Haywood_Well Abandonment_20230419

•
WELL ABANDONMENT RECORD For;menialUseONLY:: •
This foim can be used for single or multiple wells
I.Well Contractor intbrmation: WELL ABANDONMENT DETAILS •
Scott Runt, Jr 7a.Number of Areas being abandoned: 1
. <tieltCorlructorNante(orwellowaarizadnauyabantoningstllenii-:idlerpropeny) For ridop(e tojeol(oit or rwra-'iaerfcr supply wilts ONLY- wall the 'swine
constnrcrrwvithandowneeg orrceursobnOtarsfarm.
4561-A
74.Apprnsimatc voluine uf"4Fatir remaining in wdl(s): (gal.)
NC Well ContractorCef ifrcalion Nuttier 1
SAEDACCO Inc FOR WATER SUPPLY WELLS ONLY:
Conva-u)'Name 7c.Type of disinfectant used:
2.Well Construction Pectnit ll:,
Lar .cil irppihvblsarl permltr,ti.c_Cwnty,Slats.1$riore"d.if ior, .fo lJ,Gtwrra 7d.Amtiulit of disinfectantt13ed -
3.Well use(check n loll r e}:
•Water Supply Well: 7e.Sealing Materials used(cheek all-eliat apply):
AAgrictlturat pmuriicipallPublic ❑Neat Cement Gmut• 17 Berntanitc Chips or Tclicts" -
❑Creotltertnal(HeatinGICooling Supply) URcsidentiat Water Simply(single) ' ❑Sand Cement Gmut ❑Dry Clay
❑hrdiishml/Comnteminl ❑Rcsideutiat Water Supply(shatcd) .❑Conciete Gran( 0 Dull Cuttings
❑Irritation' • ❑Specialty.Grout 0 Gravel ,
. " Nun-Water Supply Weil: r .IN Bentonite Slurry ' Cl Other-(explainunder 7g)
KIMonilorine OReco.eta'
•
• Injection Weil: • -7f.For each material selected above;provide amount of:materials used: •
❑Aquifer kechatge •❑Grottialwater Remedintion
UAquifer Storage and Recovery : []Salinity Barrier
❑Aquifer Test ❑Storm ''aterDntinagc Iientonite.:3501b ;Wtr:gal: .
❑Ea7retiutettIal Te`bnotogv . DSubsidet>Le Control • 7.g.Provide a brief description gf*.abaadnnmcntprrrccdutr:
.❑Geothermal(Closed Loop) .ElTracer
over drilled to remove pipe and trimmy-grouted aqua guard to
ElGeother at almtingiCooling Return} ElOther(eaplain under 7g)
fill annular space
d,Date w'cll(s)abandoned: 3-09-23 _ 4 ( _- '. ti-.,2
5a.Well location: • APR 1 Q t)n
23
White Oak MSW Landfill
FacilinlOwnerName FO:iliti'ID3(ifapplicable) (t.CertllirJtion: -:i Pi{.r -.g lJi li
3898 Fines Creek Rd. •Waynesville, NC 28785 3'C.eZGCiLt v n'`a Cali 3/19/2023
Phy'sical'Addres,City.andZip SignoureorCeniried wen con •teror Wen evanr Date
Haywood By si wing thus feria,•1 iremby certifp that the we'l(s)tr'ac(were)abandoned in
Caunti' Parcel ldcntif ulon.No.(PIN) €acwnkrtace with ISA hC4C,02C.01Qt.or 2C.0200 Well Csaraslruction Staarktrels
•and that acopt,earls record has been provided ta The well owner.
5b.Whittle and longitude in degrees/minutes/seconds or daciuud degrees:
(ifucll E td,one lit long is s tmcici1) 9.Site diagram or.additlonat well details:
You tuay use the bad of this page.to provide additional well site details or well
• . N W abandonment details. You my aLso attach additional pages if necessary.•
CONSTRUCTION DETAILS OF WELL(Sl BEING ABANDONED SUBMITTAL INSTRUCTIONS
• :plod,tall.caratrarriop record Ifavudaabli. KO-undopte hjerricea or raan-notu..aupply
net&ONLir with the-a-again!Yonaroctrowabdrrrharrraeot.hour cnta admit'onofirat? 10a.Fur All*elk: Submit this form Within 30 days of_completion of well
Ga welt m§:BLE-35 abandodmcnt to the following:
.. DiiisienufWVaterRcs urecs.Information-Prucrising Unit,
6b.Tarot well depth: 42 (O,) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For infection Wells: in addition to sending the fora,to the addles&in tOn
6c Borehole diameter.2 • (;u,) above,also sutiniit one copy of this form within 30 days of completion of well
ahiindomtteni to the following:
Gel.Water level below ground surface: 19 (R) Division of Water Resources.Underground Injeelon Control Program,
1636 Mail Scrrice Center,Raleigh.NC 27699-1636
6c Qutcr a acing lcregth(if known): 4fr) I4c.For Water Sunnis.at iufectirim Welts: 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.Innercasing/tubing tenymh(if Imaw•n): "(ft)
where abandoned.
