mail] Ct1M Vfblhrt enrefam". loa. For A11 WcIN: Submit ibis form nithin 30 days of completion of w-ell
6a.Well IDO.MW-04 abandonment to the following,,
Division of Water Resources,Information Procemang Unit,
Glr.Total well depth: 15 (ft.)
1611&fail SeiviccCenters Raleigh,NC V699-1617
Job.For injection Wtgls: ht addition to sending the fa nn to the address in IN
6c.Borehole diameter 0 �u,) above-also submit one wily of this form within 30 days of completion of well
abandonment to the followirng:
Division of Water Resourct ,Underground injection Control Program.
6d.Water level hclomm'Rnv►und smmrface: 8' (ft.) 1636 btyil Service 4cntcr,Raleigh,NC 276994636
6e.Outer casing length(if known): 0 to 5 (ft.) Joe.For MECr Eligrily -urlssLtn M41s: In addition to Sending lbe four►to
the address(es) above, also subliih one copy of this firm within 30 days of
completion of Hell abandonmant(6 the county hcahh department of the coun(v
Gf.InnercasinWtnbinx knyKh of known): (ft)
where abandoned,
6g.Screen length(if knnt►n):5 to 15
V—RRr_lh u....6!•...,.u..•.f�,.........•......rn....i................•. v...,,... o.�..,..,...,. rv..:.�.....rvi...�..n........_-_ n_..�-.,.._.-....,•

WELL ABANDONMENT RECORD �
Ttlis form can be used for single or mullip[a a•e11s For Imcakil Use ONLY:
1.Well Contractor information: %%TLL ABANDONMENT DETAILS
John Miller 7a.Number of n•elIs being(Ibrnduocd: it
1,101 Cootrallor Nante(or well ow ter personal!)abardut a u�tlEE11._1tis11r;pea For mnlnple tryrertrwr a� elan-wvrer str/Y.Jr wdis ONLY with I/&- sane
y`• 5 � R cv�rrsfrrrebrkruta-AmAY"'Jotr,it►nCarr�vj&u(atefuror,
4337-B a�-
NC Wcl1 Conlr�gorCenifiatlion Nnn Vt r AU Q 2�2� 7h.Approximate nduntc of water rcnwining in n•cll(s): (gnL)
u
SAEDACCO Inc FOR WATER SUPPLY WELLS ONLY:
E);N! 1i3DG Ir.Type ofdisinfi'Ctantused.
2.Well Construction Pcrmlt#:WR0300117, ,
Lt3t idl opplicv$le well penrriix p1 e.Cusnri+.Stine,1 urLvrrc•_br'eciiom.etc.t it 1ornuq
7d.Arnnnnt of disinfectant ustw:
3.Well use(Chet!:we0 use):
Water Snpplr Well: 7c.Scaling m;1tcd;1Js u5cd(cbccic all II►Rt apply):
❑A.gricultumI ❑hltmiciptalftblic 0 Neat Cement Grout 0 Bcntonitc Chips or Pellet;
❑ kothcri al(Flcatiug)Cootino Supply} ❑Residrntial Water Suppf)•(single) ❑Sand Centeni Grout ❑pry Chry
❑industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Culdnp
ofirrigition ❑Specialty Grout ❑ Gravel
Non-Water Supply WciC W Bentonite Slurry G Other(explain under 7g)
IgManitorine ❑Recover•
injection Well: 7f,Fur each material selccted�above,provide antount of materials used:
❑Aquifer Recharge ❑Gniwttlaater Rentedintion
OAquiter Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Slornr%t-lcr Drainage Portland cement Amount:360 ga
oExperinrerrtal Technology ❑Subsidcrz:e Corttnrl 7g Pra►ide a brief dcscriptinn of the abindonmeat procedure:
Meothennal(Closed Loop) CJTracer
❑Geothermal(lieadopi'Coolie Return) 00thcr(explain,under 7 ) Grout pump with tremie pipe
4.Date well(s)-abandoned: 6-23s24-2022
52.Well location:
McAlpine Creek WWTP
FacilFtyi hvwr Namc F.xilhy 1DN(if appli able) Ah
12701 Lancaster 6wy, Pineville, NC 28134 6/22/2022
Ph}�sical Address:City.and Zip Ca Ir=Iai r WCII UriTL`r p pc
Mecklenburg in, I ltemby corrfy that the irell(si wac('Were)abandoned ire
CAwrth' Forcer I.&MI&i i1►nNo.(Pibl) nuvrd(o)cc o•ltlt i1A XCAC 02C.0100 or 3C,0 200 iFT11 Con,t/rrtc•tion Stnni&inIs
and drat a copy'of fir&record hm beett prmided to Are well onver,
Sb.Latitude and longitude in dcgr+ccslrninu(cslsccontls or dcciru;rl dct;nccs:
(if Well felo,Otte kd me is twtticicd) 9.Site diagram or additional vi'cll details:
You may we lbe back of this page to provide additional tell site dnails or well
N W abandonatertt de'taiLs. You rua)•dNo attach additional poses if necessary.
CONSTRIK710N DETAIIS OF UTLIJS)BEING ABANDONED S[TBM11[1TTA1..iNSTR[TCTitp
.&Mh wrll cvrairticdlda ravnits't it'ovaN h1e. .For nralrtple hijection or rwa-mve r supply
rt,ell.,ONLY)NIAnck.nrtitrcwnirruitrnr'arwtriknrri�ntr.iortcwRsrrhmltarel4,tm l00a.For All Welk Submit tbLq farm nitbin 30 days of completion of well
61.Well I9g.MW01 thru MW-03, MW-06 6 08,MW-10,MW-il thru MWA andonntcnt to the following:
Kvisioa of Water Resnur ccx,Information Processing,Unit,
6b.Total%soil depth:_15 (ft,) 1611 Aired SerAce Center,ltalci(li,NC 27699-1617
tab.For Infection Al ells.: In addition to sending,11w fornt to the address in 10a
6c.Borehole diameter.8 (in.) above.also subndt one tope of tl is`form within 30 days of completion of well
abondonmcru to the following:
6d.Water level bclon gnupnd surface: 8 r (ft.) Division of WaterResoure Underground Injection Control Program.
1630 Ntail Scnicc Center,Ralei-h,NC 27699-1636
4
6a Outer caslufi Icngtb(if 6vown): 0 to 5 (ft) Inc.Fnr Wrarrr 5annh•&in�ffon_�ells, In addition to sending the fort to
the address(es) above. also submit one copy of this forth Within 30 days of
completion of nrll abandonrrr.•nt tie the eormly health d,&^panmcts of the county
6L Inner casim ftrtbing Mny;•th(if known): (fL) n•hzm abandoned,
6v,.Streea length([thaon a):5 to 15 _(ft.)
Fomr GW-10 North CamULa Devanaxut ofEnt ironmerd tad Nstumt ResAtt_•em-ntr•i<iett

i
NVELL ABANDONMENT RECORD FatlrncnwlvscONLY:
Tads form can be used for single or nluhiple wells
I.Well Contractor luformation: %MLL ARANDONh1EIKT DF.TAiLS
John Miller 7oL Number of wells being alo ndumcd: 12
Well.Coutractof Name(Orwell owm p--majolly For widnPle fryecatat w• r,°vid-vtoer sitpph• wu11s O.YtI' will) doe sane
hxLamtCNaue714n1rrkNvnptr6 fart teoi,.ailvntf arefr,nn,
4337-B
NC Well CordmctarCcrili.•?lion Nmni,er �'' �@, 7b.Apprrrsinlate volume of wa tLT remaining in hell(%): (g r()
'PEGS W
SAEDACCO Inc FOR WATER SUPPLY M..LLS(N1 IX.-
Canrpanl Namc 11 7c Type of disintirtant used,
2.Well Caustruction Permit N:WR0300011i7i`�i: �_' '_: -}�":`�U'-41
ltsredl upplhvhh rrpNppr,rurx tip.Cuurur,Sruh,1 uNmaop.b !' hr k92. �huwq 7d.Amount efdisiaketant used,
3.Well use(check-well use):
Water Supply Well. 7c,Scaling materials used(check ail that appl-):
❑Agri`ulturnt ghluniclpiftVic p Neat Cement Grout ❑ 8cn4onitc Chips or Pellets
❑Creathcnmal(licatingtCootino Supply) ❑Residential t,Vatcr Suppb-(single) ❑Sand Cement Grout ❑ Dry Clay
❑hldustriAlCommercial Oltmdcntial Water Supply(sh:rrod) O.Cbacrete Grout ❑Drill Cattinp
[Irrigation ❑Specially Grout ❑Gravel
Non:Water Supply Welt: is Bentonife Slum- ❑Other(explain under 7g)
Ightonitorine HReco%rry
injection Well: 7f.For each material selected above„prviyidc ankount of materials r!scd:
❑Aquifer Recharge ❑Groundwater Remcdiiltion
l7Aquifer Storage and Recovery ❑Salinity Barrier
Portland cement Amount:729 ga
OAgnifcr Test ❑Stomnv•alcr Drainage
❑E.q+erirrrerrtal Techna[ogy ❑Subsidence Control 7g.Pmiide it brief d6criptian of the abandonment pracedun:
13Gaothetn al(Closed Loop) O•Tracer
OGeothemtal(HzttiniKoolina.Return) QOtltcr(explain undcr7,) Grout pump with tremie' pipe
4.Date well(s)ahan(loucd: 6-22-2022
52.Well location:
McAlpine Creek WWTP
FocW1)-X)wncr Nomc F ilirc lT)Y tifappliGrblc? 8.Cert irNon:/'
12701 Lancaster H Pineville NC 22 wy, Pineville, 28134 � 6/ /2022
Physical Addrass.City:mid Zip r me r of C ' d Wen ry Cootcar ar W'e11 A r Date
Mecklenburg l3j.•signing thrs form, 1 hereby certify tint the irell(s) w•as(were)abemdoned in
C'ouut?' Pavel ldenlifie w1i No.(PINj accwMmce trill?1514.hC.4C 0-IC;.0100 or:C.0 00 Well Consdritchan Sdan(kirvls
and drat a cop),of(iris record hots been prm-ided to Nre k c8 Owner.
