Mecklenburg_Well Abandonment_20230428

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WELLABANDONMENT:RECORD Rif Intenol Use:ONLY.: I
.7p4ftiiin!.0iybei 1.14.fni.: ini..12.:60noliiii,le. .'veli : ;
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I Well co nti-tplint.laninettion• ,WEIL ADAND(')NNIENT:nr.tAiLs ..
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Brian Ewing ,. . .7a.:&Wilier ofNielbt.being:ibandoneil: . ..
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4240-B • ' ''. I I . '
'lb,Appniiltintie litlu iiir of-,*atet'rienliiiiiing in AiellNi. •:--.---
(gal.)
Nc..wol rioiti4toiekiiiiiivaiiiiii1;„iiii-i. . . ,
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• . FOR-WATF,:g$1.1FP1,Y WE.U.;.i.i..01.Y.I':• .
SAEDACCO Inc
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2 Veil Cu itsfitiction:Piiiiiiit II:70 002 0 6.9,., ,
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0 Indastria lir.bituiti ekl- 01.tesideniial'Watef-Siipl•(§,leiteti) 0 C,ohrst:11P!0:p1 '.--13 Doll(niiit
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'-Injcctinw.Web:.•- ,. . . . ,- 71 For ekli linittiiiii-klettedAlio*e4iiivide tittiOinit Pt-niiiteiials tiseil:',
b Aiii!i fee,kd,Atirgiii, bdriiiiiiiiii-lit5iliiiiii•:iiiiii I, Neat Cern.:471b ,Wtr:7gal. Sand Cent.:lb ,Wtr:gal.
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ElOccOtenn4tICIPsedLopl* llitraCer;
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- ,- • • " i,'"•••' . ::.•... ,- .. TREMI GROUT FROM THE BOTTOM TO SURFACE
136cOt1nna t(14i-iintipje001 hip.Return)• &oilier(e\-niaittn ildet.110 . . .. •
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4,.Dite well4).,nbatidoned: 4'13-23 ••
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a.Vel location: APR 2 S
Centre South Brownfelds Site . . , ,• , 2,.0V
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kit/ s4;i rOlily1) (ilrptiA0 8-CtiftniiPi:
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1221 S. Caldwell St. Charlotte, NC 28203 Brian Ewing ...
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Mecklenbur . ...tIp-sityylite".this Or" l•1z1ellb ckrikti,•-:that.the lre,10,3iws tit•oes.#4 ondone 4.in coiiiily- P-oi,cellOztilific-fiiipq,tio:AP1Ni •i'01--; 0riliiitrty it'ilk15.1;.:VGIC,94?.C.,z9100-brIX..()20-9',.11:-.111:Coil*tioi)..,:tartilai-ds
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(irne0e..iiid,,0th.,Lit',1!ig:-0.'jiiiii*nn .9.'.Site diagram-Pe Ad iti Offal weft tip!ai4
1.-dti=nia-y:iiso';,0;,64t:I:of this pa .tO.'pini‘itki,444(tipntit wilt si(P]..d'..:'ORs: r,'Isi.ell
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t.,ONSTiiiirf ION"1:oE'!i!;it IS ilFiVEI:t0.4 BEING AliANti()NED. ;.:StIRAIITT,1TINTRUCTIONS!'..
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. . •Pit,Weil I iiiitTl414-1 nbitkIntuli-in'In die folloivinti-
Dlyiion of Waicelii*iitirijabil.witiiouPOtessing Unit- •
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Obi Totil"ivell.ilejitin 28 (fCt'
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6c.torcliWIllametert 1 lio- .:thiiidisomcioiiiltie e911owil4;
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.• Mail-Sei-vire-Centcr;Rnlei2h;NC2769%i6-34:.
