Mecklenburg_Well Abandonment_20221114

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
aeLontract Information; WELL ABANDONMENT DETAILS 7a.Number of wells being abandon Id: I
Well Contractor Nam�(orwe vner personally abandoning well an his/her property) For multiple ii jection or non-water supply wells ONLY with the same
u33a C. constructionlabandonmeni,you can submit one form.
NC Well Contractor Certific tion Number 7b.Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS ONLY:
Company Name
p, 7c.Type of disinfectant used:
' 2.Well Construction Permit#!: �00 1 �l L
List all applicable well permus(i.e.County,Slate,Variance,injection,ere.)iflomwtt ,
7d.Amount of disinfect
ant used:
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) n ial 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 LB-$tffr(explain under 70
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected abcLve,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation 5b l4s ���1
❑Aquifer Storage and Recovery ❑Salinity Barrier (J
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned•_ g/2 T 2,2—
5a.Well location: -
/6'//��l�'.. Pel � lft+vy r x
Facility/Owner Name Facility IDR(ifapplicable) &Certification• Ci�'b:Qlr't+
191133 DA_1V1d S'
Physical Address,City,and Zip Z?aTSp Signature of C d ell Contractor Owner Date
G " /.f, tta . �Z-�
/ B3 sighing!iris 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 Conrtniction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and thal a copy of this record has been provided to the well owner.
(ifwell field,one Iatilong is sufficient) 9.Site diagram or additional well details:
. 44�o l N -rgo You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Amach well cottrtruction record(s)if available. For multiple it jection or non-water supply
wells ONLY witb the same construction/abandonment,ymt can submit one form.
! r 10a. For All Wells: Submit this form within 30 days of completion of well
�r
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center-,Raleigh,NC 27699-1617
10b.For Iniection 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
l abandonment to the following:
6d.Water level below ground surface: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): p (ft) 10c.For Water Supply do Iniection�Y'ells: 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
6f.Inner casing/tubing length(if known): —(ft.) where abandoned.
6g.Screen length(if(mown): 4 (fL)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

SILL P1RAI\Tnniu­iv,,1E1NT RECORD
Illls form can be used for single or multiple wells For Internal Use OIQLY:
l�Contractor ormation: ii'ELL AB.4t\DONiviEti i iDE—TAILS
Well Contractor Name(or well Wrier personally abandoning well on his/her property) 7a.Number of wells being abandoned:
For multi le in ecrion or non-waier supply u•e1Lv ONLY midr the Sol'),C corrvtnrction/abandarrnieni.you can stibarit one form. )
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS ONLY: (g )
Company Name R
2.Well Construcfion,Pet•mit�:
00 3 3/ -7 7c.Type of disinfectant used: //
List all applicable well pernniv o.e.Cnunh.S�oie,Pariancr.h jecrion,ere)ifk»au n
7d.Amount of disinfectant used: Z 1 n�S
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
❑Agricultural
❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or pellets
❑Geothermal(Heating/Cooling Supply) LEN cst id`ent(al Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay}
❑Residential Water Supply(shared) mete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout
Non-ii'atcr Supply Well: ❑ Gravel
❑ Bentonite Slurry ❑ Other(explain under 7s)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /f
❑Aquifer Storage and Recover,
❑Salinity Barrier -'�
❑Aquifer Test ❑Stormmuter Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal Closed Loo 79.Provide a brief description of the abandonment procedure:
( P) ❑Tracer A
❑Geothemtal(Heating/Cooling Return) El lOther(explain under 7g) 8 �P� 3 / e r ,,
4.Date well(s)abandoned:
. 5a.Well llocation:
V\ 1 V 1 t�5`�r •u� < �:�...Cw0 ll..i �..+.,Y.R�
t qq
rFac�iil'iittyj/OOwn�erName ') s) Fja�cili[ylD�tifappl-ijcaable) q S.Cerdficatio NOV l tI LUL
43CE Ut`�1� �lt�L j I� INC Gp 1 �tliufAeCu�r lttrL ll
Physical Address,City,and Zip {
n�u tetl Con
^� 1 / rgnatur � tractor or\Vdl On•ncr Date
/ �� r
Countyty �1 0Z /- (o L ! ��� By signing this form, I hereby cer (h
r6r thai the well(s)was(here) abandoned i»
Parcel identification No.(PiN) accordance with I5.4 MC4C 02C.0100 or 2C.0200[yell Constriction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has bees provided to the trell owner-.
(if well field,one IaVlong is sufficient) C� 9.Site diagram or additional well details:
5 ( j N — p (7�^�� g�� 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 DiISTRUCTIONS
Attach cell convirucaou recard(s)rf arailable. For anthiple i4ection or non-water supply
u•clly OA'/•Y u•ih the scone canstn¢7ion ahatrdamrent,you can sarhnrit anejarnt.
log. For All iileils: Submit this form within 30 days of completion of well
6a.Well IDm:_- abandonment to the following:
r Division of Water Resources,Information Processing Unit,
6b.Total well depth: ( 4� (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.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 fotlovtiring:
e Gd.Water level below ground surface: 3� (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known).. (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 counn•
6f.Inner casing/tubing length(if known): (ft-) nitere abandoned.
6g.Screen length(if known): 'UP`L (170
Form Gw-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources
Revised August 2013