'KIP,Ltttihrdc and longitude in dcgrceshnfnuteslscrnnds or dccin>.•rl degrees: ,
(itwe116 W,one bOutia is bvtfici*rv) 9.Site diagram or additional well detalls:
You way use the back of this page to provide addilion;d Drell site details or well
abatAonnteui details. You may also attach additional pays if t►ccessan,.
CONSTRUCTION OFTAII.S OF WEIA-61 BEING ASANDONLD SM11711'Ai.INS TR[iCTIONS
:taudr rr>rll cvrcravcYiart mcvrrl/sl!f avatlu6le. Fur m�hiplr infrtYiurr cv nun-nxrrrr wpplp
M�°ily t7eVLY M'IUr flw Ftifilp'rziarretnr»ragturckrwr vie.ywu c,oR srrh,n.itare frunn. 10a. For All Welk: Submit tks form within 30 days of completion of well
Mi.Well ID96SC01-01 through SC01-11 abandoumcat to the following,,
Di►•isim a of 11'aterResourees,Information Pr•oceming Unit,
61o.Total well depth: 15 (ry,) If,ll NfAil Seiiicc Center,Raleigli,NC 276"-1617
10b.For-In.iection«°ells: In addition to sending the form to die address in 10a
6e.Roreholediameter.8 above.also submit one copy of this fonn within 30 days of completion of well
(iu.) abundomucul to the following:
Grb Water level below grvund surface• 8' (ft) Division of Water Resent recs Underg!mud injection Control Program,
1636 Mail Senicc(:enter,Releigh.NC 27699463E
Gc.outer caring length(if Imrown): 0 to 5 lft) 10c.For 335rlf�r ily -fit[a jaw Mils: In addition to sending the fora?to
the address(es) above. also submit one Copy of this form within 30 days of
completion of well abandonment to the county health dcpanmenl of the county
6C Inner casinghubing length(if la,own):
where abandoncd,
6g.Screen len);th(I latowr):5 to 15
Fem�G11t�0 u,,..ti r•e...u.,.n�................an............,,........a v.....R.n_._..�� r....._r___e..----^'----- - . . . _...,

WELL ABANDONMENT RECORD
�----- For IrAcrnitl Usc t)IYI,Y;
This forth can be used for single or multiple wells
1.Well Contractor lurermatiou: WELL ABANDONMENT 1?ETAiIS
John Miller 7st,Number of wells bcing albanduned: 19
►Well Cot4rac 01 Nanic(or isell on tics penoaally ubialai o ttrBit.IRfil raperI.,Y,*• Fcu mulnple rrltecmwt ur I nv n-alter st74rh, wells 0MLY wide gee sane
4337-B
4 •'.,,��.�.� s `� <rsteelnrotxxi:rtE�mrchaunr7at,�vnt csut st,lvntt rxtr�,rui.
NGWc1lCortlmaorCcrliSr~tliDnNnn$4r 7b.Approximate►vlume of water remaining ire w�clt s: ..
quo ! 4 2022 1 () ("aL)
SAEDACCO Inc FOIL IVATF,R SUTPI.Y iV'El ES ON Ly.
Conan}•Kamc ,`,'.Q; 0G 7c Type of disinfectant uset`1:
2.Well Construction Permit#-.WR0300117, ,
LL-4 lift aprlhvb4"T11 penritx(i.e.!_`tman',Shoe,I1marwe.bErevaoq,eh:i ybrawa 7d,[tmt►ttut ofdLsinfectatii used:3.Well use(shed:well use):
Water Sleppky Well: 7c.Scaling neateriais used(cl ccic all that Apply);
❑AgTicrultuim1 ❑Municip Ii/Ptlblic A Neat Cement Grunt ❑ Beruoni(e Chips or Pickets
gCarntlemsttl(HcntinWCooling Supply) ❑Residential Water Supply(single) ❑Sand Ccntent Grunt ❑My Clay
131ndustrial/Commercial ❑Rcsidrnti,al Water Supple-(sharcd) ❑CloncMI0 43110111 ❑ Drill Cuttings
Oirtigation ❑ Specialty Gtoul ❑Gravel
Non-Water Supply Well: 0 Bcrdonite Slurry 0 Other(explain under 7g)
®]vtottilurirte Mccaxety
injection Well: 7f.For tact material sOcctedjabmr,plv►ridc au►OtiDt of materials used:
❑Aquifer Recharge ❑Ground►tater Rentcdiation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer T&A ❑Stomninter Drainage Portland cement Amount:47
❑rNp-.mental TechnoloLm ❑Subsidcite Comm] 7g,Provide a brief dLicription of the al►ondimment proccAurr:
Mmthennal(Closed Loop) ClTracer
❑G.othemeal(HeatinplCooling Retum) ❑Other(explain under 7 ) Grout pump with tremie pipe
a.Date well(s)abandoned. 6-22-2022
So.Well location;
SCO2-01 through SCO2-19
Fs<clAyAhvwr Kim; Fa ility ti1,9(Capptigiblc) R•CclRitll`a ir:
12701 Lancaster Hyy,, Pineville, NC 28134 6/22/2022
Physical Address:City:and Zip Si_ t or Ce iti ►Nett Ca litmtaor or W 11(herL1r D lie
Mecklenburg signing this form, l herehy certify dial the irellrrl eras there)ahmidoned lilt
Cttnnl>' Pat-M ILIZmit3� 110ILNo.(PINj it"a. ltnlru,with 11 ArC.4C?;k_0100 or 2C,0200 rVell Consintrlfun tens&trllx
and lirizt a copnr oJthis record Tern be car Fern i[ /to lire►t cif n►once
Sb,Latitude%toil longitude iu 414,9rcc51minutcs/secnnds or decimal dgrMc%:
(1twoll%'tilt,m4 i itAitig is siiliicierl) 9.Site diagram or additional vrill detaEfs:
You stay we the bad:of this page to provide additional%tell site details or%sell.
1\ W abaridonntetu detaik. You e113}•also nttaClt additional pages if itecess a.
CONSTRUCTION DETAILS OF IVELL(S)BEIN(:ABANDONED 191MMITTAi.iNSTRUCTIONS'
:tiladr pulp cwrrstrurlian rrcurrt(al i/mulla6le. Frio mnl�;rre injrcrpea w rr�a=«%leer xupp(i
Meth ONLY With dk.Mvilt' tttllt#11 elte fume. 10a. For All Wells: Submit this form nittdu 30 days of completion of well
6a.Well tD#'SCO2-0l through SCO2-19 abandonment to the following;
Division of Water Resources,Information Processing.Unit,
Glr.Total well depW: 15 (ft,} 1fi 17 Mail Service Center,Ralci{4i,NC 27699-1617
I
111b.For Irtleclion VVeilti: he addition to sending the fonu to the address In 101
Ge.Bord►olc diameter:a abote,also submit one copy of this form within 30 days of completion of well
ftr') abandonment to the followfikg:
6d.Water lcycl below gr oand surface• 8' {ft.) Wilshire of Water Resources;,UndeM!nwtjd injection Control Prograter,
1636 Mail Service('enter,Raleigh,NC 276994636
1
6c.Outer casing Icngh(if known), 0 to 5 (ft,) 10c.£nr Mter§jip ily&In ttl fgn Mils: III addition to sending The font to
the address(es) above. also submit one copy of this form within 30 days of
completion of well abandonment to the cormty leahh depurteeteni of the conttty
6L Inner coArig tubing length(if brown): (lt,} wl=abandoned, I
6g.Screen length(if knots a):5 to 15
Fentm G►►r-)m Minh r4mlim ft mirfau ra arPn irnntu i nod MJ ti nt Rnrnue•ne—niui,"n nr rL'nr...f).�...,._

NVELL ABAMONMENT RECORD FoTtnl milUsaONLY:
This forin can be used for single or mu)lipte wells
1.Well Contractor information: WELL ABANDONMENT DFTAiL4
,
John Miller 7x.Number of wells being abandoned: 19
l►'c1f('OrlrrtlOt Name(erncllotynCtpersanatl)alu n ltatrwmgprotf Fw• (0nlnpre t[t;ecrfwr or rtgmtirter jiliph- wets ONLY well: My sa»re
_ ; y_ crxr�rrrrcn[xr.rr:rdrNtNli7lf,ir,rr r�ui,ruNnrt arrlran,
4337-B t1
NC W01 CommoorQatifrartion Number A�J r 9 2022 71P,Appniximatc volume of Later remaining in w•ell(s): (fat)
SAEDACCO Inc ¢; ._ FOR WATER SUPP1,►'WELl.;5 UN9.Y.
