Wilkes_Well Abandonment_20220909

«ELL ABAl !tE,I RECORD Foriroar6l UscONLY:
'iftix forth catrbe tiscd far sings Of rttttltipl7e Wells
i.Welt C.aotrat�r information: r►+t r t AtiA1VDC)iti14iE1WT D1?FAR.1
Robert Miller 7a.Number of wells beingahaodou�d: 1 --
Wdl Coam Naum(or%ell ovinei pa wHy ahandoning action Nslirr ptopeny) For RNYttJplf ft{({tiPalt or Min'Kwter BJ�}' 1 t+eis 0\Lt` wrlN ON sole
E:onxtrrrrnre�e����raYmnmi�eet:,t+�n,xoe itJhmru nuc^/FJrtvr:
2675-A 7b.Approximate volume of vtatcr rshnraining la w dt(s)t
NC Writ ClemaegorGMitrcationNiimber
Irbil WATf.Ii45EIPYLYWELISON Y:
SAEDACCO Inc
convans tianne %Type of disinfeetunt used:
2.Well Consttuctiou Pftzdt t4:
List arl mdt abk Vey pernub ff e.cdam{vt lgfiwiaae rtt P j'kawW a 7d.Amomtt of diAnfeetsut used:
3.Welt oje(check well use):
Water SnpplF We11 7G Sealiflp rnatcrlals used(chcct:ail that apple):
17AgOceltmi oNltmoGipalfFtlbtic 9 Neat CYtm of Gtaat 0 Retttonttc Cho or Pellets
OCaC9ttlerlfaat(7lcatinr�C'Motiog Supply`) aR mint Water Supply($in&) a Sand(I tern Grout a Dry e��r
❑IBdttttripUt�ommsrcinl oltcsideraiai 1iVaterSupp�y(titaiW) o C66MIe'Grout a DrillOdtinga
t]irci riofl a Spesiatty Gtottt a Gravel
NOA W 'Well: 0 Berdonite Stuffy ❑Other(ee.Vloin under 7g)
121douNoring aReew y
iitjcixiort well: 7fr For each tttatcrial selected above,pro-side atrroittat of Materials wed:
0A9 R=harP 130rounduaterRcut diafion Neat Cem.:941b ,Wtr:7gal: Sand Cem.:lb ,Wtr.gal.
aWU SrOntgr MO ROMVM' Mgfitdiv Rattier
❑Aquilld Test 13SiotftM1dcr Df2ijAge
Mxpttitnental Technotogy OSubsidetxe CotMt 1g.Pr avide*bed drseriptiau of the abandonment proecdum:
D Geotheffnat(Closed Loop) OTtacer
Abandoned Temporary teell.via tremmie grout
t7Goothertltat(lieatin CooHe Return) 001119rC ,lain Under 7 )
;,pateRt'(lit(8)tthandoecd: 08/23/2022
NL Well lM lon:
Wilkes County Landfill - Eller Property IftiL'0'�"`'�� 'r.�"'" "�UM
- 8,Certification: D%A;'
FmcililyJbsv'rt;rName Fatctiity iDm(ifapptisabta) C{12.yOG
9219 Elkin Svey. Roaring River, NC 28669 8/30/2022
Plgsical Address.City,lead Zip 6t1 "+'` `" ':;;'s aa' DIM
Wilkes B'V,gigMW they finmi; 1 hemAy ceriffy that the ueflfr)was(vem)tah mdoned its t,
Cort�ly lured idesaificatiou No.(PI`d) amitcfonce wilt 13A XCAC OTC.0100 or 2C.02W 17 ell t:cuatirueaRM St1#nliarrfs
and tUaf a rcJpt,of dris record has beEn provided to i to well awnm.
ib.Latioude and Iongitude In d►gr+cc ad nutatsm nds ordcdwal ftms:
(tfaell rakt one LOW issaf ukra) 9.Site diagram or addidonalwcl dcta€ts:
you In*use[tie batik of ttus page to provide additional well site Mails or well
Ik W abaudountent details. You may also attach additional pages if necessan'.
