Mecklenburg_Well Abandonment_20230315

r i
' 1.Well Contractor Information- /) WELL ABANDONMENT DETAILS
Jci /'i 0 --�< eeC® '�'z/% �
/[- 7a.Number of wells being abandoned: /
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
C :,,s . A- consiniclton/abatdonment,you can submit one form. / �
NC WellContractor Certificattiionn�N�u�mbeer y� 7b.Approximate volume of water remaining in well(s): 4L/% (gal.)
. 5 C ,$ ,i2�d'"`CO//G/ ' 1,t 6L- C. FOR WATER SUPPLY WELLSIONLY: !!J
Company Name �i, /
/r7�^ "�/�1 7e.Type of disinfectant used: v�t/4-41- �`
2.Well Construction Permit#: C/ V 5---
, ,_._ `'-5
List all applicable well permits(t.e.County,State,Variance,Injection,etc)if laio+ivi '---
7d.Amount off disinfectant used:
3.Well use(checkwell use): MAR 1 5 2023
Water Supply Well: l 7e.Sealingmaterials (checkapply):
❑A cultural 3'` "`:„,:2n ,,rt7:;.. 'st3 ii r used allllthata 1
b'ri ❑Municipal/Public,:Q J G ❑Neat Cement Grout ❑Bentonite Chips or Pellets
OGeothermal{.Heating/Cooling Supply) .❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dr Clay
0 Industrial/Commercial l�idential Water Supply(shared) ncrete Grout 0 Drill Cuttings
❑Irrigation • ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Shiny 0 Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each terial selected ove,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ! e0 selected
0Aquifer Storage and Recovery ❑Salinity Barrier 111
❑Aquifer Test ❑Stormwater Drainage C C4jG`•el(
❑Experimental Technology OSubsidence Control 7g.Provide a brief description of the bandonment procedure:
13Geotlrermal{Closed Loop) OTracer "OM_ / 1 be'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date wells)abandoned: A "
Sa.Well location:
7- .771,-Cie.... ,
Facility/Owner INK Facility lDtl(if applicable) 8•(rertillentitin:
Physical Address,City,a d Zip gnatur�fiied Well Contractor
Al r(� ell Owner '73 Dat
YU� i By signing this form,I hereby certify that t4be 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 iat/lon issnf icient) 0 9.Site diagram or additional well details:
-� L O £ 3 You may use the back of this page to provide additional well site details or well
(v'l�IN abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constnrction/abandonment,you can submit one form. 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: 2/4T (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 •
( i( 10b.For Injection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (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: `-� (ft.) Division off Water Resources,Underground Injection Control Program,
1636 Mali Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): it� (ft.) 10c.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
6f.Inner casing/tubing length{if known): 1 5•- (ft.) where abandoned.
6g.Screen length(if known): r/ (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
1

. ,
WELL ABANDONMENT RECORD
rot initunal Usd ONIX:
This ram cin be used for single o nimbi&wells
JULI-j\
I •
I.Well Coritraetur Information: WELL ARANDI/NIVIENT DE:PAILS ,
1.
Stefan Smith. 7a,Number of wells being abandoned:
Well 1.1;Oinraefor Montt or%tell Onaidp.e6nalli,iiitatkiiining nett on lifsiber.Orapeny), hir ondopie no:alio-Jr or g I oa=ketir ..'npidl. wells. .ON web II LY e •some
conaore0onvbandrf'meet,pro can.intAdtHe.ihon,
3576-A l• . .
71i.APprniintate illlitItle of water rentairung ru"siell(s)?1 (gaL)
NC WeliConrdraorCettilication-Nantai E.,„-/, :„,„r? ''''- - .: , Tr.r-, • . • 1. ; -
,: -.
—-' ' •---,•-• .]
SAEDACCO Inc FOR WATER SUPPLY WELLS ONLY:
Conivany Name. MAN 1 5 2023 7 .Type of disinfectant uSetl: 1
.2.Well Construction Penult 070003116, ./.r..-7,-.71 Pr-'-
flit ddl ei.rpheakte well permits'iie.Coenty.Se .de Yorioree.ligeoirmeirdtijjiai
7d.Anuittul.oftlisinfeetaut used:
3.Well irk(check well use): • - - - • ' • ' '
Water Supply Well; . 7e.Scaling Materials used(Cheek all that apply):
I0Agrieultucti 0 l4funicipa liPtiblk.. di Neat CeniciiIgrout - 1=1 13creonte Chips or Pellets..
.•
0(lecalterited(BcotingiCooling Suppl)) gResidential Water Slipply(single) ElSainliCentent'Oren .13 Dry Clay
. .. .. .
0 IndostrialiComnicrclot Oftesidentin Water Supply-(shared) El.Concrete,Grout . El Drill Cuttings •
13 ktiption • . • b Specially Gimil •b'drawl • •
. -
.Non-Watei..59 poly'Well;
lid 13entdoite.Slupy Cl Oilier(ert-plain under 7g) . .• .
, DllMonitoring. ,ORecovery
-Injection Well: 71.For each material selected above,proside amount-of Materials used; . ,
ClAtiniferlteeborge . pGreindtvaler Rentediatian Neat Cera.:941b ,Wtr:8gal.. Sand Cers.:lb ,Wtr:gal.
ClAquiter SEOpig6 acre it..0i;hvery OSahrity Harder• . • .