Inf- 05 ti a r r;aa !lo re
Can>panq Namc �'. iti�OG 7c.Type of disinfirtant used.
2.►YdlCnnstructimrPtrmitk:WR0300117,
fiv[[11rg�j,ftt5uhfu N'e11 f4rmi[.r p:N.CueurJt',.Stu;e,I ariruse.hy�eriiur;etc!(fk,m ero 7d,Amount of disinfutAnt m41:
3.$Vdl use(check Well use):
Water Supply Well: 7c,Scaling materials used(clicdc all drat apply):
❑Agricultural ❑MvnicipultWblic 0 Not Cement Grout Q Rcrttonitc Chips or Pellets
❑Grntltcn=d(HealingtCaaling Supply) pRcsidenlial Water Supply(4inale) ❑Sand Centent Grout ❑ Dry Clay
❑iudostrial/Commercial. ❑Residential Water Supply(Atrod) ❑Concrete Gmut ❑Drill Cutting
❑Irdi •lion ❑Specialty Grout ❑Gravel
Non-Water Supply Well. IN Bentonite Shirty ❑Other(explain under 7g)
99 htonllorine 11911ccovrn_
injection►Yell: 7f,For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Gw'undnnter Rcinedintion
❑Aquifer Stonige atxl Recovery ❑SalilfitV flamer
Portland cement Amount:35 ga:
❑Aquifer Tess ❑Stonynt:iler Drtirrrge _
❑E.,qxrimerdal Technotogy ❑Subsidence Control 7g,Provide a brief dLicription of the abindonment procedure:
Mcothennal(Closed Loop) ❑Tracer
❑Gcothemtal(HcatinplCoolin„Return) pOtlerl explain undcr7 )
Grout pump with tremie pipe
A.Date wdl(s)abandoned: 6-20-2022 I
So,►►left location: I /
McAlpine Creek WWTP /1
Feed 4 hkwr Narm: Txilitr im(irappsmbic) S.Certh(ic (n:
12701 Lancaster Bwy, Pineville, NC 28134 / 6/20/2022
Physical Address.City,and Zip S' ire of c6afta welltentcraar or 14'e11(hwnr 5-"
Mecklenburg -vignirtg thin fivin, I Hereby certify dial the vefipq wain tvere)ahmidoned in
County Parcel ld:aUG2w lbir No.(PINT nux+rllnJtcc it,i1h 114 AC.4C 02C.;.0100 or 2C.0300 if'ell Cons/ntclton Stan(kmis
and drat a canv of this mc ord hoi been prrotdded to fire well mown
5b,!Latitude and lougitudc in dcTms/rninutcs/seconds or decimal degrees:
(ir.sr0 AA1,Otte 1:11 Apra ns„1r,cieti) 9.Site diagram or additional ecll(loafs
You may use the bad,of this page to provide additional well site details or well
1►` ►M' abandonuteut details. You way also attach additional papas if accessaq.
CONSTRUCTION DETAI1S OF RF I f-(S)BEING ABANDONED S111114117TAi,iNSTRIW.T10NS
:lfludr Nrf1 cwrestnrrlttlra rLrorelfn!!r[milf[ariti•. Fr,r mehipfr bljrefiun W raunrx,du•supply
Mti'11,Y D,VLi't.•Ifh like Mnnf c'G1r.5YNtYf/DJe`24cLr[tfilrhitNlL)�r1 c•Ah V,fHh(!4irCJrUlflt 10a. Fur All ►1+'e[tc• Submit this forin nithin 30 days of completion of ttrU
6m.Well(Dgl:SC03-01 to SC03-03 a SC03-05 to 19 6 SC03-21 atmndonnicnt to the falloiving,-
Dtvision of►1'atcrlkcsnurces,Information Processing Unit,
6h.Total well depth: 20 {ft,) 1617 Hail Sei Ace Center,Ralcigli,NC 27699-1617
10b.For injection Welk: hi addition to sending the form to the address fa I()rr
6c,Borehole diameter:a (iu.> above.also submit one copy of Iris forin%Athiu 30 days of coruptelion of well
abandonment to the Ibllowing:
6d,Water level below P-ound surface• 8' tit) Division of WalerResources,Underground Injection Control Program,
1636 Afal Bence tenter,R41cigh,NC 27699-1636
I
6c.Outer casing length(if Imown)• 0 to 5 (ft) Joe,Ur MtTr rMiglIly fi-Lrj CLIOn}}'elts; In addition to sending the fomi to
the.address(es) above. also submit one cop- of this forts within -10 days of
completion of well abandonm:nt'to'the county health department of the county
6f.Inner casinWtubirg kn)kh of tarovt•n): (fl.) n h.-rc abandoned.
6g.Serrea length(l(knottn):5 to 20

WELL ABANDONMENT RECORD
• _ For ltrlcrnrrl Use t7NLY; `
This form cantle used for single or multiple mells I
1.Well Contractor information. }VFLL ARANDONII.TMI7 UETAR S
John Miller 7m Number of wells being abandaned. i9
Well Coutracior Kanto(ar h xr ell oa, persfln,t13 obwdoniaa Nell on hie.er pruperp i Fcr omfople of a(mir or `6 oon-utnrer slrlyd)- welts ONLY wlfb l6e mie
tyNls(rlh hGY1 IT5plhh'NIn1.NJt,IYjrl ftVt SlJryJllr WIS 4N1,
4337-B 7 c G, F
`'=
b.AppnsxhNC 1VcI1 Corer clorCcnificalipn Nnnbcr note x►hrne of Water remainingin nR(l);
AUGJr ��?� R i
SAEDACCO Inc FOR SUPPLY"EL S ()
ONLY:
CantpantiNamc ^gURq 7c Type Of disinfectant wed,
2.Well Construction Permit)i:WR0300117,
ltet.dlnpplhv6f�uz'!lpermilrp;e.CaxJrJli,Sle:k,Purlwxx.Lr'a�iiinr,elc•.tlfkJmwn i
7d.Amount of disinfectant used;_
3.Well usr(check-well use):
Water Supply Well; 7c.Sealing materials used(cheer:all that apply):
❑Agricidttrrtt ❑hltmicipaltT�lblic ❑ Nrrt Cement Grout ❑ 9entonito Chips or Pellets
OC"thermal(Heatinjr oolinp Supply) ❑i mdential%Vatcr Supply(single) ❑Satin Ceuieni Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Cbocmtc Grout ❑Drill Culling
131trigation ❑Specially Grout ❑Grnvel
Non-11rater Supply Well: 0 Bentooke Slum' ❑Other(explain under 7g)
®Nlanllorfin! ORecovety
Injection Well: 7f,For each material selected above,Provide amount of materials used:
❑Aquifer Recharge ❑Graundi►itcr Rcincdiation
❑Aquifer Stotage aryl Rectn•ery ❑Salinity Barrier
❑Aquifer Pest ❑Slonmyatcr Dreitciec _ _ _ _
Portland cement Amount:684
❑Experinumlal TochnotoLm ❑Subsidence Con trul 7g,Prni{de a brief description of the abandonment procedure:
❑Gcotherntal(Closed Loop) ❑Tracer
Grout pump with tremie pipe
❑Geother»lal(EikttinJ:Coolin Return) ❑Othr:r(explain.under7g)
4.Date n'etl(s)abandonetL 6-21-2022
ia.Well!location:
McAlpine Creek WWTP
FaclitlrOirncrNJumc Ti.;ilil�•11)y tirapplic,•Iblc) S•GCrtlQrttlon:
l l
12701 Lancaster Ew
y, Pineville, NC 28134 6/21/2022
Physical Address.City,and Zip St• 1 - rf Wdilied Well t`rJw=tat or Well O Ter Date
i
Mecklenburg .signing dles_farin, I hereby cerr/,fy that the wells) eras r em)abandoned in
Cflun1,' Psrcel 1d:n11Ce6 ulna No.(PiN) act-orda ce wiflr I irf hCAC 0.1C'.0100 or 2C.0200 Well Cunrtntclivn Skartc&rnls
and Thal a copy ojdris record lasi been pr Or;tided fo the►roll on cis er.