fYr„f►° Ltf'tiifflN b "A1L5 t?F WEL S)URINC:ABANDONEQ §iWi[TP'AI.WSTRUCT[ONS
.ifftd,%Wp rataxtr dkw retrarolrso i}'tn vlldbk- Fbr nwhiple roecrtoan to iaa a-www=M4
Wr&ONLY vrifh&6.7am!`,1t.1 teKk 91-QbdYT&-gM1''Ut.IV"Mn is bWt exe,*"M 10a.For all Submit this harm within 10 days of eomptetion of lull
61L Well[M.6EP-1 abandonment to the following:
Uh,is"af Water ire kout Wormation ProetWOM pnit,
1617 Aiail Senice Center.Raleifih,SCZ76".4617
6b.Total well depth: 44 (().}
toe.For iniecilon W-d : In addition to sending the form to the address in 10a
above,also subtWl one cope of this form uitbin 30 days of compIttiot,of well
6c.Bordeole diameter.8.25
Ciir.) Ammdommd to the foft6Wins:
6d.Water Irtcl h owed surface• Cft) DIAisiou of Water Resources,Underground injM&O COMM Program.
1636 Maul Sisviec Ccuter.Raleigh,NC 276"-1&%
6e.Outercasin 34 ti1t.) 10c-For Water lSsrsml &Inlecftnn♦Yells: to addition to settdittg ft fOnn la
fi t (if the addresses} aborre. also submit one copy of this fotni within 10 days of
coutptetion of isvil abandonmut io the county health de-factntri t of the OMumY
6L Inner catlughuhinglength Of known): �p} Wlt�cabattdotnod,
6F,Scut lento(N Imowfi)s 10 -_--_----__r tfi•) j
Force GW-IA NonhCarotim Dquam od o9 Eadrouotent and]Vt uml Resources-Division of Water Resomm ftwised AWO 20B

WELL AB }ON RECORD For t►MW' UW My-,
Tots foittr.cattbe used fat sitrltie.or mlddple Wellt;
1.Welt Conoaebr lrrfunustion: �V1r1.L Atl?1ttSD{f1 M1i11161!'ETAU
f
Robert Miller 1a.Number of wells heittg abandatied: 1
NTAI CaateuCfOFX28W(at tteltaataer personstic aWnkning well on to 4w ptapetl}) Fur mnftlPle flyicvtki+r a raw++rnter seer .e"Ila ONI.f° wrtli tla� savie
irons:fMcfWiarhornai'asrJM+ trodrwtswfnl)Iftolefirrn
2675-A 7h,Appr li=tc v'alnnte Of vFitar renaiinhrR in Wtll(s):
NC wepcalydmacirt wificatirmNamber ,-,
FAR WA' Elt SWPLY*1F ,S iC1Iv'1.Y.
SAEDACCO Inc
campan)'tune 74 Tylte of dWafectant uted:
2.Well C'otrsuvctioa Permit M:, - — --- - -
LW 441 itpplbrahlr%V11 perm tv o'*-C:,nru,:S&re.I arfm-,hy'fttu,M ete;J y.lariw ra 7d.Amount of dlslnfrxtanit used:
3.Wd1 use Achtxk>Fe.9 use).