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Ypt*i'AN90. ,*iri)i:carptina Pc itlwnerii.of Eps iri,4n)(4)1 4t4I*0.4iff4.-:FAIr..qcs--:.'01%tsiot 0",Vaip,rlipspikr-cs,n :Revised Augusf:4,11::::

II
WELL A BANDO NIEN.T RECORD • . Ftirini.n>~ilUss ONLY" j
Tlus form can:be octal 3oi Siii ate oc ntuitiple'irclls:
1.R'cll C ontractor lnfi i•m ttiiin '1CFLL ABANI)()NMFNT DF'i`-AtL5
Brian Ewing 7a: tumher ofA4tlts helm„ibandinird .1
WAA (pt irtoi ,irn>.6i:,'.tlnsus.: i,eoiulh siti»lcudrirui,rlu I i 'tl.erpop rn) t':u': 'nr4rtplc `'ntr trarr '-time ru►a il-i1 r i-xs!v its°ri. .°-.Y.S' 4:1'i:' 16.. s'40i
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4240-B 1
NC4ti 11 Contras bt'OtuF innti itiii;ri:r ,11 i n.mainiui,tniti ll(')i ( .il)
SAEDACCO Inc FOR WA TF.R SUPPL Y WELLS ONl Y
Coin y ir,1i isiir, h':'f}pe nr(tn uriilitnt:uscrt:
Z Woll Con;Utictran Pcrnui tt 70002069, , • •
i a,'J l t,-01 ad fF 1rdl,.tr r°i r Yi c (c,t J 5o ,.1 ueliihit.I.ve runtz.Ir t if d rrririt
7d AniUi,tnt iif dtiinfect tnt uciiti
3 W,d1ui(diecl.nill;l0-ui,)
• Wittcr bupph Wt11 • to 5e d'ng nuten rlc used fchecJ:at1 th Lt apph
0 4 nctittunit iuuieip tiVubli .. • IX N.kit Cement GronL Cl Anrto inc Chips or Pellets
0(;i,kottcni sit.(Flcatiii i(uol►n, Suppts! CJIt^sidrnri i!Watr r nptili S rcusrlcj;' 0 Sfiv3 Ccnzxiu(atuttt :.'O Dit Cl,n
O►nidris(r-il'Cotnntcrcitl` 0R sidinttal'%'flerSuppt} (sh.tnit), 0 Cbiun.tcGrout_ 17 lPillCutiui s
Dliiiii,Uhioii . 0 SpeciaiN Ciuiit; "0 Grn.l
Non-% ater 4upplp.Well •
Cl Bcnloni(0 Slu(?)'' ,.W Otti4f`(e\pt.iin_under 70..
• CDh1oiit0 ing ORecoie,
lnjcctrou %ell:_; 71:For each'titatcriid sdlec1c4t ab►.Vi,'prti�i.ide,lntoi,ut of_'ni;ih rials usi dt'"
D A.ynih.r Rccli.irle; DGrotitidst-rter lieurcdwi on`: Neat Ceni.:97lb ,Wtr:7gal. Sand Cem. lb ,Wtr:gal.
O aqunfer Stecige 461 Recos ciii. OS ihniti 13 ima<i •
OAi)nifulest: DSiorit toei.Dinu4gt•;
OCp nurcnt 1 Tizaiint i v 0Sii..:, :,>.e ,...„jl: ?i; 1'nis nti 'tinif dnici iptian at the.mh nitnnunent prncntutri:
UG0th4rnai1{Cta r.d I oopt NrOTrucr
TREMI GROUT FROM THE BOTTOM TO SURFACE
. ElGeotticnl`al f ieatiiilt Cooliiilz Rcturnr. t3Dtlter(cs-plan(=under•7t
i Dtictte�t(5}abtniitioc 9-13-23. . �L.
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5a.V:kil lutat i►"n: PR 2 8 2023
Centre South Brownfields Site il�OfLTi tct°S;1
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T asili(jt izscs�r Iaar� I;r:ilq�lri 3(iC,lppl�vFsl Q .a(-_,G
1221 S. Caldwell St. Charlotte, NC 28203 Brian :Ewing": . . .- 4/17/2023
I Ims t.alIi'lildiets Cali::t4Zitr. "u tlu 4•of Ci:if.0:-4-t Y t.il'Gtratri i0F,T✓ i141i�;4r' 17;it
Mecklenburg t:t_t,711n .IIt1.s joi ii l-1rtreby,'e i tipttr ill at_llte TI ell(;+}m.,as.(iv r.i itri4)iitio t4d-in
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unittireflacop.)nfthicreed r?lras/icrnrrnrtrler1tot'1retie/1 on•ncr.
Sh Latr0rdcand longrtu(14 in rlcgrcesluuitutesisecoirric or,(b rim d dcgrcts•fr
(iftr14li041.t any tjiil it.2 iX`')it1'i,r„titj 9 Site(h11;t:tlil orAdttltlon it•ltidtl dltdils
YOU nu i e the b7Cfi of this ptiine to pros idt..tdditionat.rti.U'.site d4tails or Well
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li W ibandlonmentdetait : You nt.i, •tl:oattach.uiditioii;lt' 7pesif ycessit}'•
CONRTRII('rIOV.Dl TAll"ti OF Y IA L Sl lit IN(.ABA i it)ivED S17BRi1T7..its i i i uc r([)sIS`
'ii,ii;:tie1'LClrt1nit rur ri,iwret(ti fiitrkt tifti'.I olr 1r irlhpi nJ c t Nt is rain ii t er iiiii.��'h'' ,.