$ti.ii stitude and urngitudc in sit rreslrnlnutcslccrnnds or dtrimal dermas:
(if well rivld,one 1•nl.%ug is Sntriekr!) 9•Site diagrar or additional will detalls:
You may use the bad:of dtis page to provide additional well site'details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DrTAILS OF WFLiA)BEING:ABANDONED SURAUTTAT.TNCTRTTGTiOYS
Allude wril Liumvuvetrart mcurdal ljaYialkhL- For nm1aple&jeetforr or nun•rtirmr suppty
wtils ONLY with ilk a imr eG/ubrkYian ahanakJunrertt.Jur1 ant mbiwi o)re ir*. 10a. For All Welk Suhndt this font nithin 30 days of completion of tirll
6a,Well IB#-.SC04-01 through SC04-19 abandonment to the followikq,
Diiisionof 1VnterResources.Information Processin-Unit,
61►.Total well depth: 20 (ft,) 1617 Hail Seitice tenter,Raleil li,XC 27699-1617
i
10b.For Infection Wells: In addition to sending the font to the address in l0a
fro.Borehole disntetcr.a (in.) above.also sitbndl ouc Copy of this form itidriii 30 d4s of completion of ivell
abandonment to the following:
6d,Water kw•d bdon•gniund surface 8, (ft) Dhislon of Water Resnik ke�,Uudergroa.nd Injection Control Program.
163E Mail Scrxice('enter.It rteigb.KC 27699-1636
f►e.Outer casing length(if known): 0 to 5 (ft) 10c.Far Mer Eli pjilv
-Injaft .Its: In addition to sending the fort to
the addwss(es) above. also submit one copy of this fort within 30 days of
completion of%-ell ahandonmant to the Minty health depannicnJt of the county
6f.Inner casinoulag length(if known): (R,) n'hffc ibandorcd,
I
i
6;.Screen Icngth(1f 1Mml n):5 to 20
FarmG%1-ill

f
WELL ABANDONMENT RECORD For lnlcnw)UscMY; `
This form can he used for single or amlliple%ells
1.Well Contractor luf4r•uiation: 3tiT.LL ABANDONMENT DkTAlt 4
John Miller 7a.Number of wells being nit I:in.donc(l. 16
Well Codmaor Name(or►.ell ow ncr pc=joty a miPj-'.S cU�p9r�,ltcr<' ), Fa' fltlrlople. It wfivt orrail-Hater su1r1.J� wells ONLY rilh Me alai
i A s.-s Vp+ cv3t►471tCM,Nl,�rbatnfruarngit,ir,n curr,rtivnN a;cJF,rm,
4337-B P
NC Won Caalraclor Ccnifrcrlion Knn>b a q U G i 9 2022 71►.Appn►simate milaine of Mate-remaining in ttiell(s}: (..aL)
r
SAEDACCO Inc p;;:C::,j i^g Un"i FOR NVATERSUPP1.YNYELESONI Y:
JRl"i r�u
Can ,m Kame o":' Qi:';OU
'F } le.Type of disinfi'ctant useth
2.%N'ell Construction Pcr'mit*:WRO300117, ,
l sraNrytpAaublr well prrmllr(i.e.Cuaran-,Slate,Iunm.ce_brti'nuorr,etr.}ifhmAwl 7d.Amount of disinfectant ttsed•
3.Well use(check:well use):
Water Supply Well: lc,Sealing materials used(chock.all drat apply):
❑ASric-c-ulturat ❑TNanicip,•tltPublic ❑ Neat Cement Grout i7 Bentonitc Chips or Pclicts
Mcollicmr.'rl(11catikiKoolino Supply) ❑Residential Water 5uppty(single) ❑Said Centent Grout ❑ Dry CLay
❑hulustrial/Commcrcial ❑Residential Water Supply(shared) ❑ConcrcteGrout ❑ Drill Cut.tiap
❑Irri •lion ❑Specially Grout ❑Gravel
Non-%Vatcr Suppky Well: In Bentouite Slum, ❑Other(explain under 7g)
IMMonitoring, ®Rev open
Injection Well: 7f For each tuaterlal selected above,prv►vide airtoont of materials Nosed:
❑Aquifer Recharge ❑Groundwater Reincdiation
0Aquifer Storage atJ Recxwery ❑Salinity Barrier
❑AquifeiTest ❑SlomnititerDraitume Portland cement Amount:720 g,
❑E ►erinrcnLrl TechnolqW ❑Subsidet>`e Coraml 7g.Provide a brief dacriptinn'af thr abanduninent procedure:
❑Gcotlten»al(Closed Loop) ❑'T(acer
OGeothemtal(HettinFlCaolinrRelurn) ❑Otltcr(explain under 7•) Grout pump with tremie pipe
4.Date ssetl(s)abandoned.. 6-23-2022
5a.Well location:
McAlpine Creek WWTP
Fod1iW0,cmrN;un4 S•Ce leatio
12701 Lancaster Bwy, Pineville, NC 28134 ;•� 6/22/2022
Physical Addreg.City,avid Zip �gtnn of Ctisliliw!Wen Coutraaar ur 'ell D+cmr Mae
Mecklenburg 13) si€wing d4v Ji►rstl, 1 heraky c�rditl dtnr the irellfs) u•ar tlreref abandoned to
County Pjreel Idenli5:: loa No.fPIN) act-vniance w(di 11.4'CAC 02C.01 i10 or 2C.0200 ir•idl Cvttslnrcliui►Slandrtnls
and drtrl a rnptr of Nris record lrmi been pnnided to fire well owner.
lik Latitude avid longitude in degrreshnfnutcstsccon&or decimal degr+ecs:
(ifuen Wd,one tote ma Usiifrirfiant) 9.Site diagram or additional will details:
You may use the bark:of this page to provide additional well site details or well
T �1' abandonoweri details. You mu}'also attach azkditiorsal pa 's if rtecessan.
CONSTRIi(_TION DETAILS OF W'ELL(S)BEING ABANDONED STTBIVT11TAT.TNSTR ITC,T10I S
:llfurlr+veil cvRstrucYiun recvrdfs�IJmvllrerik'_ For muUiple byerdon or rxrn.rxrtar aarpp/r
me/dr ONLr rr ith iltr sumr rotctitivrltr»rahcurtkntnt•nt.Jon ear.SSIM11 fure,t"Fr. 10a,For All W ellc• Submit this form n ithirr 30 days of completion of urp
6a.«'ell ID#.-SC09-01 thru SC09-05 t: SC10-01 thru SC10-11 abandonment to the folloNving;
Division of$47ater'Resuurces,lnformath►n Processing Unit,
6b.Total well depth: 25 (ry;) 1611 Dfal Service Center,Raleigh.NC 27699-1617
tob.For lnlcelion Wells: In addition to sending the form to[lie address iu 10a
6r Borehole dlantetew e (io.) about,also subndt one copy of Wis forni tvidiin 30 days of completion of well
abandounrenl to the following:
DiAsion of UlaterResouries,Underground injection Control Program.