Bentonite.:11b ,Wtr:gal'. •
CIALliilikiTeM. OStornimmter Dog/take
OExperinentoi Technology .1.3$6sidence Conn! 7g.;Pro Vide:a brief de.scriptimi-of iiii•aboutinument procedure:
OGeothennal(Closed Loop) . EITIracer
Pulled entire well and grouted.
GIGeothormal illeatiogiCooliog Return) . 00ther(explain under 7g)
. .
4.Date wills).robandoned; 2716-2023. -.
____________,•_______H____•_____________________ -
Su.;Well int:adult:
. .
Sealand Contractors/Space Craft
S.Certification::
Facility/Owner Nam Fa:41V Me(trapplicablci
525 Parkwood Ave.. Charlotte, NC 28206 1 2/17/2023
Physical Addron..City:aid Zip • .5.k...gina,,-.Cmined Watt Coarmaaer or Well OWDer Vine
. .
Mecklenburg 08304212 . - fly,visrpirkg iN.V,/iii,:I hereby certifj..!•that she irell(S1 was pvere)abandoned In
catinty - PorcalIdantirt6t1sit NO,(PIN). . ricatihuire with li-f:!..V.,IC":02C,0100 or X-.0200 IT'141 CondirectiOn Staadards
. .
. . and Mat a copy of dr.e.i rcc rd has boen provided to the well owner.•
Sh.-I.atitude-and langiMitein.degreegaliontestsceoods or deciavid degrees . .
(itwi;la rokl,out latiloikstSsollickei!) 9.Site diagram or-additional well details:.
.... You May use the ba,ch-Of this page to-previde additional well.Site details or well
N • - • - W abandounten details;.You may aLSirattacit additional pages it nece'ssary. ' •
CONSTRIIC.TION.OETAIIS OF WELL(SI BEING ABANDONED .SUBMITTAL INSTRUCTIONS,
Affair vy,f,cYliqtrdIditil2 rikyr41(s)'.if uvinfebtr...grir,trealtiple liffriEritik or-rkin.irater xuppti, ' ..
*els ONLY.wag'Ilk,511111e.a.Nrattkrif?!7424/0.011Lyit,pitl cr4i-/mrbirti?tom,Aim. 10a. For All Wellsr Sulpnit this fawn within 30,(Joys of completion of well
6a.Well 111d;Tmw-.1
abandnuncin to the following:
•
Division tif Wager Restuirci ,Infortnation-PrOenising Unit;
1617(4.1all'Scrvicc ....etiter,,Raleigh,Nt 27699-1611
6b.Total Well depth: 16 _ (ft.)
IOU.For In iccOott Well ; In addition to sending theforakto"the address in-ign,
aboye,also sobiall.one copy of this fiann•witliitt'30 days of coMPletioit of well
6e,Borehole diameter:1 - _ Ow) abithlOtaitem to die fallowing':
•
•Divislontif Water Itiotinies;Uuderg. round hijection Cantrid Program,6d,Water:level below ground surface: 13 (ft.) . . .. .
1636 Ntoil Service('enter,Raleigh,NC 27699-1636
10c.For Watt_Sunolv&Iiiicctinn Wells: In addition to'sending the form to .
6e,Outer casing length(if known): 6 (ft.) tile tiddre-ss(es).above, also submit,One copy of this foun Within 30 days of
completion of well abandonment to the county health:department of the county -
• whom abandowd,
6f.Inner easitiWtithirtg'length(it known): (ft.)
6g,.Screen length(if knots n):16 (ft.)
Fame GW-30 Non)Carolina Depoitinent of Environnigni aft!Natural ftesonmes-Division of Water Itesources Revised August 2013.
! , .
1

• WELL ABANDONMENT RECORD Forintenl:tlV ONLY: .
This form can be used for single or multiple wells
I.Well Cantractur infm•tirution: WILL ABANUf1NILM ENT.DETAILS
Stefan Smith act,Number of wells being abnuduned: 1
Well 60112Cielbare(of st�lr Olt rs`fllC15011a11yLlbafilOrtlilgfiO11.91(1iL4iilefpfal7C fly) rror rnulnpie lrlt+'rrfoir or von-neater s)rpt!)1, wells. .ONLY korrh NW •folk,
coniThretioaii7bolYlriirowitt.ltrn ci,,•17rf41nt Wldflr n
3576-A f77 ri -, I.---',
. :,.
NC Well ConlrlporCenificiliou Nitubcr k �_�'�b ` --.�..._ lb.Apltrnsinratc volume of water t to iinin in tit cll(S)?1 - (nuL)
SAEDACCo Inc MAR 15 7073 FOR WATER S.UPPLYWELLS ONLY:
. Conran-Name. '7e.Type of dbinfectant u3ed:
In 4-; 1+-❑ Pi _;., c_.,o 'lnt .•
2.Well ConstructionConstructionPermit#:70003116, , r., :. ,',-,,,;•�._
Lai di t,dp@Cable ire permit,'G.e.Crnlnfr,Are.d'arlruwe.lificit owietc.1 If Wool 7d,7ltnonni of disinfectant used:
•
3.Well use(clieckwell use): .
Water supply Well: 7e,Scaling materials used(chock all that apply):
• ❑AArieultund ❑i innicipaliPublic• .12,NGit Ccnreut:Gnont la Ben onite Chips or Pellets.- • •
O thoikermil(Elcatingi'CooliugSupply) . ffcsidcntiul Water Supply(single) ❑SandC., Mall Gmut ❑ Dry Cby .