itt 1.,r OryLY,r ilir1,, i4im4+4+LiCrzhii4ari iiwki. rit,rurl eon urt at o e t nrt'' 10ae'-I.nr All:Wi Its :=Cubnut-.Hits fall--ittltin.O d.il•s-of'4oiliodiun of tstll
6a:Will 1D 9
TMW-2 =thikkiii vent to tttr• follnst int. '
Dt_t'lsion of.Water Rcinurci's rnfurmation Priic _vs►ny.i trait::
16171inil Sc»uc C uster.,Raleiti S.0 27 617.
4k.rfotal tvcll ileiitli: 30 (`!'t 1'
lUb..;For•lniettion-Wills In addittoi to wilding tl„feint tal:.
?the address ul l is
fiC.Elgrclt0lc lianteteY;<1 abtilp,also btit ittit out,cop' of A•las fonnatithui-;,fi days oif tomil.lion of Etell"
{in) .ib:itidonn ent to du.,Lolloiiit,,„. ,
tilt -„,..r .,..cl hctott'invu•nrC .., •_ ;. (ft.) Ditrltort of1'iitterRe Dora,lludei-ground fiktection Coitnits1'nidrttu
_,_,:•• -•. `634 Mail Senicl.CenterRalu^1i;;lr'(,27.6994.I634
. 10e.�'Fa Vate► Grnlil'•,* 1iijictrnn Rsllc in ailiiitioo to n tiidi the tota.to.
In.Ouiirrisli►;;length;(if6ioisii) (ft:) time addrts(es)4.tbot.c'.:iilso•submit aue'cops of►his fount.iiitiun u di}s.;of
' ts ietionofel1'atia aiitirn to.the uii Ise11k dcp:tuic.
i•itofltcounts
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tsl;ec absidoid:. ) ..
61.I inertasiniJtihrnw:ingth(iflnattn) 20 ''(It)61r.Srun leitith(tf laintin).10 (fl:)
611.n(s1{,f`110, •Naiih t at efirr,f?Lwrlirt�tn af)ns irpnnk it riri wuturat Resrsir�r s 17iru un r3f l`,ru r( anrees- `Fiev ed Austo a�1 t3':
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WELL:ABANDON NIENTIRECORD . • -
F.,t•Inici*11119.-110NIX: ! ..
71410iiiiIIcO'br,‘,Os41.for: iq.le:2.41likilii00'.WdIS
I.Well'Colite:kttitt listorni:ithin: ..•W ELI..A BANIIIINM ENTIDETAIII.S
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Brian Ewing - '7a.NUmber iit•Will$bririg!.:ibandonrd:.•1 • •• . • .-
'iiIiiil:C)6r1Mcirt!;I:tii(iiri'l,I4:019i-,Ikii.tic.101iiilb•'.,.*Iii.ki•iiiiii;ii,.lj-6-.111ii:4..i.,0160;:ny) "FOP; frilifilpie..:...f.11:ci.."1!0..i .(l, .!:601^iiiifit. .,..:$14,f it,..... ifelb.:::, ONLE ..,,,,:di.':a.,,-„2.;,--:•.-,-.41,,ii,;,
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42407B .•- • • . ! ..
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-I-71i.Aliprii:t1iriotr:Ibtomr Of ivateritriminink in Wc11(s)i
NC'4' 11 Cipm.ra0orcIqni1ic4IitIOTlii•TriS:i
SAEDACCO Inc FOR WATER-SUPPL LL Y WESONLY: •
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2:•Wc11..Con•strOciiliii"Piinitit 4:70002069,, , , . ..
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1".:1kgrizwiltir.i1: OMilicipiTubiiC,.! , txt•N'ot•ctIttottorsioitt ..11 flcntonue'-chips bilvelleW
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attyltistibt/cottuterito, • OHL..skim-Vial 1..V.attrStippty( hiertly, • Li:ConaPtc POli.,I. ., El 13rillit.'itliiiikIii
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ONtoiiitoiiilf!,,s oftecov:e iv., . •
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c34ttiiiiit:Itctiluttge" 171010priilir:Or ROI:till:11i iOli-. Neat Cem.:471b ,Wtr:7gal. Sand Cern.:lb ,Wtr:gal.