6g.Screen length(if known): (ft.)
Font GW-30 Noah Carolina Department afEnvironment aid"Nana©[Rcsouiccs-I/Visfan of Water Rcsaruo s Reamed Auguu 2013

WELL ABANDONMENT RECORD For infernal
This form can be used for singte or multiple wells
1
1.Well Contractor Information: WELL ABANDONMENT DETALLS
Scott Bunt, Jr 7a.Number of wells being abanda nedt 1
• Welt Cotlot1ame(Or weltonnan-p.;sflnauynha44nin;ttellenbfs�lierprog,:ny) For trwhiple tryenrar es' !kill-i141res sippfy ' 'Oils •0 ONLY with '14 snriie
. _ - eotistntchotb4ka do n eel Ion cyorsubilatloneforer,
4561-A .
NC*ell Cvitt>aaorCei1iticatlon NnntGcr 71t.Approximate solnme ofWatar remaining in sulks); • ( al.)
SARDACCO Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: .
• •2,Welt Construction Permit 0:. ..
• Lid all opp{l ei it tcell p rmils(l.t Cteirlij:State.Variance,htlecfiaa.,reel if kr`mwo
7d.Amount of disinfectant uSed: •
. 3.'Well use(check h ell use): ---
Water Supply Well;• . 7e.Serarng n lte:Oais used(check all that apply): .
. • ❑AgriCultaiat tJMunicipal/Ptiblic 0 Neat Cement grant 0 Ucmonitc Chips or Pellets
❑Geoti heal(Ileating'Cooling Supply) ❑Residential Water Supply(single) ❑.Saud Cement Grout 0 Dry Claay
❑lndtastria1/Commeaeial• ❑Rcsidential Water Supply(shared) .0 Concrete Grnut' ❑Drill Cuttings
• ❑Inigatiou 0 Specialty.Grout .0.Gravel •
Non-Water Supply Well:1 18 Be donite Slurry - Cl Other(explainunder7g) -
KlMouitoritag. •. . . . . • ❑Recover . - .
injection welt: • . 7f.For each material selected above,provide amount of materials used: . . . -
❑AquiferRer1ty e • .❑GtoundwaterRentediation .
•l]AgtaiferStorage and Recovery ❑Salinity Barrier
Bentonite.:3501b. ,Wtr:gal. .
❑Aquifer Test ❑Stonnwater Drainage . . . - . • • . - .
' ❑Expenntenlal Techuologv l7Subsidence Central
7g.Proiide a brief ascription of the altandonmcnt,pnicidure: •
0Geothetilat(Closed Loop) ❑Tracer .
• over drilled to remove pipe and trimmy-grouted aqua guard-to
❑Geothetmat(iieitugtuCoohng Return) • [Miter(explain under 7g)
fill annular space
d.Datcwell(s)abandoned: 3-09-23 1:-..''',.
' y �, ::,‘.,J L 7 :,ayqu v 1_..
5a.Wean location: . APR 1 9 7023 •
• White Oak MSW Landfill '
FacilityOtvta:T Nunn: Facility lD9�fat+plialbic) 8.Certillralien: Irt,'c;+-.;;4E21 art:^?• •!n9 01:i
•
3898 Fines Creek Rd. Waynesville, NC 28785 cjCB GLN.t 3/19/2023
PltysicatAddr .City,and Zip • SiputtoeofCertifredWetCon :tor orWcllOwner DalC • .
Haywood . . . . . . . . Bye sighlag this,form, I hereby,eereify.abut the trellis)*as.(icepe)abandoned in
Ceulity Panel id;antiticittaallo.(PINT accordance*flit 1i:=1:VCAC OlC,01QO.or 2C.0200 WelConstruction Standards
and drat a copy ofthis record tins been provided to the well owner.