❑Industrial/Comntcrciai ❑Residential•Watcr Supply(shared) El Concrcfe'Grout ❑Drill Callings
❑lunation • Cl-SpecialtyCiott -• O Gravel .
Nun-Water Supply Well: iN BentoniteSltnry _ El-Other(explain under 7g
®hlouitoring ['Recovery
injection Welk if.For each nraterlalselccted above,provide ainnnnt of ntatcrials used:
❑Aquifer Recharge ❑Groundwater RentedL•nian Neat Cem.•941b ,Wtr•8ga1. Sand Cern •lb ,Wtr•gal.
❑Aquifer Storage rind Recovery ❑Sulinily Barer
❑Aaluifer Testy ❑Stornwater Drainage Bentonite.:llb ,Wtr:gal..
piNmeiintenlol Techuulo r '• DStillsidence Caitt_uil 7g.Preside.a brief description of the ab:indimment procedure:- .
EiGeothemmal(Closed Loop) EiTracer
Pulled entire well and grouted.
ElGeodiennataleatint/CoalingReturn}'.JOther(explain under 7a) •
_.
d.Date wel(s)abandoned: 2-16-2023
•
Sa.'Well location:
Sealand Contractors/Space Craft
Facilltrtf_wrgr Nrunc Facility UM tifnppli.;abict R.Certllic rtiaiii:;
525 Parkwood Ave. Charlotte,.•NC 28206 . . �t+r�Yj.. C-if 2/17/2023
Physical Address;City;acid Zip Sit-Ohro ctitrell Well Coiur.ioor or Well ureter Dale
•
Mecklenburg 08304212 lit'signing this inn, 1 fw p-certifj tint the tid44 tras(were)ahanrlosicel in
corinij' Nigel lrtaitifiCiunir No.(PIN) rtixvnnlmc•rr with l CrIC 02 2C',alit°or -.0200 1re a+in m 11 Coristiltr Stoodrt/s
• and that u copjr of -I`�tlris record/ttfs becvr provided to the well owner.:
Sb;,Latinrde and longitude in dcgncesintinuteslscconds or decimal degrees: •
Orwell road,Oaf latilung is suiticicla) 9.Site diagram or-additional well details:
You may.use the hack of this page to provide.additional well.site details or well
. • N . . . •. . • W abandonment details'•You may also-utach additional xigcs if ucteesssaty. ,
C(INSTR11C ION.11ETAtL-L(iF WRLL(S).BFINC:ABAND(iNI.D .SJBbirTTAi,INSTRUCTION. •
:Math nell cvnarucliaau racvrd(.)if aiiilabk.•For irranprr it jettfain.or•rvnri-water suppiy
w•e1Ls ONle t•1i•ith the Mite ty tal:OCr, r-a•!ounh,ltiac-nr,_WO con;it/nail are fui n. ioa: Fur All Wells Submit this fem.within 30 days of completion.of well
abandonment Mille following
60.Well ID#:TMW-2
Division ui'Water Resources,.lnfiirmation-Prucesring Unit;
1 16 • 1617 51nil Sentice'Ceatcr,.RLmlcilgh,NC 27699-1617 .
6b.Total well depth: (ft.)
• lob.For inlection Welk: In addition to sending the brat to the address iu t0a
6c.Ilomehole.d:tnieteo 1 (ill;} :lhut•e,also submit one copy of this form within 30 days.ofcompletion of well
abnudommnent to the fallowing: ,
•fill.Water lcvcJ-holm►ground surface: 13 (ft} •Division of Water Risourees;Underground brjec(Ion Comfit'Pitigratu,
. 1636 Mail Bowleg;Center,Raleigh,NC.27699-1636
6c..()uter casing length(if lamina): 6 (ft.) 10e.,For Water Snunlr& tnjectisin Welk: In addition to sending the form to
- the•address(es) above, also submit.one copy of this fort Within 30 days of -
completion of well ahaudonment to the county health-deportation of the county
where abandoned.
6f.Inner easing/totting length(if known): - (ft.)
•
6g.Screen length(If kuoan):10_ - - - - (ft.) .
i
Feint GW-30 North Carotlta Dcpauin n1 of Environment aril Natural Resorerci-Division of Water Resources Revised Augur 21)13

WELL ABANDONMENT RECORD For i1 ONLY:
This foist ant be"used for single or multiple wells .
1
I.Well Cantractor lnformatiOn: WELL AIANi)f1Nh1ENT DETAILS;
Stefan Smith 7a,Number of arils being;abandalnerl:.1
WeRC'eurmnorNanteotl+ llutit�persaiedly.ulantdnine'. 1lesIiisrh.ergirepcny) 1w r:„tln�,rt. wawa( or am-water supply malls ONLY wr11r flee -some
c?rtetnrcrtamabandon tnnt you ennsnlmat wraitrra,
3576-A
d---`,-.,,1._'i V'Z.:71t.APprnitimate•valuine of Ovate:remaining in Wells)'1 (gaL)
NC Welt Contractor Ccitiftcalion Nnnirer
SAEDACCO Inc MARI 5 20?_ FOR WATER SUPPLY WELLS ONLY: •
Company Name. 7c.1'y pc of disinfectant used:
2g Welt Construction Permit 0:70003116, , C Qi<:;'.�= •
•(.Lit rrdl uppltcoode(sod wain&tie.Claud);Am!,l urliurce. ection.rtr i ifkruwtr • 7d.Amount of disinfectant used:
3.Well use(check well use): '
Water Supply Well: 7c.Scaling inatesigds used(cheek all that apply):
17;3.grtculturd ❑hiimicip;tl/Publie, bt Nast Cemetit_Crroitt El Bentonite Chips or Pellets.,
OC eothermal(llcating Coolirt Supply) ORRcsidenttal Water Supply(single) 0 Sand Cement Giunt ❑ Dry Clay•
❑lit ii trial/Comntcrcial' ❑Residential Water Supply(shared) ❑.Contrite Grout ❑Drill tinting,'
❑Inietrlion ❑Specially Grunt 17 Gravel
Nan4Vater.Supplr Welt: . IX Beptonite•Siam• 0 Otter(explain under 7g) .
