Gaston_Well Abandonment_20221208

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.lid pa�Q' ,.'' �: � ^� �• •
' 'rt' :; • . ` WELL A.BANDONNM1 NT RECORD ' ;f
-'; No dhC linaDepmtnentofEnvirontnentbndNatundResourc i'n'of
i• es-Divis o WnterQuality
QUM `1'': WELL CONTRACTOR CERTII!'ICATION# t
1.WELL CONTRAd:it: I •
- �` S. WELLDETAiLS: 1:
J ,A ri`?f�' ���C d:1:r��t%� eXclal Deplh fa it. Diameter. _In.
Well Contractor,{In ivldual)Nafne = ` b.GVale�Lave((eeiow Measuring Point): (S_(t
rat •;.:. � Ii
MCCALLEIROTA41RS,INC. '
;Measuring polnt,lk:, <5" JL above tand surface,
Well Contractor Comlpany Name
6700 6ROOKSHIRE 6L�/D,
5ireetAddress• �.j• :�?`. G. CA51NG• t''?' Length Diameter
- ":
;• CHARLOTTE els;j' s l' ' 'NC 28216 & .'4: a.test' Depth(IFt own): _.R in.
f CI[yorfawn :•_=�=1.; I ;:State Zip Coda: ' b.CaslrigRemoveti•!, s f1, in.
70( 4 1 39915IJB,i': i s' c s :•=r
Area code Phone pil'mber ,i 7. DISINFECTION: ;i- 2
ilt f 55°e7
2.WELL INFORMAL Or oti o / 5la;calclurri hj►poehlodla used}
•ol'I "; a. SLING,MATERIAiT.e . s .I
SITE WELL ID# ('applicable) i ,
N"t•C`•otnent .; Sand Cpmpnt
STATE WELL PERMIT# (If eppitcable)
.:1•.
lR ::Cement !' lb. I cement
COUNTYWELL�E?ERAIT #(Ifappiicabi N ;'Water gal, Wate ul L
9entonite
DWQ or OTHER PERMIT#(If applicable) ('
WELL USE(ChecR;t3pplfcabieuse)[I:.Ilflonitoring al,116alden1lal ,'eeiltonite 6;C;6' lb.
j.;Type:❑Slurry:❑'Fellels• I.
,
❑ M uniclpaliPubllc�`•❑ IndustrlallCctmnerctal ❑ Agricultural "Water o.
❑ Recovery 0•4016ctlon ❑ Irilgation
DEC 0 8 2022
!14-
iTyipmaterial
3.WELL LOCATION. Amdunt ❑VJ '3OG
• COUNTY dAdIUADRANGIE NAME
i NEARESTTOLWN + T ca i'1 9.• -EkOLpA�1N METHOI]OF EMPLACEMENT OF MATERIAL:
Jt
• (StteeURoad Neme;Numheq Community,Suhdfviefon,tat No„pateel,7lp Cade);•: ,
TOPOGRAPHC f l'AAb 5 JNGc °
❑Slope ❑Valhy; tat 17 Rldge❑'Odier 3; '
j,
(Check approprtale saselling); 6.
..q 10. WELL DiAGRAM¢Oraw a detalled sketch of!heed on the back ofthis
LATITUDE " '' .S , ' fo'' showing total depth,depth and diameter of screens{lfany)remaining
' �.�yl; _.'�, �Cs`i'.!]AllS'Oit3X-XXXX)CO000p Tnilhewell,graveltnteivel Intetvalsafcasin e
LONGITUDE .•�'� t DMS 7X '' g P 1Fotagons,and depths and
;sue. 'OR .XOOOOoDgbp typed aim
<.; ,_,,.,C : r
Latitudellongitude source: t :trS )]I'o o ra
,,,„ p g,amapgr 11. DA7EWELLABANDONEb; •'��1( .