Sb:I.atitude and longitude in deg ccstmtautestscconds or decimal degrees:
(ifw•od flew;otw IatilongISmillicicitl) 9.Site diagram or.additiooatwell details:
You-may use the bat.k of this page to provide additional well site derails or well
N W • abandonment details. You tuay also allaeh additions po;;es ifnecc cry.
CONSTRUCTION-DETAILS OP WELLS}BEING ABANDONED SIl13MI•f FM INSTRUCTIONS
:Nash n.ell.evritnleliari recvrdlst if al:Oita:de.. Fer!multiple ntiecticn or tiun•uvta'supplt' ' •
-
ti,rlla t?N4i will ate pilot a'rue.trartmn?olieirrdor:mcnt, iu ait1 srrbnra one put. an a.For All *du: Submit ibis form t i[Ilin 30 days•of completion of well
seas-34c abandontuent to the following:
6a,Weil IDd:
•
DirisinaaiWaterllesoaarem,Informatiou:Prucessing Unit,
Gb.Total well depth: 43 (ft.) 1617 Mail Service Center,Raleigh,NC 17fi09-1617
1011.,For liniectiarn Wells: In addition to sending the form to the address in(Oa
Gc.Boreltolediauactcr:2 (in.) above;also submit one copy of this form within 30 days of completion of%veil
abandonment to the following:
Division of WaterResottrces,Underground Lrjetitian Control Program.
6d.Water level below ground surface: 19 (ft.) 1636 Mail Scriicc Center,Raleigh,NC 27699-1636 '
Gt.©over casing length(dFlmt►ven): (fL). IQG For Water Stannic R infeerhin Welts: 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 department of the calmly
GEInner casing/tubing long th(if istows): • .(ft.)
where abandoned.
6g.Screen length(if known): • •(ft.)
•
Fenn GW-30 .Nonh Carolina DepaMtcm of Environment and Nattuat Resources-Division of Water Roronrr es RevvedAngusa 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or undtipte wells
1.Well Contractor information: WELL ABANDONMENT DETAILS
Scott Hunt, Jr. 7a.Nutnbernf.wdlc being abandl ned: 1
Welt-Cot:tractor Name(ort►4 okinq NanWally al,Minldnlno net]anIiisi erpropenl) Jim ii+dttph titti'rdd$t or' rvara i'uttr siipply wefts ONLY with r& 'saii�
emerroethxt+"iaban none at,'as van satrtur,motorist.
4561-A
NC\Yell CoitunaarCciliBu—tUon Number7b,Appnndmate t•nlume of Watt remaining in w•dl(s):. (gal)
SAEDACCO IncFOR wxrERSUrPLY WELLS;ONLY:
Company Naar 7c,Type of disinfectant used: • .
.2.Well Construction Permit tit, , .
L8t a eppkorb/e u v I n mite(i.a_Ca*,Stator,I orinnee,hi canon,e J ifktuisri 7d.4tnotuiE of tlisinfeetainf used:
3.Welt use(check well use): • . •
Water Supply Welh-• . 7e.Sealing ntatetiads uacil(cheek all that apply):
ElAgricrtltuiad I:Municipal/Public 0 Neat Cement Grout CI Rcratenitc Chips or Pcilcta- "
❑Carothcrmal(Beating/Cooling Supply) ❑itcsidcntiaal Water Supply(:tingle) ❑-Saud Content Gtnut 0 Dry Clay
❑htdushial/Counoemial ❑Rcsidentiad Water Supply(sbaied)' i ❑ConcreteGrout ". ❑Drill.Cutlints
• ❑hrikation . " . . 0 Specially.craut' . ❑Gr►Yel•
Non=WatcrSu(iply Well: BepfanireShiny ❑Other(explain under 7g)
IMMonlloring . fRecovet
Injection Well: 7f.For each material selected above,provide antonnt 4f Materials used:
❑AiquifetRecharge ❑GroundwaterRentediation. '
fAquifee Stamge and Recovery OSalinily barrier -
❑AquiferTeat ❑SlotnmailerOnsunige Bentonite.:3001b ,Wtr:gal.
❑E:weriuteutai Teehnoloev 0SubSidettee Cott(tnl 7g.Ptviide a brief description of the ahatadnnmcnt.prncetluir:
❑Geothetnmt(Closed Loop) tDTtacet
over. drilled to remove pipe and trimmy grouted aqua guard to
©Geothenmat(lie atine/Cooling Return) ClOther(explain under 7a)
fill annular space •
4.Rate well(s)abandoned: 3-09-23
.•.5a.Well!scallop: ,. .� t. yy! n f ? ,+..
