WQ0037555_Well Abandonment GW-30s_20230201

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Michael Patrick, Jr.
Well Contractor Name (or well owner personally abandoning well on his/her property)
4498-A
NC Well Contractor Certification Number
M&W Drilling, LLC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (1.e. UIC County, Sate, Variance, etc.) iflaiown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Non -Water Supply Well:
[]Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned: 1 0/25/22
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater Remediation
❑Salinity Barrier
❑ Storrrlwater Drainage
❑Subsidence Control
❑Tracer
5a. Well location:
Trillium Links & Village
Facility/Owner Name Facility ID# (if applicable)
48 Links Drive, Cashiers, NC 28717
Physical Address, City, and Zip
Jackson
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35008'39,93" N 83008'11.88"
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
s Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
❑ Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite Chips — 43.5 pounds
7g. Provide a brief description of the abandonment procedure:
Well was dry, therefore, chips were poured in from
top.
8. Certification:
M.it,. A�� 11 /9/22
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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 WELL(S) BEING ABANDONED
Aaachwell construction reconi(s)ifavailable. For multiple injection or non-watersupplywells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: M W-2
6b. Total well depth: 20
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: None (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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 Supply & 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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Michael Patrick, Jr.
Well Contractor Name (or well owner personally abandoning well on his/her property)
4498-A
NC Well Contractor Certification Number
M&W Drilling, LLC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC County, State, Variance, etc.) ifknown
3. Well use (check well use):
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned: 10/25/22
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under 7g)
5a. Well location:
Trillium Links & Village
Facility/Owner Name Facility ID# (if applicable)
48 Links Drive, Cashiers, NC 28717
Physical Address, City, and Zip
Jackson
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
35008'40.50" N 83008'10.75"
For Intemal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
a Bcntonitc Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
❑ Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentorme Slurry
❑ Other (explain under 7g)
7E For each material selected above, provide amount of materials used:
Bentonite Chips - 43.5 pounds
7g. Provide a brief description of the abandonment procedure:
Well was dry, therefore, chips were poured in from
top.
8. Certifrca 'on:
'al ,t L - 11 /9/22
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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 WELL(SI BEING ABANDONED
Attach well construction record(s)ifavailable. For multiple injection or non-watersupplywells
ONLYwith the same constructionlabandonment, you can submit one form
6a. Well ID#: MW-3
6b. Total well depth: 20
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: None
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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 & Infection 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): (g,) abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Michael Patrick, Jr.
Well Contractor Name (or well owner personally abandoning well on his/her property)
4498-A
NC Well Contractor Certification Number
M&W Drilling, LLC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIG County, State, Variance, etc.) tfknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Non -Water Supply Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
4. Date well(s) abandoned: 10/25/22
5a. Well location:
Trillium Links & Village
❑MumcipallPublie
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility 1139 (if applicable)
48 Links Drive, Cashiers, NC 28717
Physical Address, City, and Zip
Jackson
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lattlong is sufficient)
35008'37.17" N 83008'09.07"
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
a Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
❑ Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7E For each material selected above, provide amount of materials used:
Bentonite Chips — 43.5 pounds
7g. Provide a brief description of the abandonment procedure:
Well was dry, therefore, chips were poured in from
top.
8. Certification:
?Oe�-- 11 /9/22
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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 WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non-watersupplywells
ONLY with the same constructionlabandonment, you can submit one form.
6a. Well ON: MW-4
6b. Total well depth: 20 (ft.)
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: None (ft.)
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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 Snooty & 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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016