(tocalton of well mu§t'be shown an a U50S topo map andaHached to .
thts famr if not using f:TPSJ ,
;. .: 1 DO HEF6E—.CERTIFYTHATTH!S WELL WAS ABANDONED IN ACCORDANCE
4a,FACILITY-Theri6i't)fthebusinesswheietheweilTslocaled•Complete4ar :;: TFgSREG�tiRDW1WITH 5Ht9:LLOO ItSTRUdnOE OWNER NDWTACOPYOF
(Ira n�ldenitel weQ,skip 4a; N.
tsmplele 4b,welt c'm6rinformalton only,)
FACILITY ID#(Ifjapplicabie) .
NAME OF FACIUTYI• z de,r 4`rPr� 'vi''Jy r'. 1 /(', SIGNA EOFC 71FIEDWELLCONTRACTOR DpE
STREETAODRESB'! '
t,f�. G t ' 1�5•r'T 6 SIGNATURE OFPIUVATEWELLOWNER'ABANDONINGTHEWELL DATE
City arTown '^t ;1 State
;; pCode t ; (The pdvalagialownermustbesntndMduaiw arso eri bandonsh;alharmfildsnllalwell
4b.CONTACTPERSONrWELL OWNER:
. Inarrardancaw1h15ANCAC2C,D11s.)' '�
NAME
+--�- PRINTEDr
NAME OF PERSONABANDONINP THE ELL
STREETADDRE55°7G' Q q.t7 dbk,6
srl'y,ti,7�1"•;'YL.•,'I(fl'`jt.'=1'H,:�.•,':4 t'i�".::?:•-'�St,:y�•,lp`:!.', •7 3.1•..rr�.K....=„�q�l.=:• •• � •• i I.
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t p. =t(aetowfier arilth or ; iis(oi•ofallVtiate"� ,q �• :6 pt •!I Il:t�l'�it ! , ,.. , l 4 .•,�'S•r-,•,.�i�y�..Y�rb�;•'�l
•i a u. r: m,ifid ti•t i+ Ur.t�.ttS� �•"t-.'iNct<a�`L•ry ,^itut�., �• , r a Q,a�� ,;'3.1,nonriatJOTI'ly'•fGCe55in r'
*�N�bis71V1a1�:Ser, d, 7 .;, r•.t n t�,rxMa0 !r 9! FormGW30
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WELL ABANDONMENT RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells i 1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned: I5
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
construction/abandonment,you can submit one form.
NC 3322-A I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc)ifknown 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 171 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: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 6.3 Ibs/ft(63-126)lbs/we11)
❑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 Filled/hydrated from,bottom-up; Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
SVE-1(20'),SVE-2(20'),SVE-3(20'),;SVE-4(20'),SVE-5(10'),SVE-6(20')
3 3
4.Date well 11/3/2022
s)abandoned: E����; tad 5 ,
5a.Welllocation: 6 /lfL2
Petro Express 16(Pantry 3934) nu
11
Facility/Owner Name Facility ID#(if applicable) 8.Certification: )Rini t+?n ?l i
Unti
2483 East Franklin Blvd. Gastonia, NC Lawrence Opperf__„- _,_ '�1/21/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Gaston 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.2605331 81.133791 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-water supply
wells 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
Soil Vapor Extraction Wells-See 7g abandonment to the following:
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
66.Total well depth:
See 7g 1617 Mail Service Center,Raleigh,NC 27699-1617
(ft.)
10b.For Infection Wells: In addition'to sending the form to the address in 10a
6c.Borehole diameter: (in.)
well dia: 4 above,also submit one copy of"this form within 30 days of completion of well
abandonment to the following:
" I
approx 15 ft. Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: ( ) 1636 Mail Service Center,'Raleigh,NC 27699-1636
i'
loc.For Water Sum*&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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number ofwells being abandoned: 19
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the some
construction/abandonment,you can submit one form.