Elhlonilorine ❑Recovery
Injection Well 7f.For cacti matcriad selected above,provide amountof materials used:
❑Arpilfer Rec[targe DGrouridn uer Rentediation Neat Cent.:941b ,Wtr•8gal. Sand Cem.:lb ,Wtr•gal.
❑Aquifi Storage ant Recovery ❑Salinity Ranier
❑Aquifer Test MS intimater Drainage Ben---__- .:llb ,Wtr:gal.
❑Eepeiintental TivIrnology • °Subsidence Control - 7g.ProVLde a brief description-of the abandnument procedure
°JGeothermal(Closed Loop) CiTracer
.OGeothemul(Hattintc'Cooliug Return}• . DIOther(explain under 73i1
Pulled entire well and grouted.
4.Date well(s).ahandnnctl:2-1672023.-
Sa.•Well location:
Sealand Contractors/Space Craft
Faoilit)ithus r Ntunc Facility IDs(iiappti ablei ft•Ccrdilicatig%
525 Parkwood Ave. Charlotte,•NC 28206 fI 2/17/2023
Physical Address.City,-and Zip .S.-liioe Cattier'Well coturr.tnr nr Well Ow'tsr Dim
Mecklenburg 08304212 • 13v smiling this farm, 1 hem by cs.rtrfy.11na the rrd11{s1 urs(were)abandoned nt
Gaming . . Parcel Idaniifi'Ilan Na.(PIN) uuv choir atidlt IS \\CAC 02C,0100 or 2C.0200:Welt Cotislntclion Standards
and dlrnt a copy ofthis record has been gravid&I.o?he.well miner:•
Sh.I.stittidc and longitude:4 degrecsitit€nutcs/sccnnds or deeinutl degrees
(itwcll t`u;td,tare Istitong:is auiriexts► 9.Site diagram oradditiooat well details: .
You may.use the back of this page to provide additional tmt,lt site details or well
• N W a ha ndonnten1 details. You may also•attaclu additional pages if rrecessaty_
(:oNSTRt1cTit1N.DETAIL.0(FF WELL(S)REIN(:ABANDONED .StinitifTTAt.INSTRtTCTIONS
:toot t,.rtd con.Wlictlaa max:i4l 1 available. For nrnTplr ugfect1ea or ova-water"supply
tit*ONL1'.1110)IN,a one a Marecreu r'JtrrurchtglWrlr.f art rare serf mr1 wee felon. ➢Oa: Fur All Wells: Submit this farm within 30 days of completion of well
6a.Weil[D�:T -4 abandonment to did following:
Division of Water Rcsauries,lnformntioon-Pr tcessing Unit;
1617 4i[1 Service Center,.Raleigh,NC'27699-16L 7
6h.Total well depth: 16 - Mt.)
lOb.7;ur frilce ietn Wells: In addition to sending the feint to the address in lO
above,nlsu submit one copy of this.forts within.30 days of completion of well
6c:-t3orehole diameter:l (in.) abandonment to the following:
ITLvislou.of WriterResuurces,Uudergruurid iujeetimr Control PrOgruin,
6d,Water tevcl..hcion.ground surface:13 (ft.) i636 lltnil Service renter,Raleigh,NC;2 7 69 9-1636
•Ge..(lntercaging length,(ifimntrn); 6 (ft,) Itle,.Fur Water Snnnls& hitsction'Yells: In addition to sending the form to
the•address(es)•above. also submit.one copy of this fbatt Within 30 days of
completion of well ahandontnent to the county Iteatth depannteni of the coinay
6E Inner easing/tnbing length(if(mown): (ft.)
where abandoned.
6g.Screen length(if Nam a):10 (ft.)
1
Form GW-30 North Carolina Department of Environment aryl Natural Resources-Dh-isian of Voaler,Rtsmutes Revised August 21)13

WELL ABANDONMENT RECORD Forlttleni:att3s ONLY:
. Tills-form c in be•used for single or multiple wells '
,
I.Weil Contractor information: WELL ABANDONMENT DETAILS
•
I
Stefan Smith 7sa.Number of tvt'1L,being abandoned: 1 '
WeliCotiraeiorNank((irtyclloure prsotcally_.aUan.dningceIlauliistherprepcny! For too/tote trfccloir or taut-rt'[trcr smem) aw8s ONLY teeth lire uteme.
rv;osrieetavvoSwrriunmrnat,,tart calf,+rthrrut care firnc
3576-A — I
NC Well ContradorCenifacation•Nnni�ci C ''.;.� 4,,,, ... r'r'i -„
E� 7b.Apprnilinete volume of wat�'reinaining in well(r)?1 (gal.)
