Gaston_Well Abandonment_20230724

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" 1 3 WELL.BAND901NMENT RECORD ,
it `r North Carolina Department of Environment and Natural Resources-Division of Water
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'17 ;f v Quality
WELL CONTRACTOR CERTIFICATION# y
1.WELL CONTRACTOIC S. WELL DETAILS:
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' -)C>� `IkC�AGI:f HOuc.cMM,o _.. a-To Well tat Depth / 6 ft..Diameter.- In.
Cantraci IndMdua now 11 11 b.Water l evel(Relow Measuring Peat):/�' IL
oh G• - Measuring point hi (S ft.above land surface.
�-4! —rCompanyName ,
--• . • 1\ 7u.l�L2:irc �1AC.t. Lid
I. tAd n H.._ CASING: Length Diameter
L•l \k 5 d J , .-s 3` a.Casing Depth(if knownt): , • '. T It. In.
I CHI/or� ('"►�� )��o1 S.� d��-3� �� Zip Code b.Casing Removed: ,f�� ft. �is
Area code-Phone number. 7 DISINFECTION: Zl� �iL
tt.WELL INFORMATION: (Amauntpof 65%759f,caidu m used) .
SITE WELL ID##•(Ife cable) 0.•• SEALING MATERIAL•- �!
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STATE WELL PERMIT* (if applicable) .
fQ�15�A 1 C, Cement td lb. Cement lb.
COUNTY WELL PERMIT 1Ofapplicable) : & I l ` 3�`),"1 Water get. : Water
• (if applicable) f�+ F 1 `s 8entonko DWQ or OTHER PERMIT# 114-5
WELL USE(Check applicable usey 3 Monitoring �' Mdontlal `. BentoriiterP �itbe�.te , 5-'2/b J
❑;IIunlclpatlPubllc 0 IndustrielrCommeretti ❑-Agricultural. ❑t3 �
❑ Recevamjr .0 Injection 0 IrrigatioW414n • agat R� I V L r
1 o otrler(uatrse) /'- ' 4 2023
`r Type material - - .►1 HI
3.NtEt L LOCATION: (' �_ Amount / / e 3c�`:.:2:•
ti�'' Ar^ 9P Ur tit
COUNTY ] 1J QUADRANGLE , E` `` DVr1Qi3t?Z
NEAREST TOWN: elil-r0� /J orr^ ' _ 9. EXPLA METHOD EMPLACEM OF MATERIAL:
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(StrertlReM Name,Number.Community,SubdiaMon.-L t No..Parcel,Zp Code) - ,
TOPOGRAPHC/LAND_,.•-�G .
❑Slope 0 Valley O' taF t D..Ridge°Other
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(Check appropriate setling,�)l - 10. WELL DIAGRAM:Drava detailed sketch of Ike on the back of this
• LATITUDE 3 „ _ /"T / "DMS OR 3X.7clt]DtiotitiApp form showing total depth.depth and&waster ef screens(deny)"re remaining
In the well,gravel Interval.intervals of casing perforations,and depths and •
LONGRUDE'ter "DMS OR 7X.)DDDCCDoctpp types of till materlatsaed
( affen&Teel1makbeshosmonaUSGST�M�uyp� 11. DATEWELLABANDONED
"Iles fan»WnasusingGPSI map armdatlached to ()11 �S rjli �� 3
I DO HEREBY,CERTIFY THATTHIS WELL WAS ABANDONED IN ACCORDANCE
4L FACILITY-The srerfte of the bust mea whamthewet Is located Complete Oar TTHIS REC NCAC ' �CONSTRUCTION STANDARDS,AND THATA COPY OF -
(lf a iveldesdhu welt.alp 4e:complete 4b,well owner INbrmation only.)p tiAB B N P DED E ER.