NC 3322-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Regional Probing Services,,., FOR WATER SUPPLY WELLS ONLY:
P Y
Com an Name 7c.T e of disinfectant used:
J._ r F
in, •'h F IS yP
2.Well Construction Permit#:
List all applicable well construction permits((t ry, tdla, ,etc)ifknown ,
7d.Amount of disinfectant used:
3.Well use(check well use): IniOiiatC a;9 1 �1;.r�G {R�(�rE(1
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout RI Bentonite Chips or Pellets
❑Geothermal(Heating/Coolirig 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: ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 1.6 Ibs/ft(36-83)lbs/well)
[]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 Filled/hydrated from bottom-up, Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MW-2(27'),MW-EDPS-2(27'),MW-3,(30'),MW-EDPS•3(21'),MW-4(30')MW-5(29'),MW-6(30'),
4.Date well(s)abandoned: 1 1/3/2022 MW-7(30%MW-8(30%MW-9(30%MW-10(30')MW-11 (30%MW-12(30%
Sa.Well location: MW-13(30'),MW-14(24'),MWA5(24%MWA6(24%MWA7(23%DW-1(52')
Petro Express 16(Pantry 3934)
Facility/Owner Name Facility ID#(if applicable) S.Certification:
2483 East Franklin Blvd. Gastonia, NC Lawrence Opper,., 11/21/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or We11 Owner Date
Gaston By signing this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I SA 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:
35.2605331 81.133791 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 records)if available. For multiple injection or non-water supply
wells 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#: Monitoring Wells-See 7g abandonment to the following:
Division of Water Quality,'Information Processing Unit,
6b.Total well depth: See 7g (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
Well dia: 2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: well abandonment to the following:
1
6d.Water level below ground surface approX 15 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suoaly&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 abandoned.
6f.Inner casing/tubing length(if known): (ft.)
I
6g.Screen length if known): (ft.)
f
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 multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS I
Lawrence D. Opper 7a.Number of wells being abandoned: 5
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
construction/abandonment,you can submit otie form.
NC 3322-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)i(known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural P ut ci�1/Ilublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Su ply ❑Rnne�ssidential Water Supply(single) ❑ Sand Cement Grout El Dry Clay
❑Industrial/Commercial S�iih�i�ential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation _ _; ❑ Specialty Grout ❑ Gravel
Non-Water Supply W�Ih?urb�" ' ' '' ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring `�grdr+ l J Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 1.6 Ibs/ft(40-64)lbs/well)
❑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 Filled/hydrated from bottom-up:'Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
AS-1(40'), AS-2(25'), AS-3 (40'),AS-4 (40%AS-5 (40')
4.Date well(s)abandoned: 1 1/3/2022
5a.Well location:
Petro Express 16(Pantry 3934)
Facility/Owner Name Facility ID#(ifapplicable) $•Certification:
2483 East Franklin Blvd. Gastonia, NC Lawrence Opperlm 11/21/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Gaston By signing this form, I hereby certify that the well(s)was (tivere)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: 1.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.2605331 81.133791 You may use the back of this page to provide additional well site details or well
N �� abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-water supply
wells 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#: Air-Sparge Wells-See 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
See 7g (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition'to sending the form to the address in 10a
well dia: 2 above,also submit one copy of this fd'm within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
approx 15 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
i
10c.For Water Supply&Injection 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.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

,IVELL ABANDONNIENTRECORD. l F'oi•lntcrzW Wd ONLY:
-. " 'hus fomfeari Ue us�l.fa�siiegEe of inullipte tr.�eUs - � ;•
6_.Wct1'61ntYatWfr Inform4o6ni ` �, )YELL ABANIjE)A1h1ENT IDItTAILq
John Eisehman '� I:t,Nnwber oft t41Sbeingpbando,ed:.1
EVt1tC'ormreeorAFa (4rtxrllortr�rpeG+ii,ally;ibaszddnine�ti�dl.onli�tl�rprdticss}) F, ivitippm. htl+r�r a rare-rikrttr srppb 4elfs•-.ONLY ioub the •sew,
emasrrrrcn,xr m'eairctnmlrc7at Jun iim.170wt It twigs(iiriae
4439
NC woo Caarlrrdoresttifr rlion Nniritcr A.A011ram lmetc vtrinini:of water im�eiu twrng in tiell(pjo
SAEDACCO'Inc C+bR Wr1 CF:R.S.EII'I'I,1'1I.1 S f?N_1Y;
Camgmanp Name. 7c,Typenl�rslnfifaut riled:na)
I I
2 en Commictron Peratit#:
Lt3ttJrjit11c3ubl�iiellxm,tY(i t'C�arrls SIrN,{ariiux�.lirjetitnr�.rlr 11J4uutcrt na
" - 7i1.Atnottnt.of:dlstiifrxtattt uscil:
3:`t'dl u* (eLerl.Well 6 je
Water Supply WetL in ma#ends use_d(cket;all tbat;pplrj
C]tkan.nittrmal_ l7hflitntcmpalfl'tllitic 6t Ncat 4'emcn#,Gi?aut �� � perrtot!ltic CftTps ar Pellets;,
i7Cotlteevx►t(Hcatin�rJCacylit>g Su!}FCYj pItesiilends►t"tf attic ts'tiPpl}'(ir�lcj L7'S:1uil Crnts itt Gtttut D lit}DLit
❑IudnsWaYCownmcW' ORcsidm6at Water Supply(5haucd) CtitiatetL'Grou[ I7'DtillCiitiings
t3hti tioa b-Sperwty'b. of 17 Graa 1
0Bentonite8lurl I C9=0tter(eiplautunder7g)
®14lonitcrdirg<: t7Recocer3• "
Lnjcction wcu:. ±f.For each tuateAd seltac above;Provide awoontof:nrtteviats used:
�1l4ulferttechae4 �Grtiuiimi�i�leridetneitixfion Neat Cem.:941b ,Wtr:7gal.. Sand.Cem.:lb ,Wtr:gal.
OAqunferSianrge ats<1 Rctiaimvety l7$nliuity F3arrier .
Bentonite.:851b ,Wtrg alj
❑:4ytemferTest i]StoamtKateri7rsinage,
pE�:prr{nieutal TilrouCuy �$imbsldemmee Cosml i;
?g:Provide a Irricf diticripti ti of Qfir:`alrtndpnmcuf prne�Aurei
Menthenmi(Crowd Laup) [1Ttacer.
tremie grout cement fromibottom of hole after overdrilling
.13Gcolhertmt(Iieati2arCoalin Remnt) 00thcr(ex lain under 7u)
well. pour.bentonite pellets prior to overdrilling
J.lbatdwellis).ANindoned. 11-14-22
I�
S:i.We61 CaemiQt+iqg I+ i
Gaston County Landfill 'c as N ^p
8.Cer1lRe itlan• V '.r
r�ilimrithvnerNarrio t�xilhvtp�.(fapplicablc} ��E C0 r(� -8 2022 11/21/2022
l
3155 Philadelphia.Church.Rd,. D -;allas, NC.28034 �
Ph}s9 ,Address;Cttp,alyd Zrp $tefo t Ny.+.
WaPe
Gaston - eyswil"t !hm fir,': - ?ify Nu>rvjP c f irar/retire)trb damd JR1
Ct%uij li=eild,nt3Cie3ituitNn.(PIMi rrrs<rrrltrnerviftrdJ�€�rG�IG'Q"'C.01,00-or2C.0200WellGojuliucu&o ,Ntar kfs
and lfrdt•arnp),oftlrisrccurd 1*Aeeu proi z.'ed?b dre.n}ell duiier.
5b:;iatitm�doandlougittmdcindcgrnecslintnutes/sccranrtsrtrdedin lAcgrces:
(it:�tcll F4tcl it„c 4�b7oly:fs arri;cier ) 9.Site diagram or additional welt detaits:
You.ma}use t)te bac}:of tbts page to provide additional null site.de6j[!sof wV11
T� W abahiioinueui deiails You tua5 at ;utnr!►additional p:is if rseeeswry.