6d.Witter k-t d beloss(;rr►and atirfacc: e' n) 1636 Dial Service Enter,Raleigh.NC 27699-1636
Kc.fluter eating lenrmth ff known): 0 to 10 (ftl 10c.F2r tlrpter Eli Uh,fi;Infec,fon Rk.lis: In addition to sending the form to
the address(es) above. also submit i one copy of this form within 30 days of
completion of well abandonment!to the county hrrhh department of the couray
Kf.inner easin;•,Itubint;length(if Icrruwn): (tt,)
nhcrcibandoncd• 4
i
6g.Screca length(if known):10-25

. , WELL ABANDONMENT RECORD ff;Forll1svONLY,
Tids form can be used for single or multiple tit'e11s
1.Well Contractor lnformation: UTLL ABANDONMENT DETAI1.t
John Miller 71.Number of n•clls being;air lndoncd: 1
Wetcownetor Kann(or weti ovi lki p:rsmlatty atmulaliq Netl On hsi IICr propcn5) AW Muh1lrlr NIf8c9 OUt ar r 1 Ht Otlfer M111,h' Wells ONLY Wrlb lltV 3tN11e
hNl3tr12ft(NI•`(Atiflllt(lfNltlltll�1C/N CYVI�N�N11f fNli�f F1fNl,
4337-B NC well CoatrlgorCcnSu�lian Nnn#cr : ti D 7b.Approximate volume of wali�
(tr remaining in wolf r: „ L)
SAEDACCO Inc AUG 1 G 2022 FOR*VrATF.R5UPPI.Y%rFF,, S0NJLY:
CvniparlyName r'i;`- .:: '!.nJ Urnil 7c.Type of disinfectant uscd::
2.Well Gaastrvcth5u Pcratti N:, , "'
ldtf 4111 appbavb/e well perswu(i.e.Cvaray'slate,!unamv.brlerfiall etc f J&rmwd 7d.Amount of disinfeastut w4l:
3.Well use(chcel weti use):
Water Supply Well: 7c,Scaling rnaterIS1,5 used(chccl;all that apply):
O. Agric--ulturtI ❑hfunicipat/Nlblic ❑Nett Ccm cnt Grout ❑ Bcntonitc Chips or Rticts
❑000111cmmal(HcatingtC.00lino Supply) ❑Residential Watcr$ippt} (single) ❑Sand Centenl Grout ❑Dry Clay
13lndustd3l/Comnxraial ❑Residential Water Supph•(shard) ❑C01I=te Grout ❑ Drill Cutdugs
131trigition ❑Specially Grunt ❑Gravel
Non-Mlater%ppty Well: M Bentoaite Shia}• d Other(e-\plainunder 7g)
®Monitoring lSRccoen-
injection Well: X For each material selected above,provide atnonat o0naterlals used:
❑Aqukfcr Rcchmrgc ❑Gruundumcr Renrcdiation
❑Aquifer Stonige and Recovery ❑Saliuity Darder
❑Aquifer Test ❑Slornm;nter Drahage Portland cement Amount:l0 gal
❑rNperinrdntal Technology (JSubsidr»at Control 7g.Provide a brief d�icription of the abandonment procedure:
ClGcotherumal(Closed Loop) ❑Tracer
eotherumal(Hetttiui~•'Coolin^Return) OOUtcr.( lain under 7 ) Grout pump with tremie pipe
©G
C Date rrell(s)sbandoned. 6-22-2022 %
52.Well location:
McAlpine Creek WWTP ,r
Facitiq•!'divmrNarrn Facilely 1Ds(ifapplimbic) S•Ccril cation:
i
12701 Lancaster B , Pineville, NC 28134 /l " i� 6/22/2022
Physical Addy.City.and Zip 013111m of Ce fa�f W'It Caarrtclar', r Wetl OuYcr D nc
Mecklenburg BY signing this,forma, I hereby ttirrlfy t/m/the ire!!{q)Nac(were) rrb�uidoried et
County Parcel Walll"bemkta No.(PiNj aarrrdance will?I M ACAC 02C!,0100 or 2C.0200(Bell CvnaYrrMtfon Slaruhmis
and That a copy of"!iris record tars beat ft'4ridled to lire Nell owner.
5b.Latitude and hmgitude in degrcr:s/rr►tntrtcs/seconds or decimal degr+ecs:
(If-wool Mid,ore lifu`krng is s"1113eicr4) 9.Site di.Mrain or additional vleil details:
You may use the back of this page to provide additional%M]site details or well.
aband0nntemd details. You ruoy also attach additional pays if necessary.
CONSTRUMON.DETAILS OFUTLUS)BEING ABANDONED S(11 MFTTAi.1'NSTRIICTfONS
:ktadr well eummudiort rveurdA?1/ovalfaliifa For muhiple lirfeeYinrt w•win-VI-a r supp(r
welfe ONLY t-lfh Me Mil L»lttbrk ttortYJJtLKkNlMlerlr.-1 W nail M&Mil ime Poem. 10r. For All Welhz Submkt this form nithin 30 days of eomrpletion of t all
abandonment to the rellon•ing;
6a.Well ID�•DW-02 i
Division of Water Resnurces,dufi►rmation Processing Unit,
61r.Total well depth: 15 (ft;) 1611 Mail Seivice Center,kalei{tli,NC 27699-1617
tOb.Fur)niectlon Wells: In addition to sending the foral to the address in 10a
Gc.Borehole dlanteter.O fin,) above•also subndt one copy of this`forni 8vithin 30 days of completion of%ell
nbandonsupil to the folloiving:
DiAston of Water Resources,Uodergr imod Injection Control Program,
fill Water kw d helot gr nand atrrfacc: 8 00 1636 Mail Scnicc Ccntcr,Rald,fr,NG 27699-1636
Ge (later easing length(if known): 0 to 5' (ft) toe.Fnr Watgr'&ynl�ink-Kdon nkiis; In addition to sending the form to
the address(es) above. also submit jone copy of this form within 30 days of
completion of well abandonment to the county health department of the county
U.lnnercasin:4hubin);k'ntKh(if known): (ft.)
a h-cm abandoned,
6g.5ctticm Icngtln(If lannrr'a):5 to 15
V—rrlr_tn v....i.r•.....rt..,..n,.........,......rn....j.,.—,.-. u........r

I
. .., WELL ABANDONMENT RECORD For inwmtllUscONLY: �
This forin can be used fbr sikete or multiple wells
1.Well Contractor Information: )I LL ARANDONM ENT Dk AiLS
John Miller 7a.Number of we113 being nb I nduned: 1
WC11Contractor Mane(of l cllonno p-rsanall)dban&-111 N}'d�0.4 hivkcr prapeny) Far malnple tntetwou W. rs a�xrter s�rpp& wells ONLY earl dw sane
y i, --�v {� tgitt4Rtft:fAN1�Tl•Otr(1fyone t,wed cwt,wrlvnu wieforNL
4337-B a.R,.
NC Wcll Clardmctor Ccnir=lim NvubcT 7b.Approximate volume of water rcumining in wcll(s):
Y I
S � 2022 FOR WA'I R SUPI'UVA Fi:I..R.S ONLY:
AUG
SAEDACCO Inc
Company Nanre :a;r,: r;,:.." 4.,"
o Unri 7c.Type otdiAnfadantuxctl:�
2.%'ell Coastrttctiarl Pcrmlt R:r_WRO300117
1lxr all appltedDle well pernrilr p.e.Cuurur,St:la,l urlamr.lirfYrilmi rtc.f ifktrrr�rrt 7d.Amount ofd6laf ctaut us 61,
3.Well use(check-well use):
Water Supply Well,. 7e.Scaling nu itcrialsused(cheer;all that apply):
O ftricrdturat 0 Nail Cement Grout CI 13cr4onite Chips or Pellets
❑Geathcrmil(HcalingJCooling Supply) ORasidentiai Water Suppiy(single) ❑Sand Cement Grout ❑Dry Clay
❑hulustria)/Commcicial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Caliinp
❑Ird tion ❑Sped3hy Grout ❑Gavel
Non-Water Supply Well: W Bentoaite Sluts}' d Otliet(ex7llainunder 7g)
®Monitoring Mecolrry
injection Well. 76 For each aeaterial selected abocc,provide amnount of materials used:
❑Aquifer Recharge ❑Groundaatcr Rcntediation
❑Aquifer Stontge and Recovery ❑Salinity Barrier
❑Aquifer Test ❑SlonowalerDfaimp Portland cement Amount:10 gal
❑Experiuomtal TechnotoLm ❑Subsidence Control 7w Provide a brief description of the abandonment procedure:
Mothematl(Closed Loop) Mracer
Mcothemrat(HatingJCoolintr Rentm) L10tlt`r(et laiaunder 7 ) Grout pump with tremie pipe
4.Datc ncll(s)abandoned: 6-24-2022
Sa.Well location:
McAlpine Creek WWTP
Factlit}•/OtvrrcrNamc F..j-ildy tvv Cirappli--lblc} S.Cert .�tiou:
1207 Lancaster Bwy, Pineville, NC 28134 6/24/2022
Physical Address.City.and Zip Inn or C ifa V C40lr:r:r or W'ctl t>,vmr Mac
i
Mecklenburg / fi)'signing this form. I hereby certify thal the rrell(s)war(were)abtvsdoned or
County Parcel WnIJ6616a No.(PN) awardinwe irilh MA(!4CAC 01(7,01 i)0.or 1C.0200(veil Cvnslruclion Stondrrrrk
and drid a cops,of Ibis record hos beett pr m-ded io lire M•el1 nutter,
5h.)lAtihtde and longitpdc in digrccsfrnlnutcsfsccouds or decimal degrees:
(ifur:n r ire,ow Wtnen;iS*trineimA) 9.Site diagram or additional well details:
You may use the ba&-of this page to provide additiowlt well site details or well
1\ �I' abandonment details. You may also attach additional pages if necessary.
C.ONSTRU HON DF_TAIt.S OF WELL(S)BEING.ABANDONED Si1BNTITTAt.INCTRIICTiONS
:triode torR omrtnrttion munlAt!f atvlWAs. For nruldple blecdon or aua•nxrler mipply
w-elfa ONLY with dw A-anid Submit dhe feHrc. 10a.For All WeRc• Submit this fort within 30 do`s of completion of well
6ti.Well Ing.SC09-03.1
abandonment to the following,
btrvisioa of%VatcrRecoumm,Information Processing Unit,
6b.Total well depth:25 (ry j 1617 Afail ScAice Center,Ralci;;b,KC 27699-1617
10b.For intection_%MI : In addition to sending the forat to the address In IOU
CM.Dombole diameter.2 fire;) abmt.also submit one tops of this ferns%%ilhin so days of completion of well
abardomment to the folloning:.