SAEDACCO IncMAR 5 L L c .1 �}o�}3 FOR WATERSUPPLY writs ONNIX:
Cowan).Name 7c Type of disinfectant lifted:
2.Well Construction Permit t!:70003116;",` ' ',....,,. ,`''' t.;;
liar tell a rpttcoite Well per itiav ri.r_Cvttuft.State.}'urlmroe.fi eti iiV,rtr rt.7.miarrt 7d.Amount of.disinfectant used:
3.Well use(check well use): -
Water sap(iiv Well: 7c..Scaling materials used(cheek:ill that apply):
ElAgricnititoit Eli4onicipnliPttbtic Gd-.Neat Ccmetit.(mitt ❑ Hciitonitc Chips or Pellets
❑(icotltcrmad(HCgtii Cooling Supply} [Residential Water Supply(single) ❑ Sand Centenl Grunt ❑Day Clay
❑Irtdusirial/Commercial [Residential Water Supply(shard) ❑.Cciuetete'Grout D Drill Cuttings
❑litigation ❑•Specialty Grout 17 Gravel
Non-Water Supply Well: ❑Bentonite Shiny ❑artier(explain under 7g)
Ehlonitorine ❑Re*uvety
injection Well: 7f,For each material selected above,provide amotrutaf in:aerials used:
❑Aquifer Recharge ❑Groundt)ater Rentediiuion Neat Cem.•991b ,Wtr•8ga1. Sand Cem.:lb ,Wtr•gal.
❑Aquifer Storage ant Recovery ❑Salinity Barrier
❑Ailuift lest. . ❑SlorinwaterDrasllrnaee Bentonite.:llb ,Wtr:gal.
❑Expeinrtnutul Teehttsitog_a' • DSubsidetre Contrail 7g.••Provide a brief description•of the•abandonment procedure:
L`IGeotbennal(Closed Loop) OTracer
Pulled entire well and grouted.
DGcothemtal(HesttinPJCoalins;Return) fJl7titer(explain under 7tt} •
d.Date well(s)abandoned: 2-16-2023
•
5a.Weil location:
Sealand Contractors/Space Craft
Facility1O'ra:rN:urie Fa;ilily 1Dg(iIappti;ab1e1 li•Certification::
525 Parkwood Ave. Charlotte, NC 28206 • .,. 4 Vj`/d7/J7t]i 2/17/2023
Physical Addn;ss.Citp,aand Zip Slu,..a re:?.Ceslirigd Welt Co ttlrt.lpt or Well o to Wie
Mecklenburg 08304212 By Swaim;this firm, 1&ettbp ecrtr(y'•thnt Me tt'e11{s) was(were)uhltrufatned in
County Pared ltlanlif ii ttlau No.(['IN) octal•drrtice with 1.5.1`+C.IC 02 C,P100 or 2C.0200 welt Ct istrtlt-rl,r;Seth:&trds
and trot p copy ofthiv record hos beat provided to the aid owner.
51);,Eatitvde and longitude:in.degueev(ntinates(seeonds or decimal degrees:
(if.vclt card,one tit hens is sutricteta) 9.Site diagram or additional well details:
You.inay:use the back of this page to provide additional well she details•or well
- - - - • N _ W abaudomaieati details. Yon may also attach additional txtges if necessary...
(_7IDNS'I-R11Ci7(m lw'I'AILs OF WELLS)BEING ABANDONED SUBMITTAL,INSTRUCTION
:laud,mall corarlrnwiiutt rccvr.11st ifuroilmrile. 1'rr multiple infeM uc-err rrnn•tran'_.uppIi
wefts ONLY belle ilk,stamp avtrstrtkleMeikaaloitecpr.iisemt.irbhnl are furirt. IOa: Far-All Wells:- Submit this forts within 30•days of completion of well
abandonment lb the following;
Division of Water Resuures,information Prveusing Unit;
6b.Total well depth: 19 (ft.) . 16i7Mail Service Center,,Releigh,NC 27699-1617
lOb.For inledlon Welit In addition to sending the fonat.tu the address to 10a
6c.Borehole dlanieter 1 above.nisi:snbaatii one copy of this-form within 30 days of coiuptetioit of well
(in.) abntidonnteut to die following: '
Divisiottof Water Boon rces,Underground injecttun Control Pregratu,
Id.Water level below ground surface: 13 • (It.) 1636 Mail Sen•ice Center,Raleigh,NC 27699-1636
6c.Outer easing length(if Imowa); 4 (ft.) 1 Oe.j n r Water Su pph'fi.Galstiota Wens: 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 ahandinmient to the county health department of the county
f.-Innereasing/tnbinglength(it'known): (ft.) where abandoned,
(i
6g.Screen length(it'knoll n):10 _(ft.)
1 !
Fern GW-ail NonhCaroilm Dcpannxm of Emironntcnt aryl Natural Resoicecs-Division of Waterkcaourcs Revi cd August 2013

WELL ABANDONMENT RECORD i ar Internal use ONLY:
. 'i its foitnianlie used.for single or mulGpCe wells
I.Well Contractor lnforniationi WELL AiIANUONNIENT DETAILS
Stefan Smith 7a.Number of nigh being abandoned!:.1 .