CONS-i R1TC'GItW,,b TA.It S 01;WCLL SV ligi R'fo AB;'ki111 014D SU13bTi7`7'AL OSTRtTCTION.5 �
:ftlridr sill cohstrarrlre,rt rtewii9(sl`tfnrrtllrarite fcv.irufnpre rrgectir'Ue ar rorim�u:a7'suirpd'p '
rrti!8e P?i\�bY miUr d}re dtrrrtt Eonsbrllitm ibrgruhi,rnicvlt,iwa can 3fiGrriil a+rt ftirnc i' '
Il9a;•Emir All'1Veltc Sirbmnii ibis farm Within 30 da•}'g of cotupletion or titrll
6a:�Ycil ID . W-28
abando intent to tha fallo'vin;
DIVIS.iirn of Water ROO ourtcs,lnfat ation-Prue�sima Unit
66.Total[tell depth., 58 A), Edi711LiifScMcc�critcr,.l2aleigG,NC 276 9--16t7
lOb.Rw[nice on Wells. In additlod to seadinu tlk:forum to We address lu IOa
f,G Ettim+zbole dlatnc#ew 2 �,,;) above_also submit[oue copy of tli�fonn s%id 6 30'days of cornptetion of wdi
:tlrriniiotnneul tti tFtc follaning;
fd,\dater I slbeto* mind sl rface�na (ft) laLvistan.4f WntcrRcSon..ei�,Uu�etgruuud 6ritectCau Coutrul Prgbr�inm,
1636 11Wb1 Scryiee Cck r,Ralcigh,&C 23699-1636
loc.Fir Water Sttnnh•&-1101NI„1F 'WrIb l: In addition to sending the foun(o
6c..Qutcrcasing ient tlm(if Imnwn): . (fr•) [lie:5ddress(es) abot•e. also subinit one copy of this-fonu tvitbiu 30 days of
completion of vieli obandannr:nt to the county hcsrtrr dep;uinmemmt or tlrc a ounty
M Ina&caslnotnlrir sg tength(if lirtnin): 43 (ft.)
wlum>r AxuWomucd.
i
6g..Scrcen leutNh(if Imoun)i15 00
_ I
Farm MI-10 Nonh Camaila l)etsuurCrJ df EIMFOOnmcot and Natumt Resomres-Dlvfsion of Watcr Acss I s Revised Arty 2013.
• I •

,NVELL ABANDONMENT RECORD Far lydc'malUscONLY:
6 faau cat)be ukd.for singhe or inuhip[�.i-a s
I...Well Contracwt?nformation: )YELL ABAN00NMEN'T.DCTAKA
I,
John Eisettman ?a,Nnmber of n•0h being abiindoned::1
ll'clfCouracfarn�ns (4r�tieltutcr pcison�IJyaUs� ti(ueocll.onlifstttcrprepFny) Fa• rrmJopfe m)aeuat ar Mrr-1i6f& srrpl . uralls. ANILY wilt) 81e smile
cxNicfrncficxl;aborrdoirrrr�7af,yin caRsnh h4iaforn,,
4439
NC Well Contr m6ff4ft1ekal2on-Nuirbci ?It.Arltrn;umsite retlnnee of Buhr ttc ainin iit"�iell(�}0 ( aL)
SAEDACCO Inc FOR. ATE.R$QPPLYNYELL51I.►1NLY
Campanp Namc' A.1}ape df disiufectunt 16(ed:na l
2.`Yell tonstructiou Permit a:,
1 �
111 I'll upp/hwdleuellperrnirs(.-C,,nR,Sta:",1`urliurafiy�trrit�.r7ell wn 7d.Ainountof.d6itifectant.ustdtna
3.1Vdl use(elbecicfVc luscj:
WaterSnpply Well:' - ?o.Scaling tria[crials tis_cd-(c6ccl:all tint ahplrj:
[irtarctihutat pblitniciptllYtititic, Ngti4"crtietitGmiit W Qcid4aitc chips orNiicts<
pfirotlurtn ut(Hcgtinq'Ggotina$apply)' die dentiul lVatcr SupPiy(sipgtC) 13 Szii&Gent6d Or nut- it .Ll Dty CL1y
t7huiusttiallCgmntcecial aRcsidential Water Supply(shatcd) 0 Coneretkrold ;. Li Dtill_Cituings
i
[7irti Gov b-Spec_jidty'Giout b Gravvl
Ncrn=11';ntee.Sapplvll' [l: CI,BeMonite 51ui Ci;Olher(eNplainuttder 7g)
®1liitititatiug- OItt covctj
injection Well: 7f.For each tuateeial-setected'above,provide atnoaut atntaterials used:
Detrjulfer Ri cGar4�e, . 1*3i6.ndiiaterdtentedWioif Neat Cem.•94lb ,Wtr•7ga1: Sand Cem.•lb ,Wtr•gal.