6d Water kw'd below vnund girface• e' {ft) DIAMon of Witter Resoarres,Underground Injection Control Program.
1636 Mal$mice Caner,RAIeigh.KC 27699-1636
1
6c.Outer easing length(if Iron a): {ft.) 10e.For Mier &er Sunniv In '.�don Y,Plls: IA addition(0 sending lbC faro to
the addresses) aboiv. also subdue;one copy of this form within 30 daps of
completion of nail abandonm nt Ito the county bcalik deparimeid of the county
6C InnermasinZitubing length(if known): (ft.) nitr^re abandoned, i
6w.Screen length(If kr mt1 a):10 to 25
Fame G%1kr-11) Non Carn irn Wnftnamot of Emironinenl and Narurnl Resonmes—Division of Warcr Reuxtrees, Revised Aatust 2013

' LT ABANDONMENT RECORD
e ree!!s �v� ZQ,.r1a ;]u ot�rS•;
7Tias fottatcaii be used f4ir sil�rle of nruitipl . -- AA
VX
I. o,will C ati'actorl tilbtmation: "ALE-L!L A13AlNb,QM9bT DM- AI tC .
Scott Hunt, Jr 7a.Number ofwelltbeingahandailcd
'eel Coutrassatt�laeue tee spoil oi�i persnntiUS 9banQsirihi�vcU nn Aic i t Propetrr) Far NalOpm- pgie i on r r r*66 r srrl+dt° vew Or!'i Y .+srdr :.tlre-'
�;, .� car�hrcclrt:w`mr'arrrlcurnrt�.tv_ru cxot suhr!�tt rHrakrrn�:
4561VE
NC'tt�clt Cam�aarfiCnif alron Nt rr t Approximate 1111htme of hate+remaldiag w wctl(s)e ( al)
SAEDACCO Inc N I'r 2Q27 FOR WATER$VPPLY NN%LLS�ON V.
CotipsnpNam' mic.,:.. .. , - 7 T1pcotitworectarrtusEtl:
2 WcJi Gti»stmc-&n Pemit#:7 0 002 8 94
LrRrtlt a ,lkeb/c,rettµxmlt,Ct_ xar+th Stetc;turtatis ldiitGnrt.Nei t JRrndrerr
7dr Amount or;disirttoctant used:
3.Welluse(chetkWen4140-
Water Supph wol:. 7e sicaiingmxteii usc8'tsA k altth»irh�fj h
OASr.kutitrml. IaMunicipalt7'iibiic; I2NratfCcmcntGtou1 13 tt:46i*t htps:orPcttets
06CO,ibttrmi(llentinecooting siq*y) C] esiclenteai.t1 atcr S#pp4,(sting tc) D SN4 Ccmefit:Gmai D Dry Ciaw
Dlifdn5ttiaLrCommrrtiat DTfesicicntial l\taSd SirpPt)°:(stwrod): ❑Cdnciete Grout ❑Drill Ciitling
Died 'iiaa D Spe,:ialty Grout D:Grate!
Non-Water SupplyWell: D Betnonue Slurs} �1'Other_`expl tin ondcc 7g)
®144Giritodiig Diteco�+cre
InjectionWed: X For'wb material sdceted aboirdproAde amnuot of matermals'used:.
!]Agt+iferidcuhargts DCirtro dn�te Re tiAm Neat Cem.:2"51b ,-Wtr:7gal. Sand Cem.:Ib ,-Wtr:gaT.
DAilidfer Storage and Rixat'r DSatirtiip t3a, r
�Ai)uiftr 7`est DStbrtihY:ltarDririiiage
p9-ve"Mental Technotog} DS si&=Coltlmt` ?� Prrl;ids ri hrtcf deae'i�ttiria arflic ahantMameat nrYrccdure .
DG®olhentxtl sed L*op) DTmcer
C1�themtal(tlenti Co0lintsReturn) 00tle r(e lainundcc? ) Tremie grouted well from bottom to top
i.Date iseil(s)abaniioned: 7-8-2 2
Sa.:�Vell.kieatnins
Former Domestic Laundry
Eit�ll.fUnreaer lVt,tnc Facilih•fD�t"it't�tJPla;.atilrl 8•Certii'eca(ion:
801 S..McDowell St. Charlotte, NC 28204
8/4/2022
Pht,ik:il Addis s.Cky.auA Zip Stl* l urr OtCin t rd Weti Gudwor.@r*Aldl(hvmr IYne
Mecklenburg Y sipling this,j'r'vm l Jierehy cvrhj, hailhe wetl{s) wac(TOM)whowi4twd.iir
toum� iraYYetWmitlaatlttd NO.(PtN1 tteeDrlsrrtevrtlk`li,t hC�ti !1?C�.(111)/Itrr2C,02110i1elt arrtlriirtidrr cirlahrcls
mrillhiit rt c+rip,o,j tirfa recart7lctrc beir proti�iill�/ro theueil oiriei.:;
{b,iratitude and longitndc in dCgrreslminutetlseconds or ifecimal degrees:
litwcil rkw.Out 110611g rs mfMc+erilj 9.Site diagram,ar addfdonalmcff dctnflk
You:that �e ttbe.ba*a of`thts page to ptot'ide addnuotfat►sill slle dalaW,or well
N' W abandomnent details. You may aim iitthell additwnal:paiges it(ecewry.
CONSTRUCTION 111E IAI1 S OFWE1 th►IItYNC ABAyNbt)iYD C(lFiAiIITAt:IIVS 1IiQIOatTS
:11wdr ttrll vrrlvlrerclitrt rvTEmA(xr It Okihbk..'.blto nrulook Wet6on r r wn-ww' AUM#- .
uTil'i ONLY ialfs the merirra�nern+c%3rrii=+t ara nssit rt.Svn:rnrr g.fkidl O W j+irin
10a:.Vor Ail'Weit1 Submit this rium'iiithiu 30 days ar completion of urtl
62,Wtit M#•MW-Is a adannicnt;tp the follotvirrg.
Dn'iuon of Water kmurctt,luform fion-ProteWag Vidt.
161'1 Mail Scrtd CCnttr,l2zatetgh NC.27699-1617
6bi Total weft Opthi.19 IN
It)b..`For n y 0 Wells lrt it "tell to sendlag dit ban, the address iu ltia
Kc 8orebolc dlametcr 2 iibovt.--also sue mit one tppy or flail forui uithin 304415 of completion arirelt
(in') ahandaf nla"tit the rolin'"-
DIAAon of Water Resources,''Underground Injection Gt1ntrol ProgrAl".
r:d Water ler cl bclon grvrund slirfacc,16 (rt) 1636 tllail Scrticc Ccitttr:Raleigh,ItC.27ft99-163li
IQc'iTt tjrgjgi �rnnly&tntttturn tiS' s< in addmoo to wnding theform to
6e.Outer caang length(if knoWn): the address(esj.a6oi e; also subriiii)oite ropy of this form �i9ttum.30 days of
Corr ictt0a of rKeii abgnd6miitnl trr't1*eotmi}'tieaifh dc�aRnre g df tile oOU1ih'
tlbm abandoned:
6f.Inner casiq�tuilin>;�ngtir.�known): (ft:)
69.Se t lerigsh Of knOwaY (R)
i
Faint GA%irt NodfiCamlim S3 Mmucaa otEaitltonmerii and Nutma)Resourecs-Nv ktan of°tWaWltssoun- Auptst 2011:

i
I
- WELL ABANDONMENT.RECORD Forldt ,t Uv ONJYs
This.fonit can be used far sitlete or multiple wells
.Mcii Contractor Information. )jXLL AtiAlYt)QKMUT DE..TAItt,C
Scott Hunt, Jr 7a.Namberof wells helftahandoned.,
Fru otrifrt fr- tnlakvt�itt +rt.3a ante✓ siJx° scFUs: Q.\'L)'. 's�llb .rim eAtr
i►ett 6uuacaut Man c(or c+elt ovilrn person 2flr Aiandsrnirg xc119n hk«9cr prXopertc•)
F
_� . .� a-; ) r�;rr�mrr.(rtw a5arrd«x�nrmu.inn t'nur srtJrvrt rHrefi3rnr.
4561 , E D
7b.Appmmtwtc cvifome tiPaatii emaiuin inn aeil(sj: __(dal)
Ate'�Vc1t Cani�ictorCenif�tiora Nnar�a �
A U G 11.1 2022 FOR WATF R$VPPLY 1VitLLS'ONLY:
SAEDACCO Inc -
Con wty Nam Unii ?€ ape of ditdnfectaatutftlt
2:Weil.Cvnsttvetio6 Permit 0,70002894
Losiult npptMaAleueUphrmirx(i,4«_"( viuh �1G6;1.rta+i.7nrrfr�rt.eth,t iJtrru�arr
7d:Atnotrnt of:dlslnfectatit used: '.