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ifiAifirifer$tbrtigaI;i14-R&OVItiy: IjS'.fi1inii).•13:iiiicr •
pAtittifet',.r . b8101*itik:.1011,040.- -, : . •
0 Ei,periliu::0131 TO luIot02 b giiidcik:ii rostit it& •:71i;:rPiiiiitW:-..i IiiiiidiSCrli)iiii4 the 1466_414re::
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c.iP0t1tcrotal itThisi.d:1,0OPY 'liTraccr.
_TREMI GROUT FROM THE BOTTOM TO SURFACE
OGebtkrIrsal.(1401i i10.[Coo I hio.Return) botliCr.(e.p1i-iiir 0 HlerIP.) • y
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4;Paic'10)1(04lbatiiloticth 4-13-23. . .. .
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" A PR 2 g 2023
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.5,.-8Ni.ok toc:itton:
lofr...47:77,.4,i,...,71 pr.:-.....-:cz,v274 I:11a .
Centre South Brownfields Site .... . . _,.... . ... Dt410/301.71
yiictjiii,Miiiii.;,f:1,i;t1iiii t4;WIS.N/Piaiiii0J110 N.tciiifiCitiO4
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1221 S. Caldwell St. Charlotte, NC 28203 Brian- Ewing. . 4/17/2023
Pksicalltddre'5s-..-Ca)'.,-atid Zip. -:-.S1,4011::0i',C,:.:Iill.4 W11(Npttiii.'.,kii .,W...110mie.r. .•p.tie. -
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Mecklenburg • .:..:•:ify si's:»trigdtii,knit,I fie rd.iv.cerii.6)that the weilfly)..-triys iwere4-.Obpylocc}:in
(70str4s, jkisciii•!cptilifiinto4c1..(pIN) .--.:ilicoil.hilici is'ilk,5,-.4.VOIC fi2i,70.10.0:iir 2C';02(10'irell roigive;i:010 St.eindari-& .
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:•,0fidlilrat a.c.o&Ofilii.F,rt7c arilkiy. eiii,proweled,t0:the-.1-q11.(miler:
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iI'../INSTIIIICTIIIN I)E'I‘,AII•ti OE WELL:4'51'11E1NC,ABASIERINER I.,SUBNIITTAL-IINTRUCTION,
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information:a WELL ABANDONMENT DETAILS
��� � �1i
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or ell owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
rp ,� ,/�1 wells abandoned:
NC We 1 Contractor Certification Number
A )� 7b.Approximate volume of water remaining in well(s): IP
117- (gal.)
0 /��� �'�' �/�ro- FOR WATER SUPPLY WELLS ONLY:
Company Name �/ ehippar&
7c.Type of disinfectant used:
2.Well Construction Permit#: kV
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 14,
7d.Amount of disinfectant used: A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout entonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
O Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
No9Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
ClYMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of aterials used:
❑Aquifer Recharge ❑Groundwater Remediation � 6�� /fri�Y'�f/ie N ):pi 1 /961
❑Aquifer Storage and Recovery 0 Salinity Barrier C
DAquifer Test ❑Stormwater Drainage
DExperimental Technology 0 Subsidence Control 7g.Provide brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer �,�� �cj- 1 f� f�f
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1 / !'7( p
4.Date well(s)abandoned: s r M. ss
5a.Well location: �r zOZ�
/�pD f�tJpA/ y� /jam {° iE �J)l
(/J!I•g �nlo pp�/ -/e t//Vll 1T1foflfi z rn fJt•^,:z3&+ng UM
Facili /Owne/Name Facility ID#(if applicable) 8.Cer' cation: , CANQWG
-4 2-h0e4/1 i-P-'7W
PhysicalAddress City,and Zip Signature of Ce fied Well Contractor or Well Owner Date
11/geA— 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) , `L 9.Site diagram or additional well details:
3 a )Ni?f�'?4 N b"�°d a2✓f�;c91 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)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
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 2 ci (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
s 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
'� 'j abandonment to the following:
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 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
6E Inner casing/tubing length(if known): / (ft.) abandoned.
6g.Screen length(if known): / (ft.)
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contracaotytor Inf rmation: WELL ABANDONMENT DETAILS
!JL tti�� 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 I GW-30 i needed. Indicate TOTAL NUMBER of
e : V wells abandoned:
NC Well Contractor Certification Number p a 7b.Approximate volume of water remaining in well(s): �.. (gal.)