Weilteirrraeror Nance for well owoer Per rrally:Ohomiflating well on liisIher irelierty) For raulnp& .ovecttwr or non-nuts, supply ertUs ONLY i uh the scone
rnaantctxsiabanlanmcn )nrreau.ifilunitratafrrii
3576-A
1' +._ �. rt.- . •e'•?sn... 7b.Approximatevolumeuf water rernriningintvell(s)?1 (0aL)
NC Well Coniraclor toil lfir,ilion"Nitutet g `
SAEDACCO Inc MAR 1 5 2023 FOR WAFER SUPPLY WELLS ONLY:
Company Nance nil7c.Type of disinfectant used:
2.Well Construction Permlt 0:70003116, , rAvoi7%,0;
list d1 aliplktibls uelllarmiir(%e.Cwrrety.Slstc.YuHancc.lidectiorr.rle}ffbtruwu 7d,Amount of tlisinfectamt rived:
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials rased(checkill that apply):
OAgrieilturat OloitnicipaliEtiblic. l •NeatCcntetit:Groat ❑ Bentonite Chips or Pellets:,
q(icothcrmal(Heating/Cooling-Supply) •❑itcsident[at Water Supply(single) ❑Sand Centeiat Gttiut El Dty Clay.
❑ItaluslrialiComntcreial ❑Residential Water Supply(shared) ❑.Coucretc'Grout ❑ brill Cuttings
❑Irri •tion • i7 Specially Gieut O Grav-el •
•
Roo-Watcr.Supply Well: . bfl BentoniteSlurry . °Other(explain under?g)
Elidunitoring- ❑Rectnety. .
injection Well: • 71.For each material-selectcdaboye;provide anroitntof.materials used:
. ❑AquiferRecharge ❑GmundssaterRemedlatioir Neat Cem.•941b. ,Wtr•8gal.. Sand Cem.:lb ,Wtr:gal.
❑Aquifer Storage and Recovery ❑Salinity Barrier•
gentonite.:lib ,Wtr gal.OSlnwaterDl e ------------
.
•
Eii l ol •
OAperrentuTctuogv []Subsidence COMM 7g:Provide a brief description of the abandonment procedure:
°Geothermal(Closed Loop) °Tracer
Pulled entire well and grouted.
CIGeotberrml(noting/Cooling Return)• . ❑Other(explain under 7}t)
4.Date well(s).:ihandrmett: 2-16-2023
Sa.Well location:
Sealand Contractors/Space Craft
racilitpe't er Naive Facility 1Ds(ifnppli able) 8.Certi(icalioil
525 Parkwood Ave.. Charlotte, NC 28206 ,r ,,YIj 2/17/2023
Physical Address:Ciip,-arid Zip SS5..ltine%`-.Ccitihed Well Caiurtrtnr or Welt Osu r Date
Mecklenburg ' 08304212 By.m'nfna this finan, 1 luarby certify-l/mt the well(c) wry(Were)abandoned i a
Canopy Darrel Id2thL ni0ait No.(PiN). ricxortlartee with 1.i;L.;\CHIC 02C.0100 or 3C.0200 TYell Ctuit'tratciioii Standards.
•
• and drat a copy'aphis record has been provided.la ihe.n.e11(Saner..
Sb._Latihu e'and loniitude ln.degrees/minutes/seconds or decimal degrees:
(itweit Ctil(1,ow:tatitwrg is willeirro) 9.Site diagram or addition:well:details:
You.tna_use the baelk of this page to provide additional well site,details:.or well
N - ' W abandonment details` You may also-atiach additional pages if necessary. '
corvsrRIIrrlorinETAII ti OE WELL(St BEING ABANDONED .St1RATiTTAT.INSTRUCTiONS
:tltarh rvrlt crras}raciiure rccoret(s)'if mwwhthle. ,1 or ran/nptr injection or'roo•aatrl'shpplt'
nelur ONLY:ii ifh the Slant:rvroo-o fiuwotuureloynrmt.i+ia can zahrtil wee felon. 10a: Fur All Wells: Submit this fumy within 30 days of completion of Well
63.Wen IDO:T -3 abandoumentlb the following;
Dlv'islitn of Water Resources,Information Processing Unit;
66.'Tot:tl well depth: 16 (ft,) I617 Mail Service Cetiter,_ltaleigb,NC 27699-1617
fob.ForTnlec_tion WellS: In addition to sending ihe'form to the address in 10a
6c:Borehole diamietere 1 p: ribove,also submit one copy of This foun within.30 days of completion of well
abtituloimterd lu the following:
.Division of Water Resort rccs;.Uudergraundiujection Couttvl Pnigratu,
rid.Watcrrlevel below grotind stirfacci 13 (ft.)
1636 Mail Service Center,Raleigh,NC 2 7 69 9-163G
Gc.Outer casing length(if Imntrn): 6 (ft.) i0c..rot' mi Water Slily IC;infection Wills: In addition'to sending the form to
tile:address(es) above. also submit.one copy of this fomt Within 30 days of
completion of well abandonment to the county health depatintent of the county
6f.Inner easing/tubing length(if known): (ft.) where abandoned.
6g.Screen lingth(If Imown):10 (ft.)
Fami GW-30 NorthCarolkre Dclvuniml of En ironment aril Narurat Resources-Division of Water rterou yes Revised Anglin 201.3

WELL ABANDONMENT RECORD Far internal l t)sc ONLY:
This loan can be'used.for single or muiliple wells
I.Welt Contractor information: WELL ABANIIf)NMENT DETAILS
' Stefan Smith 7a.Number of wells being abandoned:.1
We11'Coutractor Name Of well oict persdrtatly.abanidnLro well.on Eviler properly) rcu' rindaple. Infection w nonimite:r .supply wells. ONLY with Nte sane
3576A 1r' 7 . ".
c�irt�Yrrraits edhin onowen,,tnrrcatr,mr,mlVi 3f,rrn,
.— `_'1,—= +. ' . 7h.Approximate volume of water remaining,in wells' (dal.)