WELL ABA�(D1V1Vl�Im,1NT !m CORD For Internal Use ONLY:
'Mis form can be used for single or multiple wells
I.Wcl Contractor I f,I
Cation: WELL ABANI DOiliMENT DETAILS
7a.Number ofwells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple it jection or non-haler supply ,tells OAZY ,ril+ the some
Cconslnlctio)ilabarrdomnelrl,you can subntiloneform.
NC Well Contractor Certification Number 7b.Approximate volume ofwater remaining in tivdl(s): al
FOR WATER SUPPLY WELLS ONLY:
Company Name
11 7c.Type of disinfectant used:
2,Well Construction Permit#: �o) 3I
List all applicable[veil permit.,(i.e.Cormh.•,S�ola,Parimrce,h jection,err.)ifbrmvn 3.Well use(check well use): t
7d.Amount of disinfectant used: Z, �)✓t(�
FOIndustrial/Commercial
ter Supply Well: 7c.Scaling materials used(cheek all that apply):
gricultural
❑MunicipaVPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
eothermal(Heating/Cooling Supply) l[rl?esidential Water Supply single ❑ Sand Cement Grout
PP Y(single)) ,�� ❑ Dry Clay
❑Residential Water Supply(shared) 'iEConcrete Grout ❑ Drill Cuttings
DIrrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well:
❑Monitoring ❑Recovery ❑Bentonite Slurry ❑ Other(explain under 7g)
Injection[Well: 7f.Fox each materiWsellcted above,provide amount ofmaterials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Stomge and Recoven' ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal Closed Loo 7g.Provide a brief description of the abandonment procedure:
( P) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under7g) " « �v' 3 nn `>�(��.� /a Cn Q
4.Date well(s)abandoned:
Sx.iircll location:
IT V
Paciliry/OwnerNanil� � �Fac'iOty IDn(ifapplicable) S•CCrtilicati
t'd Z v
Ph;Meal�e�ss City and ZipIT Signature of rt*fi Vell Contractor or Well Owner Date
w C�r By signing tilts form, ]hereby cert pj,that tire well(s)was(were)abandoned in
Countv Parcel Identification No.(PIN) accordance with 15A ArCAC 02C.0100 or 2C.0200 Well Calstniclion Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copY ofthis[record has been provided to the ire/l owner.
(ifwell`field,one ladlong is sufficient) 9.Site diagram or additional well details:
\3 S', -3`7 9,6 .71-(,p Q Ll You may use the back of this page to provide additional well site details or well
W CONSTRUCTION DETAILS OF WELL(S)BEING AB4iVDONED abandonment details. You may also attach additional pages if necessary.
.attach Well construction record(s)f m•mlable. For multiple b jection or non-water supply SUBMITTAL INSTRUCTIONS
wells OA%Y with the.tame carstrvctiorriibnridonnicm,you can submit one form.
10a. For All 'Wells: Submit this form within 30 days of completion of well
6a.Well ID#: N abandonment to the following:
3� Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb. For Injection Wells: In addition to sending the form to the address in I Oa
6c,Borehole diameter: �Q (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
e 611.Water level below ground surface: (f4) Division of Water Resources,Underground Injection Control Program,
1636 Mail Set-vice Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known). Al (f�) loc. For Water Su Dlv& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this Corm within 30 days of
completion of well abandonment to the county health department of the counn
6f.Inner casing/tubing length(if known):�(ft•) where abandoned.
6g.Screen length(if known): (ft.)
Forni GtV-30 North Carolina Department of Environment and Natural Resources—Division of Natcr Resources
Revised August 2013