II- /! �/�'T 1,rIVe , FOR WATER SUPPLY WELLS ONLY:
Company Name iv Jp�/t�&
�'19 7c.Type of disinfectant used:
2.Well Construction Permit#: �'!
iii
List all applicable well construction permits(Le.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):
0 Agricultural ❑Municipal/Public 0 Neat Cement Grout entonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non ater Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
onitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation i G�9�iv ri-7p jla=� cA i p t 2A9
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
0 Geothermal(Closed Loop) ❑Tracer (J 11+-, /,//Y/ '`j P
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) _
4.Date well(s)abandoned: y 4 t -
5a.Well location: APR 2 8 2023
/riae/r e6° ),I) ')).23 jrltcrsr,.s:oil Pmc Jn I
Facurry/Owner N e Facility ID#(if applicable) 8.Certification: C+'1 e'�Q OG
l 1 ,3,� r/ �. /Pfc 034V/Le�Ø41 1-1-7- 3
�
Physic ddrelss,City,and Zip Signature of ertified Well Contractor or Well Owner Date
/7I& _ By signing this form, I hereby cent/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$, J?0 / N ?d,, �54;gig W You may use the back of this page to provide additional well site details or well
J f !/ 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 construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 0 (ft) 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: (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: c A (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): I (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
6E Inner casing/tubing length(if known): o (ft) 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

WELL ABANDONMENT RECORD For Internal Use ONLY: I
1.Well Contractor�^ Information:, WELL ABANDONMENT DETAILS 1
i769/J -5:h&t/7//
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 GW-30 is needed. Indicate TOTAL NUMBER of
l !,r wells abandoned: 4
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1: (gal.)
Ii 61Y/ 15/P$ 7:4VC.• FOR WATER SUPPLY WELLS ONLY:Company Name lt// &h i®i1/a
p. 7c.Type of disinfectant used:
2.Well Construction Permit#:S. Pi)
k 1'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if town 2.
7d.Amount of disinfectant used: Ca
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout entonite Chips or Pellets
❑Geothermal(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
0 Irrigation 0 Specialty Grout ❑ Gravel
Non- ater Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
onitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount o m terials used:
❑Aquifer Recharge ❑Groundwater Remediation
d �711`� e� J� ,
❑A uifer Storage and Recovery0 Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer /$
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) q // // e1lpw
p
ti
4.Date well(s)abandoned: .....7 r✓`'� "�'
APR 2 s 2023
5a.Well locationn:/ itiali
)l
. llts;i
Facility/Owner NaIe Facility IDA(if applicable) 8.Certification: CA'sa Q/30G
)i A 212A
Physical ddress,City,and Zip 4gJ4rf C ed Well Co actor or el 0 er Date
f By signing this form, I hereby cent&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 let/long is sufficient) ` 9.Site diagram or additional well details:
3 , /�a t/�p ,g3. OIr)/ 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)if available.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
6a.Well ID#: 1 abandonment to the following:
�n J Division of Water Resources,Information Processing Unit,
6b.Total well depth: `�/ (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection.Wells: In addition to sending the form to the address in 10a
6c.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: 1.3 (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 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
2 of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): i (ft.) abandoned.
6g.Screen length(if known): ' (ft.) •
1
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
g
1.Well Contractor Information: ..• " WELL ABANDONMENT DETAILS
9, 5,Ae it/// 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contdactor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Rwells abandoned: �
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):J ' • (gal.)
��� * // i - rv75hid, FOR WATER SUPPLY WELLS ONLY: .
Company Name !� 7c.Type of disinfectant used: 11°'Jo°f �
2.Well Construction Permit#: AIR List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1,b
7d.Amount of disinfectant used: ✓17
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that applyy)�)•
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 2P entonite Chips or Pellets
❑Geothermal(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- ater Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
onitoring ❑Recovery
Injection Well: 7£ or each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation r'�/t✓ipiii ire u✓ fro1 &A
❑Aquifer Storage and Recovery 0 Salinity Barrier 99> 9
0 Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 9 ,/ ��
1n
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) / � -p).4 _ t
4.Date well(s)abandoned: )
APR 2S202,
5a.Well
glllocatio,p^��y 1,
� G/ �V f/e t/e 5' l ie1l 11 I li1.U.�„3 u,i c3.S�t,�li
Facility/Owner Name d Facility ID#(if applicable) 8jww
fication: - r'tii'nOG
I f/ 5,giid e6'#i1Irt& •;&?'.3 /I 41-7 3
Physi N Addres`
® 1 ss,C'ty,and Zip Signature of Certi ed Well Contractor or Well Owner Date
e-L- 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:
3d, 07)(p N d)"e id 86) W You may use the back of this page to provide additional well site details or well
y 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
6a Well ID#: B abandonment to the following:
..." Division of Water Resources,Information Processing Unit,
6b.Total well depth: ; (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Pt 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c 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 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&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
T of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): o .(ft,) 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