ElAqui6i Stopige attd Re ovet_v l7S:tliitity Barrier
Bentonite.:801b ,Wtr:gal.,
l7Aynifer Test. OStiivntvter�ntitiaee ,
EitVeiintental Tr�ltpo101n, t3Subsidepce'Cdi9Wl 7S:Fruiidc�t brief desctiptian of fire ab iudnnenent(eroec)lucsi
t7C>Eothertttal(Closed,Loop) C11Yacer. - -
fill well with bentonitei'chips then overdrill well to TD and
©Gcothettttaf(Eeittin�'Caaliu Retum3 ®Other('c.� lainuttd¢e7teT
tremie portland from bottom of hole to surface
l.,Datc"tvcll(s).abandditecld 11-14-22
Sa,Well location:
Gaston County handfill
F3eiltgfOnt>rNamo racilitywgorappumblel t;•Certlficatlou: DECtt Q 2022
3165 Philadelphia Church Rd,. Dallas, NC 28039 sue' `^ -=-;}.• -•.. .11/21/2022
r~=sue r =--�,11�t>y, a apt:--,• .mot rear
Pkysical Address,City:and Zip5EgFn r�.+;..gar, - �•s)-i�.-„ :.• t>,rrec.r 4; �,, 17iu
Gaston 13}'xt )ln�.ihr° �' t.,u —�:fy-11rIIt the u•ell(s)M•as(trere)ufiivuforred no
Count), ivatrcl!d,•.njjfk itlattNo.(PIN)' riccvixfirl;r n'fdtt Il I lyC:1C t12G,DJt7�:ur 3C.02f10 Tveli'CcitrSliurllori StlirirkmlS
artd'lhdt q cnp�op Yliisrccurd leas beeit providid..(o llteai e11 nailer.'
Sit..t ltiludc and lntigiftrelc in d6t ccyliEiit<uccwlsccnnds ar dccicn:tl degrees:
(iitvi6lt fakl,ors iJlonit:(s s4mioc,�> 9.Sho diagram or additionat ►'ell.detiitCs:
You.tuap usa Elie bac1;oCWts l fge to 01to ide additional still.site.details•or csell
I1 SV a6anriowueui details You t tas atso utnch addiiiotiat'pa s of mce sary.
Q-ONSTitUCTION.ItETAiL.S OF WELD%BEINC ABANDdNED SUBb11TTAi.INSTRUCTIONS
:tHnrlr well cur hwc1hai ,l••&m1thiple irJc+iprue.ur ratio-trirtar st,Nply'
xoflvONCYm)UrrlreavliKennsox�fioic4z+,i„rchi,rr�7,�ivacarrs�rb,ruriurejaim 14:0: For All Wr[is: Sub* they tams within
30 da}`s of cotupledon of well
6a.11'ell ID �MW-35 abandonment to flue follana
+,
Division of WaterRisoureis,Information Ptve,SIR Utut;
30 f61?stail Service eeiiier,.Raieigh,NC 27699-1617
6b.Total well depth: (ft) 1; ..