VVE ,L A I BA�0LIN—A FI 11.1V T Rto'C0RD For Internal Use ONLY:
This form can be used for single or multiple wells
1.W'll ontractorInformation: WELL WANDONMENT DETAILS
7a.Number ofwells being abandoned;
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple h jecuon or non-irater suppty wel/s. ONLY with the stone
ca)7slruction/abotidottment,you can subunit one farm.NC Well Contractor Certification Number (�0 7b.Approximate volume of water remaining in well(s): •-'2 G D (gal.)
m LA,Lk 6 S v`"-LJ '4 j FOR WATER SUPPLY WELLS ONLY:
Company Name
d 7c.Type of disinfectant used:
?Well Coush•uction Permit#: ( 31
List all applicable well pernritr%i.e.Comm•,Smte,Variance,h jection,etc)ij/aw,vu %
7d..Amount of disinfectant used: (`
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(chech all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) `51t.dential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared af�oncrete Grout
❑ Drill Cuttings
❑in anon ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slu
❑Monitoring rry ❑ Other(explain under 7g)
❑Recovery
Injection Wcll: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation f
❑Aquifer Storage and Recover!, ❑Salinity Barrier
❑Aquifer Test ❑Storm«ater Drainage
❑Experimental Technology ❑subsidence Control
7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7e) J3�t0
cei S% r It 'vJI r
4.Date isell(s)abandoned: ' (,r�(Z� / —�—" ,; -'� JJ�,pg li
5a.Well location:
•� f• � �1�11 1 rl 9Q??
Facil erName Fac'lity IDR ifa licable E.Certification:
�d ! AlC ZiPL(o� I`� Pr,^ra",llrF
Physical Ad ess City,and Zip la (D ZZ
"'[ 1 Signatur of hed Ne Contractor or Well Owner Date
C !n w/ U2�—IOZI- Z3
By signing!Iris form, I hereby cent 11rat the tvell(s)was(uyere)abandoned in
County Parcel identification No.(PIN) accordance with 15A AtCAC 02C.0100 or 2C.0200 I;-'ell Constniction Standards
ill.Latitude and longitude in degreestininutes/seconds or decimal degrees: and that a copy oflhis record has beer:provided to the irell oirtrer.
(ifwcll field,one ladloug is sufficient) 9.Site diagram or additional well details:
(� i You may use the back of this page to provide additional well site details or well
R abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.dttrtch well cortrtrucnon r•ecnrd(s)tfarailable. For nwhiple hjecvion or non-hater supply
wells ONLY frith the.none causnatctiaidabandonnicitt,gait can submir one faint
IOa. For All iVdls: Submit this form within 30 days of completion of well
6a.Well ID4: abandonment to the followin-:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: cp ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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 follo�tdna:
Division of Water Resources,Underground Injection Control Program,
r Gd.Water level below ground surface: A)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if(mown): (ft) loc.For Water Sunpiv& Iniection Wells: in addition to sending the fonn 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 couun•
6f.Inner casing/tubing length(if known): (fL) where abandoned.
fig.Screen length(if lmown): (ft.)
Form Gw-30 North Carolina Department ofEnvironmeut and Natural Resources-DiViSion ofNater Resources
Revised August 2013

WE L A11DAI�([ ��ME1N J"P 4 CORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Infopmlation: WELL ABANDONMENT DET AILS
15 7a.Number of wells being abandoned:
Well Contractor Name(or well owner p onally abandoning well on his/her pmpen}) Far utuhlple ii jection or non-water suppy, wells 0112Y frith the same
consiniction/abandomnenl,you call subrnii one form.
NC Well Contractor CertiGcation Number ^ I , f l I 7b.Approximate volume ofwater remaining in well(s): q_3 (gal.)
i J S W+�^�` �p 1/ 1 i FOR WATER SUPPLY WELLS ONLY:
Company Name
0 _J
2,Well Construction Permit#- 7c.Type of disinfectant used:
'( 3�� 9
List all applicable well permits(i.e.Cawrq,,State,Variance,h jection,ere.)ifdirmvn Q— ^I n X
7d.Amount of disinfectant used:
3.Well use(check well use): ICJ 'L
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) LLIRz&klentiftl_Water Supply(single)) ry❑ Sand Cement Grout ❑ D Clay
single
❑Industrial/Commercial ❑Residential Water Supply(shared) °-Concrete Grout ❑Drill Cuttings
❑Irrigation El Specialty Grout ❑ Gravel
Non-«later Supply Well: ❑Bentonite Slurry'Ty ❑ Other(explain under 7g)
❑Recovery
Injection Well: 7f.Fir each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Sal inih'Barrier
❑Aquifer Test ❑Sionmvater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ) /�7
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7g) �,
A.Date well(s)abandoned: IZI IT
Sa.Well location: .." Nov � � 2�22
M �s _ —
Facility/Owner Name F cility 1D�(ifapplicable) 3.CertifiC <�fF'rS
CA9 4 Physics Addles,Ctty;and Zip Signature of 4cdi�W,ctor or El OwnerDate
County
By signing this form, I hereby certfii that the well(s)vas(were)abandoned in
Parcel Identification No.(PIN) accordance with 15.4 A'CAC 02C.0100 or 2C.0200 Mell Construcaoti Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has been provided to tire well owner.
(ifwell field,one fat/long is sufficient) q 9.Site diagram or additional well details:
3J, 3-J1 You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary-.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.-I mach well caiisirnc•tirni recorci(s)f m•ailable. For nntltiple iiyection or iimi-a,aier supply
wells ON[Y with the same can.rtntclior'2ibmidoiinietii,}roil can submit one form.
IOa. For Ali Wells- Submit this font within 30 days of completion of well
60.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6h.Total well depth: I (ft.) 1617 Maii Service Center,Raleigh,NC 27699-1617
IOb.For Injection Wells. In addition to sending the form to the address in I Oa
6c.Borehole diameter: 14 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
e 6d.Writer level below ground surface: 1 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if Imown): (fG) 10c. For Water Supply& Iniection Well., In addition to sending the font to
the address(es) above, also submit one copy of this font within 30 days of
completion of well abandonment to the county health department of the county
6f.Inner casing/tubing Iength(if knovv-n): �_1�p (ft.)
where abandoned.
6g.Screen length(if known):
Form GNy-30 Nonh Carolina Department of Environment and Natural Resources—Division of%Pater Resources
Revised August 2013