2.Wdl nse(cbeckaon uet)
'Water Supph WcIL 7e Sifingmatf~r+latc usctl(cACek alFthat a)fli>`
[]rlgrrcutntrat gImmicipattPttbtit:: ®t"Cit Cemcnt G"11 0 Bcrotonite Chiles o PrliG(s
IIl`icc+it�ett»�I(Ht ifin Gvoting Si p4i1)'). AlZ�sidcnttal lVAtcr$upFty'(singic) I7 Sand l cutetzi.,Gtout 11 Dry Ctarr,
OindustrinL't~0mtitential Oftcsidctt W Walcr Supply(shatnd) ❑Conttett:Grout II Dtill Cuftitigs
t]lrtf 'tion t7 S):eelalti Grtiit �:Gto�el
hnn-VYatcr pills'1f'ctl: 0 Beihonite Shifty 0 Other Ce-lain unda..:7g1
®lNotritoring (71ttY:[»�en`
i1"011 Well: ?f_For each matm al selected above,prmide amnunt of Materials used:.
DAgtnlergeawge MOW l3- Neat Cem.:2-01b ,-Wtr:lgaIi Sand Cem.:Ib ,Vtr:gal.
OAquifer Stwup sod Rtwvy P. nit),Baffler.
G]ApUifcr Test OStdi•ni"'t OrRime,
t7Eeperitittitigl Taeliooltt ❑Stdisadetxe C<»drol" 7#,fi'4 Ode a brie detcription of the ahandonment promdurie:
i cofherntal.(Closed loop) Mincer
C1Gsothemtal(Iinti 'Cool' QRaum) giatlter(ea lainuttilM 7 ) dry well; tremie grouted;from bottom to top
A.Wtc welt(6)abandoned: 7-8-2 2
5tt.�Yrll Mcatititis
Former Domestic Laundry
F€f0k,047cr Nlittic Fa ilm'tAa 4i£:uDPta stile) tl.Ccrtilkatitai:
801 S. McDowell St. Charlotte, NC 28204 8/4/2022
Miy,sical Addres,C lv,mil Zip SWntux 0f C dirjucl WtH Cojd=t9r of Well Ch:vl , Dwe
Mecklenburg rerhh,that the wellf-0 Has(iaem)abiftidrned hi
C aumj I'ar>el id lwncstkra .pllttl or 2P';62m Well Gvrixrrttctio i&indonfor
twi lhar o colwoJl/rrs reseed l ursboen-firm,i ded to the ow ottnee,
ih.1:»ritude and Mtr��itade in dr�grcea/minuteslscrnnds 0r dkxtmal d rocs". diagram or ttddittoual well"l
it:ofw'ol meld,toy M00 •t::scttl;E+rtt) 9 Site di lit:
ti ov tuay use die bad.of`ttus page.io ptoside:additiotwl Oil)she detaiis.or iveii
h SV ttbatxlonntentdctails You may al ;utacFt itionai Pages if tweswn•.
O&I;TiiiieY7b*,4 btTAII S®F WI'Cf'ia$R 1Vr.ABANUDNED SURTU ITAl::11Vsa IiQc7nga�TS.
:!(wth N+rtl.virtttraclxnt ni�nrrf(a'I it u�r�ImSte.:.I�cv rxulGjate a{Icctirur.iv knn�atcv mr�rh, .
isw&-ONLY wiot Ae per v,:Frruc6(vi 10a:.ittir All<WcI1i Submii /hiS fnrat iitthia 30 ciiij-s of completion of'util
6a,'i1`til.[Q1l;Mta-14 abttudonntcnt tri lhC f61101Virtg:'
DivWan ltnit.,
.tell,7 t tail:St: ice.Ccnter RaWjph MC276"-f617
6b.Total well deptir:.14 (ft)
IOb.` Qr { rt R'clls: Lt addht Dn to vending the forat to the address in 10a
6c.Borehole dtametcr:2 fin,) tthov�c.'stisa sttUtnit one top+ of this fontt.i tiU►iit 30 dais of coinptetion of to 11
tdlandoWfierd to the fo11on3ng,
i
Crd Water ieiel bcltna uod airfacc: NA (ft. Dlos%n a Water Resinikes,Underground lnjettlan Control Program:
err► ) t636111aii Scn�cc Gcuter,ItalCir,:hC:27ti99-1(�36
IQc`j:'p r��Suntii►tri It�fertutn ti'`eRs: :ln adt[ition io siding tBe fom►to
6c Omer ca.Ong length#if known): {0 the address(eO aboxie; also sutinut;nne:c*y of this;form rdttl*l 10 days'of
corriplctilon 01
retell aban ntnent ip'the t nto health iicpattn at of the coantye
di tuner mojn0tnhing length Ofknowu): (ft) w# tc tthand0i eti:
'i
6g:Sq"length(if known). {ft}
f
Foul GAI-10 tVorth CArpqn DquAi acni of Enrironn"I aM Natural Resourm—Dir(sion of.WatcrItsour��s Rriiwd AupsO 2013.

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: R ELL ABANDONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed,�Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally aba it fl�r le . e r ) well construction/depth,only 1 GWp 30 is needed. Indicate TOTAL NUMBER of
2725-A (� I wells abandoned:
NC Well Contractor Certification Number QIJ r Z `r- �`�` 7b.Approximate volume of water remaining in well(s): <2 (gal.)
ET ..*.mg UnK FOR WATER SUPPLY WELLS ONLY:
Company Name L)' c-ir0 k-FC-1
2.Well Construction Permit#:
WM0301221 / SI P-70003050 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,Counn•,State, Variance,etc.)if larowvr
7d.Amount ofdisinfecWM used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public ❑ Neat Cement Grout 19 Bentonite Chips or Pellets
❑Geothermal(Heat inglCoolin2 Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurty ❑Other(explain under 7e)
eMonitoriug ❑Recovery
Injection Well: 7E For each material selected above,provide amount ofmaterials used:
❑Aquifer Recharge ❑Groundw•aterRemediation 175 Ibs Hole Plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed 10 ft of casing. Filled well with bentonite chips.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 8/8/2022
52.Well location:
Facility/Owner Name Facility IDft(ifapplicable) S.Certification:
325 Rhyne Rd, Charlotte 28214 7d—&I % 8/11/2022
Physical Address,City,and Zip Signature of Cerf d Well Contractor or Well Owner Date
Mecklenburg
By signing this fornt, I hereb}• certify that the wells) was (were) abandoned in
County Parcel ldentiticationNo.(PIN) accordance with 15.E NCAC 01C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 9.Site diagram or additional wellldetails:
35.286123 N 80.967700 `y, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifneeessary.
CONSTRUCTION DETAILS OF NVELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.4ttach well constn+cnonrecord(s)ifarailable. For multiple h1jectionor non-water sapplywells
ONLF with the same consh uction/abando+rment,you can suhmit one forn
' IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TM W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above, also submit one copy of this &mn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: �27 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 20 (ft.) abandoned.
6g.Screen length(if known): 15 (ft)
Form GIV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 3-22-2016

WELL ABANDONMENT RECORD ForbitemalUseONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan
I
y 7a.For GeoprobelDPT or Closed-'Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hislher property) well construction/depth,only 1 GW{30 is needed. Indicate TOTAL NUMBER of
2725-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of waterllremaining in well(s): <2 (gal.)
I ET FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: VVM0301221 / Sl P-70003050
List all applicable well construction permits(i.e.UIC,County,Slate, Marione,etc'.)lit kno Rar
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout LE Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑hrdusttiab'Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Rater Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 200 Ibs Hole Plug
❑Aquifer Storage and Recovety ❑Saliniry Barrier
❑Aquifer Test ❑Stormvmter Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed 10 ft of casing. Filled well with bentonite chips.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
a�
4.Date well(s)abandoned: 8/8/2022 g
5a.Well location: AUG 1 9. 2OZ7
1n#cwt �`ae t Facility/Owner Name Facility ID#(if applicable) S.Certification: Pre^. rg UnA
MOOOG
325 Rhyne Rd, Charlotte 28214 % 8/11/2022
Physical Address,City,and Zip Sit-nature offer ed Well Contractor or Well Owner Date
Mecklenburg
By signing this form. I hereby certifj•that the a-e/I(s) leas (were) abandoned in
County Parcel identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 IVell Construction Standards
and that a copy cf this record has L een provided to the bell owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j
(if well field,one IaUlong is sufficient) 9.Site diagram or additional well'details:
35.284559 N 80.967923 `�, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessarv.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.4ttachwellconstn4ctionrecord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the saute con truction:abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TM W 6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above. also submit one copy of this form within 30 days of completion of well
abandonment to the following:
abandonment
Water level below ground surface: -25 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Sipp ly&Infection Wells: hi addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the co lnty health department of the county where
6C Inner casing/tubing length(if known): 25 abandoned.