Il i
lob.Forinieealort Wcu :.ht additran;to wading Ui�f6ml to tGe address ta'l00
2 ':di
fe.8,orehote.dUnieter: oiv.also subnut.out copy of(hisifarnt tvidifti 30'days of cottiplelioit of well
(iu:} tlbiindonmemi to tlre,folla�tivc
IlivistoH_d WatcrR6L1mrccs,ZTH,L ri ntid'itijectipu Gonttul Pttigrutu,
fid,Watcrlcccl:bclmv gropnd surface:na 00 I63Cr lltaii Service Center,Raleigh,NC 27699-1636
6e.nutcrGising lcnr h(i$Imngn);- - (�1 40c inr'W11tgr Srmnle.�c-intectio l 11Vetla:. Tn addition-to:sending the fount to
the:addrzss(es) aboS•e, also sutinut.one this:, copy of thu -fo tdithin 30 days of
co Won of Ncell aliandottm nt to ilbc county iteuft6 department of the county
fif.tnoracasinWtubing,length(iflotown)e 15 (f�) iiI>rrt abtndtatxd.
6g..Savev length(if ItnotFn):15 A)
Fenn G%V-3Q 'North Caroflm Departrt>.:m of ERVimonutcut and Nuurat Rcsousccs-Ulvisian of Water PesourMs Revised Aupsst 2013.
I
i

,XIVELL ABANDONMENT RECORD
Mai Itaerrrtt Us:ONLY: i;
T9 foinr eau be'useil.ioi iingle.or(nultipte.Nit:lls'
1.Well Contradbu,,information WELL ABANDONMEN'T DE:TAR S
John Eisenman 7a.Number of iMis beiot;ab mila lictl: 1
�YellCao�tactDrNsare(grie�llotda j>Lr rially:'mare[aalaoa�tll.a�lfii911tcrpfepcny) Fdr muftipk 11f4'ctitl0lt or rauaa-iitiifer .strpph. walls• QVLY will MY -smnr
_ M+a"strnct+rxa,•irhoradoans�mf,]nrr it�r ti�af�illf reforrar�
4439
76.Apprnilmsitc tnlnme of*at",temainiut in:tiill(s)�. (gaL)
NE Weil ConlradorGcitifi tiou Nntrbci I I •
SAEDACCO Inc FOR WATERS; WRGL S 1!'T'X
S�atp nt+.Name
7e.Type wiG llisinfiYtatu ti3cil:na
I�
2:WeH Constr'uctlan Per(idt 0:
iw'rcn11Ppvuvt feiie!1parulit(.aCiwr:tvS&v.luraruxY,fitfetffurt_rdctffRmiwn 7d.ettno[tu(uf.d35ittfectalltuse4bas
3.Nell use-(elte�i:n'ell use):
Water Supph,Well: 7r:Sealing niateiiials 050(cl)sci;all that apply)
❑A tietilfuntl_ plviitnicip tlll'itlilic 1&Neat Ccntciit.Cinitt 13 13cn4otiRd Chips or'Nileis',
I7GerJtlrcrm tl(Hsahnr�Canlin $ttppl}'} 17Itesii#cntytl Water•S�itrply 6ipglc} I]Sa C¢mria!Gniut El Dry Cray
171tuiu5tria1fC4mntc�ial Mesidential Water Sriipply-(shared) O•Goneiete'Grout El,Drill Qu ags
l7lni flan l7 Spec:ialty Giuul O Gravel
Non-11'atcrSu ppty,Wcll ClBentbriRdSlan 0 01Eierteeplainutider7g)
�14Sonilodvg: ORtxpteiy
lstjSction Well: 7fa Foreacli'matetnal selected abocc;protnde amount atuiateriats used:
I 3rVquifeilt@chan�e �Grouiidrialer-1RemrdIatirin Neat Cem.:94lb. ,Wtr:7gal Sand Cem.:lb ;Wtr:gal.
