Iredell_Well Abandonment_20221028 (2)

WELL ABANDONMENT RECORD jf..,le:cnui Use ONLY: {
I !
1."ell Contractor Information: WELL ABANDONMENT DETAILS
Alfred K)eslmg Jr. 7a.For Geoprobe/DPT or Closed-Loop Geothermal\Yells having the sane
Well Contractor Name for well owner personally abandoning well on hi-b: zl;construction/depth,only IGW-30 is needed. Indicate TOTAL NUMBER of
3266-A wells abandoned:I
NC Well Contractor Ccnifiwtion Number 7b.Approximate volume of w a ter remaining in w e6(s): (gaLi
B & K Well Drilling Inc FORW.ATER SCPPLSWELLS ONLY:
Company Name ' Chlorine
/f !� c.Type of disinfectant used:
Chlorine
Well Construction Permit R:(N �'1� l 'J d.2a'6 [q(La.
Cis,all appliaeb(e•well'onsrnnTion prrraas(i.V. UIC,Cou,ar.Stare. Ianan,; r. :±bn+n
'd.Amouot of disinfectant used: w/Vf-Y- S
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal Public = Nest Cernent Grout -d'Bentonite Chips or Pellc s
❑Geathermal(Heating/Cooling Suppl)) 89esidential Water Supph i angle Sand Cement Grout ❑ Dry Clay
C lndustrial/Contmercial ❑Residential It, Supph ishar;il t�rcte Grout ❑ Drill Cuttings
❑Irri ation - Soecialn Grout - ❑ Gravel
Non-Waler Supply Well: = Bentunite Shiny O Other(explain under 7g)
OMoniruring ORccoven'
Injection Well: If.For each material selected above,provide amount of materials used:
CAquifer Recharge rXimundwater Rerneshation s 1 &A s 4
CAquifer Storage and Recovery CSalinitT Barrier r�j///111 ���
CAquifer Test ❑Statinwater Drainage I
CExperimental Technology CISubsidence Control 40
7g.Provide a brief descyyypt�ion of the abandQQQnment procedure:
✓ -
CGeothermal(Closzd Loop) OTracer
❑Geothermal(Heatin /Coaling Return) OOthef(e lain under 7g) /(u a�,,�
�ZL.Lr L: V [D
4.Date well(s)abandoned: nr 4
T q
5a.Well location: 1. N
1 / ID`'-ra`i^'1 iaf^""^'PFj k�011
Tl/ C ✓ 4al��!S JarQi3DG
Poeildv/ 'net Nomr Facility ID+(ifappiimblc) S.Ce M tion:
Physical Address,City.and Zip {. signature roil ied W Cont in
r rnr ate
�.•L/I yrd f39-AT-5&fy Br signing:his ions, I hereby'cwai&rh e well r) u'ns(xrre) abandoned in
Counro Parcel Idrntilicatimt No.(PIN) accordance m'!Ih U J NC:aC 0-'C.0100 _C.0200 Be11 Construction Slandttrtls
and rhai a copy of this record has been rovided to the well miner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
I lf.11 field,one IaVlung is sufficicro 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonnent details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDOMI) SUBMITTAL INSTRUCTIONS
Artarh xrllrnne,nrcnnn rrcnrd99 i(w'ui(rth/e. Fnraiulitplernjmnon or nrnr-x:urer.egip(r well.,
OALF,,wh the same rortrirurir a6andonmrnt you ran submil on"form.
' 10s. For All Wells: Submit This forth within 30 days of completion of well
on.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: _Ift•) 1617 Nfa6 Sere-ice Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition in sending the form to the address in 10a
6c.Borehole diameter: (in.) above. also submit one copy of this forin within 30 days of completion of well
abandonment to the.following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
be.Outer casing length(if known):_ J(�(ft.) llk-For Water Supply&Iniection Wells: In addition to sending the fart to the
addressles I 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
of.Inner casing/tubing length(if known): (ft.) ahmtdoned.
6g.Screen length(if known): (ft.)
Rum OW-30 North Catalina Dcpartmem of En,m,nmomal Vu ilily-Division of Water Re+oumcs Itevikcd 2-22-2016

WELL AHAN VONMEN I KLt UUKU I For Internal Use ONLY.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Norman Travis Costello 7s.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same
Well Contractor Name for well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2251-A wells abandoned:NA
Not Detected
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
TNJ Brush Cutters, LLC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: Chlorine Tablet
2.Well Construction Permit fl: NA
List all applicable well construction permits(i.e.UIC,Comely,Sane, Variance,etc.)fknawn 1 x 3-inch Tablet
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural OMunicipal/Public ❑Neat Cement Grout ■ Bentonite Chips or Pellets
DCseothermal(Heating/Cooling Supply) DResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial RResidential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring DRecovery
Injection Well: 71.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation 13 x 50 lb bags
OAquifer Storage and Recovery OSehnity Barrier
DAquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
OGeothernal(Closed Loop) OTmcer
sass m.«o,aa.aisr awn.oa awn«see dsonea m..m..eaae a«i trios•m.unw.o,v wpm house—r«ro«a
DGeothermal(Heating/Cooling Return) DOther(explain under 7g)
The benlonae was then added until a manifested at the "ad nipohertop.
a :r
I.Date well 10/17/2022 Th s)abandoned: e tmManite was hydrated! en usma on-she
sae cooler ethics. t v
58.Well location:
GS Statesville Green Land LLC Irncrna5 o Pr :aT¢ unit
Facility/Oaver Name Facility ID#(if applicable) g•Certification: Js1aiQ/i3:`�'
326 Dover Road, Statesville, NC 28677 - . yam 10/17/2022
Physical Address,City,and Zip Signature of Certified Well Contractor_m ellW Owner Date
Iredell 4752150203.000
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 retard has been provided io 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:
35.728581 N -80.853922 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)favi ihable. Formultiple injection ornon-watersupply wells
ONLY with the some constructionabandonmem,you can submit majors. Ilia. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Well 1 (For Report) abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6h.Total well depth: 49 (ft.)
10b.For Infection Wells: In addition to sending the form to the address in Ilia
6c.Borehole diameter: 6 (i n.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Not Detected Division of Water Resourea,Underground Injection Control Program,
6d.Nater level below ground surface: Not 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.fluter rasing length(if known): NA (ft.) lOc.For Water Supply&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 where
6f.Inner casing/tuhing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016