Iredell_Well Abandonment_20230104

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CHAD HARTNESS 1.
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personalty abandoning well on his/her property) well constructlon/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2901 A wells abandoned: I
I '
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
AIR DRILLING INC FOR WATER SUPPLY WELLS ONLY:
Company Name
323866 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits#.-e.UIC,County,State,Variance,etc.)if known 2 CUPS
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well:- 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout N Bentonite Chips.or Pellets
❑Geothermal(Heating/Cooling Supply) Rkesidential 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 O Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwaterRemediation 225 POUNDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology OSubsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer POURED 225 Ibs BENTONITE CHIPS
[]Geothermal(Heating/Cooling Return) El Other(explain under 7g)
4.Date well(s)abandoned: 1-10-2022
5a.Well location: JAN C .4. eue3
VALERY HILL
urtir�illPrzn=�rvg Umi
Facility/Owner Name Facility ID#(ifapplicable) DA'Q/�,
OG
115 CHANNEL POINT LANE,MOORESVILLE,N.C.28117 -
r 110-2022
Physical Addressi City,and Zip Signature of Certified Well Contractor or!Well Owner Date
IREDELL 4614923309
By signing this forni, 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well;details:
350 29.583 N 800 57.535 `l, 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)tfovailable.For-multiple in or non-watersupplywells
ONLY with the same construction/abandonrnent,you can submit one form.
10a. For All Wells: Submit this!form within 30 days of completion of well
6a.Well EN: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 156 (fE) 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 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: (gt) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
I �
6e.Outer casing length(if known): (ft.) 10c.For Water Suooly&Iniectioir 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): Vt) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

fi
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JOSH WILES I
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(o"r well ownenpersonally abandoning well on his/her property) well construction/depth,only 1 GW t301 is needed. Indicate TOTAL NUMBER of
4547C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
AIR DRILLING INC �
FOR WATER SUPPLY WELLS ONLY:
Company Name
309397 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifknown 2 CUPS
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
OIrri ation O 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 26 BAGS
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stornwater Drainage
❑Experimental Technology. ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 26 BAGS OF BENTONITE CHIPS POURED
❑Geothermal(I-Im ing/Cooling Return []Other(explain under 7g)
4.Date well(s)abandoned: 1-12-2022
5a.Well location: JAN 0 •4 [U(3
MARr(HUGHES
Facility/Owner Name Facility IDS(if applicable) 8.Certification:
{nf�rvz •en Pr�v::C4' IJn
�//A-
127 SHETLAND PLACE, MOORESVILLE,N.C. 28117 �'PlG�r�rJG
1-12-2022
Physical Address,City,and Zip Si t e ofCertified Well Contractor or,Wol}Owner Date
IREDELL 4626985816
By signing this form, I hereby cert(/y 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
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has beers provided to the well mvner.,
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 34.211 N 800 55.683 `+, 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 records)ifavallable.Formultlple injection ninon-watersupplywells
ONLY with the Same constructionabandonment,you can submit one form.
10s. For All Wells: Submit this;form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
i.
Division of Water Resources,Information Processing Unit,
66.Total well depth: 117 (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: 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: A) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft) 10c.For Water Sunoly&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 casing1tubing length if known• abandoned. j
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department;of Environmental Quality-Division of Water Resources II Revised 2-22-2016

i
WELL ABANDONMENT RECORD Forinternal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NEILL PARDUE i
7a.For Geoprobc/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 1 GW=30 is needed. Indicate TOTAL NUMBER of
2609Awells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water.remaining in well(s): (gal,)
AIR DRILLING I N C FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
OSWO-2022-11069 7c.Type of disinfectant used: HTH
List all applicable well construction pern:its(i.e.UIC,County,State, Variance,etc.)ifknowa 2 CUPS
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural pp y)'
❑Municipal/Public ❑Neat Cement Grout 19 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
Non-Water❑I ater Supply Well: ❑ Specialty Grout ❑ Gravel
❑Monitoring ❑Recovery ❑ Bentonite Slurry ❑Other(explain under 7g)
Injection Well:❑Aquifer Recharge ❑Groundwater Remediation 7f.For each material selected above,provide amount of materials used:
44 BAGS
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stomtwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) POURED 44 BAGS OF BENTONITE CHIPS
6,
4.Date well 12-14-2022 -s)abandoned:
5a.Well location: jAN —
WINSTON MAYHEW
�
Facility/Owner Name lny"i'F!3"t"t� irzN.;5 s7
'
Facility IDil(if applicable) 8.Certif jt,t ti � QIOG
108 FORT DOBBS RD,STATESVILLE,N.C. 28677
Physical Address,City,and Zip tgnature of Certified Well Contractor or We 0 e 12-14-2022
IREDELL 4746400825 i Date
Count By signing this form, 1 hereby certify that the wells) was (were)abandoned in
y Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(if well field,one latllong is sufficient)
9.-Site diagram or additional well details:
350 49.341 N 800 52.310 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
Attach wellconstruction record(s)ifavailable.Forrrtultiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonment,you can submit one fornt.
10a. For All Wells: Submit this form within 30 days of completion of.well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 68 A) 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: 6 (in.) above, also submit one copy of this'!form within 30 days of completion of well
abandonment to the following:
t
6d.Water level below ground surface: (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 Suunly&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
6f,Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known):
r
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016