Water SupR1y well.. Of
Scaling materials used(cba�k all that l4ppiti):
13Agriailtaral [Municipal?Public Ct Nott Cemca cam"t A Berpotltic t Fps or, Mats
OGQothe OW(11cadn, rooting Supply') ❑Rmid.-Tdot Water Supply(s�gle) D Sand�€€nMU Grout ❑ Dry CLW
❑tndu5l iOvcomnlcnciat oltmWenti.•►l Water SWIY(sh trod) ❑Cancitte Grout ❑Drill.Cuttings
❑Uti ion o Specialty Giant ❑Gravel
i�oa Wa xSu)►8t3 Ws1t; t Bentotdte Sluri5• ❑Oilier(explain' lrnder 79)
lHManttbring DRecoiViy
itrjtx an Welts 7f.For each material selected above,provide amount of Materials used:
❑AquifdrRechaMt ❑GtourrtwmcrRe:medWirm Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr;gal-
❑Aquiffi Storoo Mid Ri -overt' ❑Salinity Bardtf
❑Asltritet Tea ❑Slorrtia•eterDuc oVe
❑Experimental Technoloa ❑Subsidence.Couttdl 7p.Provide a brief 4criCriptipu of the anstndonmcat priocedum;
DGeot wanal(Closed3.00p) OT)mcet
Abandoned Temporary well via tremmie grout
❑Geothettuat(lis:tti 'Coati Retum) MftrteWain under 7 )
4.Dole 0(s)almoderfed: 08/23/2022 c r��.," g
So,Well hreation: S F P 0 G 2Q22
Wilkes County Landfill - Eller Propertyfl(}n;g
8.GcrditcNdou: trn�+ ,
):�e7try;^burrerName �'�tlitt lAa(ifapplighte) — ���'CI�
9219 Elkin Bay. Roaring River, NC 28669 8/30/2022
Physical Address.Cad.and Zip cr 31t�.^'' � `"�'� '��• �•�+a aer i}tge
Wilkes B}'sefiruajg this form I fremkv certify dwt the weilixt was(WPO abwabned ni
C)DUaky food ldcrgirowlimi No.(PIN) a0mrdotxrc IPA 14 XrAc 02C 0100,ar 2C-.0M Well Construrtti6w Skmchrrds
and drat a cgFW of this retard hats 6c m -ided 7o the Well m4vier.
5b.14thudeand longitude In degr+ees/mI aates/sa'm lits or decimal dances.
(ifuetl feeld,om i.VA"a is sty ieaera) 9.Site diagram or additional WeD deMUE
You taq use the back:of this page to pfavide aM ionat well site details or Well
N W aibandomnent dnlails. You may also attach additional pages U necMsaty.
f'(!NS'MttiMw—4 DtTA11 S OF WI;LILSj BLffNGA8Ai*tb01V1rD StJR1Ni7TAL MTRU[."iIONS
tttr dr ardY ci i rtructfmr recvrdlAi i �rfl 6dt For mn1NPR rnjirs .0 tlbn waa wtrttr zhppty
uw1kONLY wjIth six am,rc c + crton'anmroAauaricrar.r�hero Ah"Tif Q,krm- 10a..For All M: Uhmit this farm n•ittan 30 daps of completion of tirtll
:tbttndonment to the following-
6a.Well @p:EP-5
btiidauef R'aterResaur'emInforndation ProceWal Unit,
1617 Mail Servirx'Cetrter,R xIert h,KC 2769'1-16i?
6b.Total a*11 depth: 49 (ft.)
10b.Err Inleellon W tin: In addition to sending die for to the address in 103
above.alga submit otte copy of this forty%ithin 30 days of completion of♦tell
6r,Borehole diameter.S.25 19n,) obandonmcm to the following:
Div)son of Water Resources,Undergrottad Injection C0111101 Program,
6d.Water Ievd below"nd sttefare: (ft.) 1636 Mail Senice C:'eafcr°.Raleigh.NO 27 '1&M
(h) 10e.bbr Wg warmly&InietAnn_3M. In addition to sending the form to
5c.Outcr casing lcngth(if lmovrn): 38 the address(es)abase, also subttut one cop} of this 16MI ti♦ithin 30 d4's of
completion of well abandonment to the crunchy Iscaith depattrucal of the cotttriy
w atxtrtdorrott,
4f.Innercasinatulrlop icnpth(Mmowd): tH)
6g,screeo knob(if lmoaV):10 (n)
Fomr G%1-30 North Carohm tDep anrrr oa of En%ronngnt and Natwat Resoines-t3h15tan of Water Rssowcts RcE sed Aupsi 2015
I
C

WELL,eBAMQNMENT RECORD Forir9enWUseONLY:
jhis form fa n be rued for$in Of THUMPle Wells
1,Wedt Contractor inFOrmatian: W1rL ASAIYbOlailtlF�i1 1 1ltJ lA1E.^+
Robert Miller 7a.Number dwells beingabandoned: 1 _.
