Gaston_Well Abandonment_20230419

WELL ABANDONMENT RECORD For Internal Use ONLY:
WELL ABANDONMENT DETAILS
I.Well Contractor Information: /
ill;
�J _ f �. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
�i p pCrty) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Well Contract r erne(or well owner personallyabandoningwell on his/herro wells abandoned:
�� 7b.Approximate volume of water remaining in well(s): L • L (gal.)
NC Well Contractor Certification Number
t f '- f_- /�a FOR WATER SUPPLY WELLS ONLY: �.y
t ) v7 n� 7c.Type of disinfectant used: 71 / -
Company Name
q r
2.Well Construction Permit#: ''''----- g/
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc)If known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that appl
Water Supply Well: ❑Neat Cement Grout Bentonite Chips or Pellets
❑Agricultural ❑Municipal/Public ❑Dry Clay
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 Sand Cement Grout ❑Drill Cuttings
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout❑ 0 Gravel
❑ Specialty Grout
on
Non-Water Supply Well: ❑Bentonite Slurry ID Other(explain under 7g)
❑Monitoring ORecovery
Injection Well:
7f.For each material selected above,provide amount f materials used:
^6ti��✓ 4 9 j
f )l`tµr,� roundwater Remediation !(i .•+ eee
❑Aquifer Recharge .� t � ; ��t'G
❑Aquifer Storage and Recovery ❑Sal inity Barrier ���j/ b J f
❑Aquifer Test .. ' '❑Stoifiwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I 1 e cc,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: t�/� ( Z3
5a.Well location: ,f/�
1`1y.)(./ 00 DeiVC'1 fl 8.Certification:
Facility/Owner Name Facility ID#(if applicable)
ri _.—
7 ? fl cvi to r)
( Signature of Certified Well tor or Well Owner Da
Physical Address, 7251h—I
City,and Zip
f e(„t"-_ill'110 pvi C By signing this form, I hereby certify that the well(s) was(were)abandonedin
„ J Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County t��/i 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:(if well field,one tat/long is sufficient) Site m 9.Site diagram or additional well details:
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)ifavailable.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
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
1617 Mail Service Center,Raleigh,NC 27699-1617
y. e'�j� (It.)
lOb.For Injection 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
t 6c.Borehole diameter: - (in.) abandonment to the following:
fl, ( ) Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: v 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): ( ) 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):________--(IL)
6g.Screen length(if known):
(ft.)
I h Division of Water Resources Revised 2-22-2016
......,rut_zn
North Carolina Department of Environmental Quality-

WELL ABANDONMENT RECORD For lntemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Shane Gossett
7a.For Geoprobe/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 8W-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
3528-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):900 (gal.)
McCall Bros I n c FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: Hth
2.Well Construction Permit#: Na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
Industrial/Commercial ❑Residential Water Supply(shared)•Concrete Grout 0 Drill Cuttings
Obligation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
0 Aquifer Recharge ❑GroundwaterRemediation 5 yards
❑Aquifer Storage and Recovery ❑Salinity Bather
❑Aquifer Test ❑Stormwater Drainage
❑Lxperimental'1'eclmology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Poured from surface entire length of well to
surface
4.Date wells)abandoned: 3/10/2023
5a.Well location:
Leg FUSE II Ilc ,,,PR 1 9 2923
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
620 west Franklin Blvd Gastonia 28052 r,...,., .. ,-. y.... a
3/16/2023
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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
3 5° 5'4 5.4 9 3 2" N 81°11'3 2.6 2 9 2" W You may use the back of this page to Frovide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)((available.For multiple injection or non-water supply wells
ONL P with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this fonn within 30 days of completion of well
6a.Well ID#:Na abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 800 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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
6c.Borehole diameter: 8 (in.)
abandonment to the following:
6d.Water level below ground surface: 30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.for Water Supply Sr Injection Welk: In addition to sending the form to the
6e.Outer casing length(if known):0 (ft) 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
0 abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: WELL ABANDONMENT DETAILS
NICHOLAS HAYES 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supple wells ONLY with the some
construction abandonment,you can submit one form.
A - 4121
7b.Approximate volume of water remaining in well(s): 0.5
(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION 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.)if known
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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry 0 Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.75 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE HOLEPLUC
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 03/07/23 APR 1 9 2023
5a.Well location:
ALLEN STEAM STATION
Facility/Owner Name Facility IDb(if applicable) 8.Certification:
253 PLANT ALLEN ROAD BELMONT 28012 03/08/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
GASTON By signing this form, I hereby certt&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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35° 10' 58.42" 81° 01' 08.50" 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. Far multiple injection or non-water supply
wells ONLY with the same construction abandonment,you can submit one form. IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: NSLF-PZ-01 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 16.5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in IOa
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 13.0 —(R.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
IOc. For Water Supply& Iniection 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
6L 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
NICHOLAS HAYES 7a.Number of wells being abandoned: 1
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.
A - 4121
7b.Approximate volume of water remaining in well(s): 1.0
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit It:
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: O Bentonite Slurry 0 Other(explain under 7g)
O Monitor ing ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.75 GALLONS
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE HOLEPLUG
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 03/07/23
APR 1 9 2023
5a.Well location: .
ALLEN STEAM STATION
Facility/Owner Name Facility ID#(if applicable) 8.(ertification:
je4::
253 PLANT ALLEN ROAD BELMONT 28012 03/08/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
GASTON By signing this form, 1 hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1SA 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35° 10' 57.31" N 81° 01' 08.22" 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifarailable. For multiple injection or non-water supply
wells ONLY with the same construction abandonment,you can submit one farm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: NSLF-PZ-02 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 17.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
10.5 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
be.Outer casing length(if known): (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
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013