NC Well ContrtdorCenitiwtiotrNnnaber $' :
SAEDACCO Inc MAR 1 5 2023 FOR WATERSVPPLV WELLS ONLY:
Contyan•Name. .: _.__ •• rz--.,„_ 7e.Type of disinfectant used: '
2.Well Construction Permit 6:70003116, , r"�._, E
L ta11 nl, ii vie aelllarnn ae.Comfy,Srutd.Liadmece.liyeziiin4,e1ea lfRnuwrt 7d.Amount of disinfectant used:
3.Will use(CLcdcwell use):
Water Supply Well: 7e.Scaling Matreittls users(cheek all that apply):•
❑Agrinuitttm) Ohituiicipal/Pubbe. ,6d•Ncat Ccittetit.Groait 0 Rcr4onitc Chips or Pellets
❑Clcndtennal(Hcatinr(Caoling'Supply) ❑Residential Water Supply(single) ❑Si►id Cement GmIIt O.Dry Clay
❑haiustrial/Commercial ❑Residential Water Supply(shared) ❑.Concrete Grout ❑Drill Cuttings
❑Iniatiou Pe'
0 Specially Grout d Gravel -
['tin-Water Su pp ly Well: 01 BentoniteSlmy li.Other(explain under 7g)
• . ElMunitoring_ 011ecoten'
'injection Well: 7f.For each material selected above,prmide amount-of materials used:
❑Aquifer Recharge ❑Gmuitdw filer Rentedbtion Neat Cem.•941b. ,Wtr•8gal Sand Cem.•lb ,Wtr:gal.
❑Aquifer Storage aid Recovery ❑Salinity Darricr• •
❑AquifetTest ❑SlommaterDnitrtagc Bentonite.:l]b ,Wtr:gal.
❑txpemiienlal TeCIIt1OIO V ' USubsideixe Central 7g:Pattide a brief description-of the abandomncnt procedure:
DGeodtemial(Closed Loop) C1Tracer
Pulled entire well and,grouted.
®Geothennal(Heating/Cooling Return) 00ther(explain under 7g)
4.Datc tfell(s).ah,indoned:?716-2023,
Su.Well location:
Sealand Contractors/Space Craft
FacilityiChro;r Nome facility Ind tirappiicabicl R.Certification:.
525 Parkwood Ave. Charlotte, NC 28206 Y)qj 2/17/2023
Plrysical'AddreSi.City:aiid Zip 5!t-it tn:`[Certified Well toiurrctai or Well Oman- U;uc
Mecklenburg - - ' 08304212 13,v signing this firm, 1 hereby certifydlnrt the we/10) was(acre)abandoned in
County ltareellda,Ulttdittait No.WIN) ac.aunlaare with 1j;t:4CAIC01C,f1.1fld.or.C.0200fre11VCVrnsltatctiodStar:thmis
and Stint a copy of this record has been provided Ia the well owner.
51}:Jatittide aid longitude In.rtegreeslmintttesdseconds or decimal[tetra,:
often geld,one latilang is saitictota) 9.Site diagram or•additlonal well.details:
You.nta .use the back of this page to'ptovide additional well site details or well
N . - - W abandonment details: You may also attach additional pages if necessary. '
C()NSTR11CTl()N.fETAIL.41 CH?WELL(SI BEING ABANDONED .SIIRMT rrAt.iNSTRUCTIONS
.Mtitad,arch comrtraciieut recorol(s)',Ifosidopio. 1ijr urn/riplr Bye tiara or rmn•nnhr snppli
welts ONLY ntilli tte asrnte,cvristrocrinn'u4riuvbirr.+tcru)iv cart arbtail one fume. IOa: For All Welts: Submit this farm within 30.ale.$ of completion of well
6a:Well IllihTMW-S
abandonment lb the following;
Division of Water Resourem,Information Processing Unit,
66.•Total well depth: 16 (ft.)
16 17[[hail'Scnicc Center,.Raleigh.NC 27699-1617
lob.For inleetirin Wells: In addition to sending the form[to the address iu(Oar
fc.•Botxltulc diameter:1. (in:) abort.also submit ante copy of this fIrni within 30 days.of coriipletiort of well
abandonment hi the following:
•
-Division of WaterResourccs,Underground injection Control Program,
6d.Water level below ground surface: 13 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-163G
Ge.(intercasinfiIcnntli.(ifImorvn): 6 (ft.) die.'
For WatvrGtlply S Ltifectl9n Wells: In addition to sending the form to
the:addresses) above, also submit one copy of this form Within 30 days of
completion of well abandonment to the county health depatuttcni of the county
61.Inner easing/tubing length(it known): (ft.)
where abandoned,
6g.Screen length(if Imoi n):10 (ft.)
i
Fond GSV-30 Neith Carotins Dcp iunen:of Enciroanreat sal Natural Rcsoteccs-[Nrision of Watcr,kesotures Ret ised.Ltgust 20t3
1

WELL ABANDONMENT RECORD For ONLY:
• lliis foam can be uscdior single or multiple wells '
I.Well Contractor Information: WELL ABANDONMENT DETAILS
I
Stefan Smith 7a.Number of wells being abandoned: 1
Welt Contractor hatne(Or udiONseefiktonally.abanicitiinaeiclt.oilliisrlacrpreperly) • Fur rmrnple Weaker or lain-aartr stay* wells- .0fVLY Wuh ll' some
consrrncOalvabanlrcualeral,ma etarr azahlair rxieJ ira,,
3576-A '
NC Wa-ConlmgorCo lfawliotf Nmnbci ff ? 711.Apprnslmate volume of water-remaining.in weII(a)?1 (gal.)