1VaCout wW Name lnr�6ett aNR91Cr pefsaJtally abaadoWH3V aeli an Ills€her paupany 1 Far .otttlttlJf>• r+rt crew rJr n��r+�ltriPr s�rp +lts ONLY �eilh t auir
•E'�T13'RfflfC-PJtNJ•JhdfktUJfAJt!rlf:)YEN CAP�I�JI/f tkJ�'�7P7#F�
2675-A 7b.Apptairdmttt Volume Of widw rtsrwining in ntll(y): __ jgatj
NC Won GoromctarCcttirxutia"Nuxiftr
FOR WATEtt T,1 PI.1'VVrEUS ONLY--
SAEDACCO Inc
CanVM Name 74 T%pe of disinfectant used: _
2.Wdi Construction Permit#:
l JafltyJtJldrabtr Jceltpermitr ry.i.CexJrata:Stu a.3 irrim nJJ crc.!JIJJuwq 74L Amount Of disinfectant used-
3.Wei rate{therk WA Uile):
Water Supply Wd 7t.Scatiog matt riles used ithta ail that apple):
17Agticttlttpttl 17Murtia i .lEPtablir 0 Neat Cement Omit U tlemOrtite Chips or Pdlm
t]GcOThrmrat(kleannglCOvling Sttpp4) olteSidt:N.211Vatter Supph•(sing,IC)
13 Sand Cement GfOUL ❑Djy Cky
❑1ndu.strial/Commercial ❑Rcaidet4iat 1i+atea Supply(shared) o Conefete Gttaut ❑Dtin Qtttings
❑ SpKially Gtnnt o Gravel
alni lion
Non-Watersupply wen: 0 HenWitiie Slnt9y CI i)ther 4pNplain under 7S)
® y ❑Reco.
ixtjtxtion.Wen: 7f.For Basil material selected above.provide amount of tiF'dCCfiaT#T��ed;
MquifetR=hatgt DGMUndvMiCtRtrrJcdiation Neat Cem.:941b ,Wtr:7gal. Sand Cem.:lb ,Wtr:"l.
oAtpaifet Sea>ntge and PWMV% Ma iniiy Banier
❑A4&A!r Ted oStor miw Drainage
oExpsimeotelTechnotogp oSubsideatCe COWA 7p provide a brief dcacriptiuu of the ahandaumeat procedum;
aGeothermal(Gtnsed Loop) Mracer
Abandoned Temporary well via tremmie grout
DGeotbemlal(Headjtglpft Return) C30 tter•4. ain Lander 7 )
. �
08/23/2022
4,11ratt'a'cp(s)atkandOpcd-
Sa.41'ell location: -
Wilkes County Landfill - Eller Property _ S.CeHiitcadon;
iac7ttrJDnP,erName F:g71t,ynU(irappliccblc) Inrcrr � '' ^�, W�3UnR
8/30/2022
9219 Elkin Haw Roaring River, NC 28669 _ y��,7/!�
P4*al Aft es.City,m!d Zip P tlli'}�v fS 4,: 'C•; ii'a'l R''�v xCLF 1}(J#
Wilkes Dl's{tmiaq this form. I hereby certify that the welh*"Ws pver abandoned rn
Cou)i) Plat d Itle jrkat mtNo.(PIN) acivrdantr ivair 15 VC4C:02C MOO of 2C.02W lt'rll Construfftn Shrra&ffds
and that to cowry of'dhis rerxrrd A.axs heed prm4ded to the well ow•rrer.