6g.Screen length(if known): 15 (ft)
Form GIV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor 111 lion: WELL ABANDONMENT DETfAILS
0 7•�+r �1 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
�0 y2
NC Well Contractor Cron Number 7b.Approximate volume of water remaining in well(s): (gal.)
j f FOR WATER SUPPLY WELLS ONLY:
Compaq Name 7c.Type of disinfectant used:
2.Well Construction Permit#: U r
List all applicable well construction permits(i.e.UIC.Cmurry State,Variance,etc.)6(known 7
7d.Amount of disinfectant used:
3.Well use(check well use)::
Water Supply Well: 7e Segling materials used(check all that apply):
❑Agricultural ❑Mun pal/Public Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) �lRResidemial Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each rpaterial selecte 7ave,provide amount of materials used:
[?Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g provide a b 'ef description o earfdaj¢ cdf
❑Geothermal(Closed Loop). ❑Tracer b .a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
y
P.�J�� i � 202Z
4.Date well(s)abandoned: /� /a�p 1/��
,• ' Y�•7�PUPM Ll rtil
14}yi.'i'M�iii'�e_:lr}
J eT —
Facility,?Ovi`"Name F ilityID#(ifapplicable) 8.Certification:
Physical Address,City,and Zip Signature of C itifiecliWell Contractor or W II Owner Date
t.0 A
By signing this form, 1 hereby certtfy that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient)
9.Site diagram or additional well details:
N W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)#favailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
� lOs. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: (^v C/ L1J abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (%) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of,this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: (R,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): ! V _(ft.) 10c.For Water Suonly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): n C (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourfces Revised 2-22-2016

WELL ABANDONMENT RECORD I For Internal Use 0NLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2725-A r e t''j_, wellsabandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in w•ell(s): 1 (gal.)
IET AUG 1 9 2022 FOR WATER SUPPLY WELLS ONLY:
Company Name G9Ptir3c}c^ t (ft�v'-:i�v1 Unit;
��y 7�,� 7c.Type of disinfectant used:
StX
2.Well Construction Permit#: WM0301221 / 7, W3050
List all applicable well construction permits(i.e.UIC,Counh,State,Variance,etc.)if crown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply'):
❑Agricultural ❑Munic•ipalPublic ❑Neat Cement Grout %Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
%Monitoring ❑Recovery f
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundvvaterRemediation 100 Ibs Hole Plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Rcturn) ❑Other(explain under 7g) Removed 7 ft of casing. Filled well with bentonite chips.
a.Date well(s)abandoned: 8/8/2022
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) S.Certification:
325 Rhyne Rd, Charlotte 28214 % 8/11/2022
Physical Address,City,and Zip "611 ll orCer ed Well Contractor or Well Owner Dale
Mecklenburg
By signing this form. I hereby certi&that the ivell(s) was (were) abandoned in
Count} Parcel Identification No.(PIN) accordance with ISANCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a cop}of*this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/brig is sufficient) 9.Site diagram or additional well Idetails:
35.287849 N 80.969951 W You may use the back of this page'to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF'"TLL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.4ttachwellwnstnnctionrecord(s)ifavailable. Fop,multiple itjectionor non-water supplywells
ONLI'mth the same constrttclion.-abandonment,you can submit one form.
10a. For All Wells: Submit this,form within 30 days of completion of well
6a.Well ID#: TMW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 32 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the.form to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
f
6d.Water level below ground surface: -26 (ft_) Division of Water Resources,Underground Injection Control Program,
1636 Mad Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&IniectioL Wells: It addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 17 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
I
Form GIV-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22_016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoni g iten�}ts Cp t)IR w'ell construction/depth.only 1 GVG 30 is needed. Indicate TOTAL NUMBER of
a y�
2725-A .,r wells abandoned:
n
AUG ? � ?l'2� 7b.a Approximate volume of water remaining m well a. <1 al.)
NC Well Contractor Certification Number � PP g (-)' (g
I ET lf)k'69MaU -1 ins L1 ;P URIl FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WM0301221 /SI P-70003050 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC.County,State, Variance.etc.)f known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑btdustrial/Commereial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ) ❑Other(explain under 7g)
mmonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount ofmaterials used:
❑AquiferRechage ❑GroundwaterRemediation 150 Ibs Hole Plug
❑Aquifer Storage and Recovery ❑Salinih,Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed 1Oft of casing. Filled well with bentonite chips.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 8/8/2022
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) S.Certification:
325 Rhyne Rd, Charlotte 28214 -- 8/11/2022
Physical Address,City,and Zip SignanuY ofCei ' ed Well Contractor or Well Owner Date
Mecklenburg
By signing this form,. I here-by certify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that o cop} ofthis record has been provided to the ivell oirner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.287318 N 80.970099 `r, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constntctionrecord(s)ifavailable. Formultiple injection ornon-watersupplywells
ONLI'with the same constucdonlabandonment.you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TM W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
fib.Total well depth: 30 (ft.) 1617 Mad Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: �25 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 15 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GIV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandonin ells hysheZ-n o�Ert�.p y� well construction/depth.only 1 GW-`'`30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
2725-A
NC Well Contractor Certification Number AUG y 2022 7b.Approximate volume of water I Irettaming in well(s): 1 (gal.)
z �
I ET FOR WATER SUPPLY WELLS ONLY:
Company Name Jf4cPn: cl ? rC'C'u"w:^:g Unit
2.Well Construction Permit#:
WM0301221 / SIP-t ELOG
563050 7c.Type of disinfectant used:
List all applicable well construction permits(i.e. UIC.Count..State,Variance.etc.)ii-norm
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunieipaUPublic ❑ Neat Cement Grout IF Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: Cl Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount ofmaterials used:
❑Aquifer Recharge ❑GroundwaterRemediation 150 Ibs Hole Plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geotherma((Closed Loop) ❑Tracer
❑Geothermal(Heat ing/Cooling Return) ❑Other(explain under 7g) Removed 9 ft of casing. Filled well with bentonite chips.
4.Date well(s)abandoned: 8/8/2022
5a.Well location:
Facility/Owner Name Facility IDit(if applicable) S.Certification:
325 Rhyne Rd, Charlotte 28214 8/11/2022
Physical Address,City,and Zip Signature of -er t red Well Contractor or Well Owner Date
Mecklenburg
Br signing this farm, I hereby Bert h•that the ivell(s) was (were) abandoned in
County Parcel Identification No (PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a cop}v of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one IaUlong is sufficient) 9.Site diagram or additional well details:
35.286031 N 80.969227 `y, You may use the back of this page'to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.4ttachwellconstnietionrecord(s)ifavailable. Formultipleinjechbnornon-watersupplywells
ONLI'with the Sarre construction:abandonment,you can submit one form.
10a. For All Wells: Submit this(form within 30 days of completion of well
6a.Well ID#: TM W 3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 34 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10h. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —27 (t1) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Injectior!Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 19 (ft.) abandoned.
6g.Screen length(if known): 15 (ftJ
Form GAV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY.
1.Well Contractor Information: DONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed-"op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
"E- e 7b.Approximate volume ofw•aterlremainin m wells. 2 al.)
NC Well Contractor Certification Number n PP g� O' (g
IET AUG ! G 20ZZ FOR WATER SUPPLY WELLSIONLY:
Company Name
qyR ��r, A'• P ,C34.,,T4.(g unit 7c.Type of disinfectant used:
2.Well Construction Permit it: WM030 i Lf I I���',�y°`�3050
List all applicable well construction permits(i.e. UIC.County.State,L'ariance,etc.)ij'knoxar
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heat ing/Coolin e Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slung ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 200 Ibs Hole Plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed 10 ft of casing. Filled well with bentonite chips.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 8/8/2022
5a.Well location:
Facility/OµmerName Facility IDa (if applicable) 8.Certification:
325 Rhyne Rd, Charlotte 28214 8/11/2022
Physical Address,City,and Zip Signamre of Ceo2f d Well Contractor or Well Owner Date
Mecklenburg
By signing this fbrn:. I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of'this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one IaVlong is sufficient) 9.Site diagram or additional well details:
35.286485 N 80.968398 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF N'ELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
lrach well construction record(s)ifavailable. For multiple injection or non-watersupplc wells
ONLY n th the same constnrctionlabandonment you can submit one for
' m 10a. For All Wells: Submit this(form within 30 days of completion of well
6a.Well IDN: TM W-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: —28 (11•) Division of Water Resources,t ndergrou id Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): (ft.) 10c.For Water Suppiv&Injection Wells: In addition to sending the form to the
address(es)above.also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county vvhere
6£Inner casing/tubing length(if known): 25 (D•) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GXV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016