White' Oak MSW Landfill APR 2023
Facility/glean-Name - Facility IDS(ifitppliatbtc) s,CertiRcaeian: 1 ..
3898 Fines Creek Rd. Waynesville, NC 28785 3)C4V 717 4-- •74••,,.3.l-`t P"C"?'+'=�3z1t974023
Phy'sical'Addres iJ.:City.and Zip Si enure oICegilled Well Coi ,tor or Well emir" 11i.- ' Halo
Haywood . By signing lhrs form, I hereby eertifv that she wears)wax(iced)Ufraindoned in
County Pattie]1dcnlilicatlonNo,(PIN) 'accordance with 1 id.CAC 02C•01 U0.or 2C.0200 iG'eli Construction Standards
and thait ar capiyafthis record has hem provided to tire ivoll owner."
5h.Latitude and longitude in degmeestmtnutestscconds or decimal degrees:
Orwell field,one utalnng is s drrxty) • 9.Site diagram or.additlonal well details:
You-May use.the back of this page:to provide additional well site derails or Well
N .W abandonment details.'You may also attach additional pages if necessary. . .
CONSTRUCTION DETAILS OF WELL(S)BEING:ABANDONED SUDIVI TTAT.INSTRUCTIONS
:merit tie/I west metier:racordfsi ii avisiherik.. Par nridbpto ii jeroon or on,,itnior svppiy -
tteIir ONL!'with the slang rorrsatir(tomziaFtivrahrariartt.Lori air:strtmit cure,unm 1Oa: Far All Wells: Submit this form Within 30 days of completion of well
Ga,Wed mg:BLS-34
abandvutitcnt to the folibtiving:'
Dtyision of Water Resuurcts,Informations Processing Unit,
Gb.Total well depth: 32 ((E.) . 1617 Mail Service Center,Raleigh,NC 27fi99-1617
•
10h.For inieeiian Wells: In addition to sending the form to the address:in Lila
Gc.Borehole diameter:2 • Gn.) abn4e,also submit one copy of this form w4ithin'30 days of completion of well
abnndotnneni to cite following:
frill �4aterRevdhcLor4�roandsurftcc• 19 (ft.) Bbalstauof Water Resources,Underground Injection ContnilPrtigram,
1636 Mail Service Center,Raleigh,NC 27699-1636
Gc.(lutcr easing file Fnr Water!Strunk&Luiection Wells: In addition to sending the form to
g 1 ength(if (fw) the addresses) above. also submit one-cops' of this form within 30 days of
completion of Well abandonment to the county Iteattit depunnient of the county
GE Inner easing/tubing length(if lmann): (ft.)
where abandoned,
6g Screen length(if known): (ft.)
1
I
Font GW-30 North Carotins Department of Pmitunmcnt ant Naruaat Rcsouires—Division of Water Rcsoums Revised-August 20t3

WELL AB I ONNIENT RECORD "
Far Irmterii]Use:ONLY:.
This form
n be
Well Q •
v tracts t or tom multiple wells ` W ELL ABANDONMENT DET
II. \ AILS •
scott Hunt, Jr ' 7a.Number ofwcILc being abandetiid: 1 . .
Feu• trarlUpla 1iJeetiost or. rwuira&r supply wells ONLY well) the wain*.
We1l'CotyraMor haste(or}tellottc�pusaually al>amtonlao score an Iiistlmer prape ny)
ecturrucrttwa 4rbosrd et,nent,mu apt,sisbbn4t iwieJFrrr,
4561-A •
NG Wstl Goiar�clorCctliCn.ilion Minter71r,Appr imate volute of;vita.remaining in well(s): - (cal.}
I
SAEDACCO Inc
. FOR WATER SUPPLY YELLS ONLY:
•
Ceni,uny Name • 7c.Type oP disinfectant.used:
2.Welt Construction Permit(i:, ,
Litt all rtppkabl .wellpsrru$s,(Le.Canto,Stele;Ma-arse.baectiou,etc)Jt;rmwu 7d.Amount of disinfectant used:
• 3.Wdt use(checitwell use):
Water Supply Well: .. 7e,Sealing nrateti lsi used(check all that apply-);
DAgriculturat 1:Municipal/Ptihlic. • CI Neat Cenicnt.Grout ElBentonite Chips or Pellets
❑Gcothcmral(Heating'Cooting Supply) ❑Residentitil Water Supply(Angle) ❑_Sand Cement Gtnut 1]Dry Clay .