Sir.Latitude and tongitudeinsdegreeslminutes ndster^dedmaldt:grcts:
(ifneel te�Id, TurJ7aJlg"t&SrJ(fuicaA) 9.Site diagram or additional wee datx9s:
You tmay use The ba&of d&page to provide additional we4l site details Or Sell
N W abandomuent details. You may also attach additional pages if necessary.
Ct1I5tS71t1IrTto,-j DFTAII QF'ATLI,(4)8 C.ARANDONIb SULB 1FITAta iNS33LV, T70N5
.ttidr heel cotaftudiew reLTo lltJv if avalhhritt. Far Jrra t k i4ecurm Ok sm--m-r6w JAM'
»xNs ONLY V0&0 wale rwrmractaue'abmrJ94JlrierJl.I'm ro)snhJJJJt tam&mm 10a.P' r All e#is:. "MR ties farm within 30 days of completion Of Urll
atbar donm¢tat.to the following;
6a.Well ID#.EP-4
Qicidon of WoUr Rew refs.Infrrttuath)b PJrot WOU Unit,
1617 afail Scrvior Center,RideMb,NC 276 4617
6b.Total well depth: 48
lob.Fnr Intettlnn Wadi: .la addition to warding the farm to the addrass in 10a
above.also submit one 60pV of thiLq Iona%ViWin 30 dt l of Complelton Of 0*11
6c.Borehole diarnt4cr:6.25 abandonment to the followifIX
Dilkislon Of Water Resourcm Undergrot)md to jectlau Control.Program,
&L Water lecei behrsr ground surface; (h,) 1636 tltail Smice C.'tater,Ralco.NC 2"46 f.6
I
10c.F_hr Watfx Surmlti•A Inieet O Vs'cO F In addition to wndiTtg the form to
be.Otrtarcausinglta h(ittotnWnj: 38 01.) rite address(es)rebore. also submit one Copy of dale form within 30 da►rs of
comptaton of well ahandonmani to the county twoth drlraatmera of Or County
u'4crc abandoned,U Inner caiinwWhiuglength(itlmown): (R.)
6g.Serves length(if 121eWrt):10
Fan)G%V-30 NonhCamtim Dcpaywvm of Entifoomm JJM Netuml Risowees-Division of Mau Rcsoufccs amid Mpg 30t3

FELL ABA1YDONNIENT-RECO" FortmffmftlscONLY:
This forth can be used for single or nudtipte sells
1.Well Contractor Information: )U IL ARANR fNMENT DETAU
Robert Miller 7a.Number of"Cps train};abandoniCtl: 1
V4'c!t'Cattuastott�tt�t ncttoxna pwrsnrntl}ahnadouitts xeEl on t�fltrr properi♦i Far withole rutiwlu+t aw sent-usher sj"F tells ONLY wA the same
c',rlc4fircMtott:ahatdanmerd;tern ezors Not wove form.