EjArluffeiSianrge otrd Rego,� 31 0$aliirity Bonier
DAquffrrTest ❑S16imm*erDnifriag'e Bentonite.i301b ,Wtr:gal:
bk'xw irate'utal tk1u afogy- OSubsidenee'(2duaral i
7g:Proiide a heirf diL4HOtiori:nf th�1ab:indoamcat pro"firri
MhothernxtF(CloscdLoop) OTracer.
fill well-pipe with bentonite chips then overdrill well to
[30eothennat(Heanit)QrC0ofig_lietum) Mdwr(',x lain under 7a)
TD, tremie.cement from bottom of borehole to surface
�.Uatc'ircll(s).abandopcdc i1-14-22 1' '
-u ka �=�!
s .
Gaston Count Landfill
y C' 0 S 2022
r
8.Cet�l(lcatiou•
Tacilitp/QtiiacrNatric- rxilill;1DAI(t'nppticablo► - r
lnz;.;•rrl3',ion ?T;:,;3G-,;pa URlii/21/2022
3155 Philadelphia Church Rd, Dallas, NC 28034 _=lsij;T' -
PlaysicalAddtem;City.aiadZip Siaylr«„=� ;sSr c,-ice;• ,:=c'} �,;�t�: Uue
Gaston fl r Al iP elite ;S �•u:•-;.•?i >tfwt the nve)14 war i ere)m5midnhed nr
Couufj Parr:ci lder Ir4tlatt No.ON crrc�irrlrrtu�'trftlt 1 t i itiG-AC,02�C,Di(ld.br 2+^_4200 i iuR Cciti3Jiztctiuri Sfimikirds
and!brat a rnpj oftlris re'crurd kin bept provided tq,llrc.tirlj giriter.
5b.j ltittidc and longitude in degares7niinutesJscepnds:or dscini:ildiet ccsi
(if«cltCw4l,liralart%tupg'(snrtttci�r ) 9.Site diagratnioradditionalwcll,Jeeta[19:
You'645 use the bac&of this page to prgyidli additional%veft site.duaits of well
N `Y a 6andounterti detatis'You roar}also utacli ndditiouaf pates if tiecrssun'
CONI,4TRIICTIOLI.DETAtiS ON WI LL($)BF-[Nr.ABANDUIIED SLIRhi1T'i AL,INSTRUCTIONS i
dfwdr urll ronyiruelreut irruhiple ii4&dwe.rar min-harmv x rpph'
n ofde.0 VLk`with Ake svtrh cr�rsu�xtlolc'r�nrrtknH!'Ma►,ir�u can sirLarril arelFriitc Ift Mir All WON: Submil,this.fann within 30 4ya of completion of well
Gat.�Yeil ID#:MW-29 ab;indcintiieiit to ttrc'follolvin;:
Diyiiii6ii of Water kesourees,Information Micessing Unit,
Gb.Total tFcLl deptb: 22 (ft) 161711Lii$S niec Criiter,.liatt igN,XC 2'16994617
IIOb,l tr Lnlce(10 Well3: In addition to sending till;f
6cRarehole.dlanietcr:2 (iu:) orm tri the address in:loa
abo•ty,alsii sitlitnit oti8 copi or this Conn w�itblii'30 da}s of catupteliou of tell
albiiridourtienl to tlte,Cnllai`iugt l
hisltxi oY Water Riesourresi.Undergruund 6ijrgtlpu Control P.rig,rau,
6d.Wal cr letrO iliclow ground surfacee (ft:) 1636 Mail:Seiticc('cruel-,italcigh,KC 27G'99-I636
6c..Qutcr Casing Ica loc.rot Water Sum11W.&inirrtFu }Vl jW In addition td sending the form-to
t; tlr{if larnrrn}' (R} tlre-:5ddtess(es) abo. also afilimit lobe copy of this:f0ttii widiin 30 days of
comptetion of will abandonment to the county health:dcptttmtent of the county
rvhert;abandoned,
Gt:jnner'utsiugltnbinq.length(if lutunn): 7
6p..Scr&n Iengtit(if Imonn)t15 (ft.)
Mori GW-9Q Nonb Caro[lm Dcpartrrrctrl ofEmironurRni aLA Neural Resowncs-Rlt•is[on of Vratcr RrsouiRs Rc red Aqua 2013
i