❑htdnstriaVConvncrcial- • , , ❑Rcsidcntittl Water Supply(shared) .❑concieteGraua ❑Drill.Cuttings
- ❑Urigation . 0 Specialty.Grout .❑.Gravel ' '
r i-\VaterSupplyWelt: N BentoniteSlury 0 Other(explain under 7g)
NMonitoring, . °Recovery -
Injcction Well: • 7f Far each material selected above;provide amount of.materials used: -
(7Agttifer Recharge ❑Grutridiwater Reutediation
[]Aquifer Stonlge and Recovery •.lJSalinity Dallier
•
' ❑AquiferTest LlSlonnwaterflraivagc Bentonite.:3001b ,Wtr:gal. .
❑Everintenlal TT,elmolog_v ❑Subsideixe Control 7g.Proiride a brief diseription of the abandonment pnicedure:
°Geothermal(Closed Loop) . .°Tracer
• over drilled to remove pipe and trimmy-grouted aqua guard to
fGeothermat(tieatinalCooling Return) 0Qth:r(explain under 7g)
fill annular space l. *
4.Date wcU(s)airandoncd: 3-08-2 3
Sa.�Wetl•(neation:
AI�K I ZL�Y3
White Oak NSW Landfill • ;raz- ,_;;:: Pr ;j;.. l It
• S.drertiflcntian: (�1:'e ;Z� .
Facility/Owner MVO Facility 10b(irappl-Icablc) Q
3898 Fines Creek Rd, Waynesville, NC 28785 3C..46)• u12t- 3/19/2023
Pltysieal'Addres;City,andZip •SiLft$itreatCotiliedWeIlCat mot or Well Owner Dale
Haywood . . ley+signlrig 11ris fora;•I hereby certify-that the well(s)ryas(1cere)ahmidaued ill-
Catwt% • Parcel Identireailnu Ne.(PIN) ii cunfcrrree with 13_l WC1C 02C,0100.or 2C.0200!yell Cmaslrnction Standards.
and that a copy of this record has been provided lathe well owner;
Sb.Latitude and Iong ttt&Ce in degneestmInurqiseconds or decimal degrees:
•
(if o%cll ACM;one laulong ia s-iallekta) 9.Site diagram or.additlonat well details:
You may use the back of this page to provide addiliotrat well site derails or.w eil '
N - W airindotmteat details. You tuay also attach additional pages if necessary_ -
•
CONSTRIIC'I'ION DETAILS OF WELLS BEING ABANDONED St1BRIiTTAt.INSTRUCTIONS
.ttfour trdd.cortaucriurs recvrd(s)IJ',rtixilsbts. Farr multiple in}tdiox or rstn•uwtar supply ' . '
odes 0,NCY a ith the:swiw eton retriost✓rrSmatqueleat,iau eau submit me:All. 10a, Fur All Wells: Submit Ibis-form Within 30 days of completion of well••
• 6a,Welt mg:BLS-4 8
abandenriurit to the follow�rig:
Division of Water Resources,Information-Processing Unit,.
Gb.Total well.depth: 47 ((�,) 1617-Mail Service tenter,Raleigh,NC 27699-1617
lob.For Inlei:lion.Wells: inaddition to sending the foriu to the address in 11)a
Gc.Borehole diameter:2 (in;} above;also submit ono.copy of this form within•30-days of cottipleiion of Well
ahs udomnenl to the.Collow•ing:
Division of Water Rtsoutet5,[Underground Injection ContnilProgr'am,
Gd.Water level below ground surface:19 (ft.) 1636 Mail Service Center,Raleigh,NC 2709-1636
•
6aOutctrcasin length(if!Mown): (ft) Rte.Frye Water Srmnly&Infection Wells: in addition-to sending the loins to-
c l ( t►trw): the address(es) aboive,also submit one copy of this-form within 30 days of
completion'of Ivell abandonment to the county health department of the county
where abandoned,
6E Inner casingitubing Length(if known): . (ft)
6g.Screen length(If tumuli): (ft.)
Form GW-30 North Carolina Dc.romucm orl_nvimnnrent aal-Naiwat Resouiccs-Division of'WaterRooures Revised August 2013