2675-A
7b.Approxirnatt mlame of water r maiding in Weil(xy: 004
NC W01CoomcurrCert rKaOon Niuraba
SAEDACCO Inc FOR WA t'>"R SUPPLV•'%T.LLS ONLY:
Convaq MW 7z Tvpt of dislotectant used:
2.Well Consttmcthtn Permit#.- ,
L W OB uprlhvable twellpernd&tLet Cmrrr{r.3 ,f'eirira.x>,Itrlictiwa chow tjtmiwrr 74L:Am utmi of disinfectant used:
3.Well utr(Check wall n:t4)
Water Supply'Welk 7e.Soling materials used Obeck ail that apply):
[.7Agrietdtttrai DMtQticipnliPttbiee M:Neat Cctawnt Otmtt A 8CIVOMIC Chips or Pt:OM
OCgothsrmg(HeatitoCooNng Snppiy) CIReside►ftat%Vstcr SuW4(sanpfc) ❑ Said Crttswit Grout ❑Un'Cluj•
Dlrahtslrial/Comntsroial DRmidcntW Water Supty(sltaral) D Conch*Gra l D t kill Cuttings
ObdiLation ❑ Specialty Grant D Gravel
Non-Water Supply Weil: D Bentonite Siurry D Otfter(explain under 7g)
ammitoring Olkeein by
Injection Well: N,For each material selected above,prvtMe amount of materials used:
❑ feteRccha DGraundumter lttntetiiu on
� � Neat Cem.:941b ,Wtr:7ga1: Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storuye and Rewwwy OSalinhy Barrier
OA40iler Test DSivrnmater DiainVe
DEtImimental TechnotoLy OSniaslden=tontmi
7g.Pro-wide a brief description of the abtindaaatent prom-dnte:
OCaeothertual(Closed Loop) OTracer
DGeothermal(Head Cooll Return) 00ther4 ain under 7g)
Abandoned Temporary trail via tremmie grout
��•^^- f�� �u
#;Date r?FCII(s)ttbandQtrCd: 08/23/2022 C-`.�....w �a ■y �-
ia.Weil location.-
Wilkes County Landfill - Eller Property
€=iit}•r'nnrtCrNV= Fmilit}•II}N(itappticaliic) ll•Certiitcation: In#�,r5<a;R1Przr;;, ;yt Urtsj
9219 Elkin Say. Roaring River, NC 28669 _ �;zO ���
8/30/2022
Plq�x1W Adilms.Qq,snd Zip �* nStiY.^' 0oMi-tv,4 R`�n'Z::;:kc MAO
Wilkes 1S-mg)Wig thkc fame, i Irenhy cerPrj�i�riwa the ut^iley)was(were)a►i: loner m
Caamy Panel tduuaif&atbuWo.(PIN) eaetstrdance..w1dr 114 XCA C 02C.0100 or 2C.02W IT."ell Cotsliytcoon Remdards
and that a 4Aqv of"rtacord lass beE9a pravlded to fire well owner.
Sb.Latitude and lapgltade in degmeslmfsuteslsmuds ordedmal degrees:
eesa:
(ifnetl t'rtld,otw 13VIMitsuit3Cical 9.Site dlagraor or additionalrtell details:
You may use lbe ba& of this page Ito provide additiotml well site details or swell
N W abandomum details. You may also'attach additional pages if nummy-
CbK 7 YDITAIIIS OF UICLUS) B N 'l D StM3117 TAL iNSTRUC MOMS
Arty&welt trurrlrucom ft%w Jae if atmvlar: liar mtrdlpte e4w mt tar rr o-w-rter tWpph
*s4k U.NLY with con tubma om fore. Ift For All Wdtti: Submit M6 fbm within 30 4-s of compktiou of>,rA
6o.Well tDi4 EP-2 abandoamcat to the of axOnG:
Division of Water Resources,Information Processing Unit,
6b.Total well depdt: 48 00 W17 hiail Senice Center,halt.,NC 276"-161 7
10b.Fsr Inleetian Wee : In addition to sending file farm to the a3dtess in 10a
bc.Borehole diameter.8.25 fin,) above,also sub(uil one:cop},of this forth within 30 daps of completion of ss�ell
abandonment to the following:
Water feed below ground Msrfacc: tff.) Ris�lston of Water Resources.1tdndergwatlad IuJection C011101 Pragreut,
1436 Mail Service Center.Raleigh,NC 276"-1636
6e.Outerraung lenob(if known): 38 (ft,} 10c.For Weser Stun(,&emcee&►n Writ in aWition to seeding the fonts to
the addrt:ss(es)above. also subtaii one cope of this forth witbin 30 days of
comptetion of nett abandonmernt to the county health depatiment of the county
6f Inner ewInWWhhV lenob(if bnown): . 00 swt=abandoned.
i
6g.Seam length(if imown)s 10 (h•)
Fumt GW-10 NoahCam im Ikputmcca ofEnvimntaaem aW Nottuol Resumes-Dtt istmaof W3wr R f ourU-s Revised Augtu 20B