"
SAEDACCO Inc FOR WATER SUPPLY WELLS ONLY:
Company Name. MAN.1 5 2023 lc.Type of disinfectant vied:
2:Well Construction Permit H:70003116(:-r,rr:;;_-1 + -.j a a•::i •
last all u iplrtable tie permits.6.e.Cooney.Srwi,d iitm e.tortoni eii j f•8'truwrr
s,(u •
7i1.Amount of:disinfectant used: .
-3.Welt use(eheckwell use): '
Water Supply Well: • 7e.Sealing materials used(cheeL all that apply):
•OA in.ultmat ❑hlttnicip:Q/Puhlie 112,Naat'Cement.Groat Cl Hcntonitc Chips or Pellets:,
00eothernr:tl(i cating.rooling5iipply) pRcsidenti:alWater Supply(*Ingle) ❑ Sand Cenrerd Grout 0 Dry Clay
❑h dusarial/Cornntercial ❑Residential Water Supply(shared) ❑,Concrete Grout ❑ Drill Cuttings
❑Ira r lion • . . . .0•Specialty Grout 0.Gravel
Non-Water Supply Well: • It Bentonite Slurry ❑Other(explain under 7g)
lEl14llunitoring ❑Rot usexy_
injeetion Well: 7f For each material selected above,provide amount of.materials used:
❑AquiterRecharge ❑GroundwaterRe:rediation' Neat Cem.-:941b. ,Wtr•8ga1. Sand Cern.:lb ,Wtr:gal. •
❑Aquifer Storage and Recovery ❑Salinity Barrier
•
❑Ailnife'.Test. ; OStonnw•aterDniitaage Bentonite.:llb-,Wtr:gal. _
❑Experimental Teclrnolon LStibsidetres..Cornrril 7g.Provide a brief descriptian-of.thc•abandninnent procedure:-,
tiGeotiermal(Closed Loop) Ci"itacer
• Pulled entire well and grouted.
.LiGeotherusal(licatinit/Cooling Return) . C70ihcr(explain under 7a),, -
4.Date well(s).ahindoned: 271672023 - - m
• Sit,Well location: .
Sealand Contractors/Space Craft • - •
Faciltty+0wtur Nara Facility the(ifapplic abtc) 8.Certification::
525. Parkwood Ave..Charlotte, NC 28206 . - - �Yj 2/17/2023
Physical Address.City;acid Zip S�r._tinn Cestired Well CuurrIvor if Well Qiwta.•r pare
Mecklenburg 08304212 !iv signing this;farm, !hereby certify•that the trolls) was iwere)abandoned nr
l`.00nly tiatIcel liketillditloitNo.(PIN) • tipcoiilrrntw with l.3:(:s:G:-ICO2C,01110.or21' 0200.tt'elfCwta7ritclioriSkindardfs
and that a copy oftlris record has been provided to the well ouner.-•
• 5b:.Latitude;arid longitude in ttegaoes(minutes/seeonds.nrdeeinral degrees:
(lttc•cli tc.rd,one L•,G'4aug_ts nankin). 9.Site diagram or-additional well details:
You.ina}•lisp 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. .
•
(Y)NSTRUCt7ON.DET.AtiLe OF WELL(S)BEING ABANDONED �t1BMiTTAL INSTRUCTIONS
aitatit upll conrtructrarr rucoratsl if mvtilabh•_ I}r multiple injettiest,or rnin-renter supply
wells ONLYuatliirk ures'viistneraivararirurrhiunirnr..errcarrsubmitonefonre 10aa:-For All Wens: Submit this form within 30 days of completion of well. .
abandonment to the'following;
6a.Well IDti:Tbm-6 . •
•
• Division of Water Rcsnuree.,Information Processing Unit,
Mr.-Total well depth: 12 .(ft.) -
1617 Mail Senice Center,Raleigh,NC 2769-I6I7
-
•
106.For Inicetlon Well3: In addition to sending the form to the address in-Ida
1 above,also submit one copy of this-form within 30`days of completion of,well
Ile:Borehole diameter
- -Du`) abatudountentto the,following:
•
Dlvislott.of Witter Resources;Uudergroutd injectlun Control Fntigratu,
6d,Water level belmw ground surfacer 10 (ft.) 1636 Mail Senile Center,Raleigh,NC 2 7 69 9-163 6
Gc.Outer casing length(if known): 2 (ft.) 10e. Slowly
For Water Satly& [election Wells: In addition to sending the Ionato
the addresses) above. also submit-one copy of this font Within 30 days of
completion of well abandomnent to the county Ireniticdepartnteru of the comity •
where abandoned. -
6f..inner easing/tubing length(if!mown): (ft.)
6g.Screen length(if Imon n):10 (ft.)
I '
Fornr GW-30 NonhCarolina Decoru ry of Eswiroun cal aryl Natutal Resouu cs-Division of Warcrltis mums. Revisal August 2013