FACILITY ID P Of apt t- ,.- I`
NAME OFFACILRY Ciale%1 c' ,(�
naLry j�� ' .8'`,- • OFC ED C !r OTOR DATE
AD00RpE,S- _ 4 ,5 1 OR('E -- a _ -
'`"'1.A C) 9(�J� SIGNATURE OF PRIVATE WELL OWNER ABANDONINGTHEyJ DATE
C or Town - Zip Code UM Ovate won mom=dim en Mace'wiwolosaabandons elsliter teedentlel toot
fib.CONTACTPERSONfWELL O`yiyNER: . In accordance toym�s,�ISA N/CAC EC.ot1,32)�f
NAME: G - m��tt_%.13 2tZ_5' 11 /!RS /7Q/Ct9 ''
PRINTEDNAtNE OP PERSON A9ANDOIItlIO THE WE IL
. STREETADDRESS .
Submit a copy to the owner and the.original to:Division of Water Quality-Information Pkocosstng,
161T Mall Service Center,Raleigh,NC 27899-1E17,Phone:(919)$0743 � Rev.00 Rv.5/1M00
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(12 lb
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WELL ABANtONMEN`l R CORD For Internal Use ONLY: . .
1.Well Contractor Information:��
o WELL ABANDONMENT DETAILS
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/1 1 Gh O.€1( 1 t"LLA.-a5 7a.For GeoprobemmPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoningwell on his/her property) well construction/depth, 1 GW-30 is.pth,only needed. Indicate TOTAL NUMBER of
2973—/1wells abandoned: I i
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NC Well ContractorCertification Number 7b.Approximate volume of water remaining in well(s): I Jp (gal.)
1 f`0..K-e-t S W e-l l a- PUyh.e (it FOR WATER SUPPLY WELLS ONLY:
Company Name1 7c.Type of disinfectant used: #717-
2.Well Construction Permit#: /V).J1
List all applicable well construction permits(i.e. IC,County.State.Variance,etc)if known
7d.Amount of disinfectant used: i .-C Up
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(fleating/Cooling Supply) Ed(esidential Water Supply(single) 0 Sand Cement Grout U Dry Clay
f]lndustrial/Cortimercial ❑Residential Water Supply(shared) 17'Concreto Grout 0 Drill Cuttings
Olrtigation , _ ❑Specialty Grout • - 0 Gravel
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Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring - ___ _❑Recovery -- - , 1 -
Injection Well: 7f.For each Material selected above,provide amount of materials used:
❑Aquifer Recharge ljGroundwater Retnediation ,C Q#---0s
❑Aquifer Storage apd Recovery ❑Salinity Barrier .1
❑Aquifer Test ❑Stonuwater Drainage
❑Experimental Technology-: °Subsidence Control . •
❑Geothermal(Closed Loop) OTracer 7g.Provide a brief description of the.abandonment procedure:
.❑Geothermal(Eleating/CoolingReturn) [lOther,(explain under 7g) _ 'r"`,..4.... '
. 4.Date well(s)abandoned: ice..
. ill L 2 4 2023 .
Sa.Well location:
IA P — FA DA114s (.' villt. LPL . I,�I4y.._ ,� rJ
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,o:. OG
Facility/Owner Name Facility ID#(if applicable) 8.Certification.
/3oiI Pal t cis i�r y 6�I)e{-u/ h 4)eis ,v.C't G7
.7 � � 7� 3
Physical ddress,-City and'Zip Signa of Certified Well Contractor or Well Owner Date
0t�J'1EYri
By signing this form,I hereby,cett fy 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one laMong is sufficient) 9.Site diagram or additional well details:
N 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 INSTRKI70NS
Attach welt construction record(s)((available.For multiple lil/ectton or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. '
A' n •
10a.l±pr AU Wells: Submit this form within 30 days of completion of well
6a.Well 1D#: . /V IA., abandonment to the following:
• Division of Water Resources,Information Processing Unit,
6b.Total well depth: 5z— - (ft.) - 1617 Mail Service Center,Raleigh,:NC 27699-1617
1ob.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 2.® (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 .
ndttress(es)above,also submit one cony of this forth within 30 duys of completion

WELL I
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v'V E LL AN DON M:�N'I'ItECUND For Internal Uso ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Flame(or well owner personally abandoning well on llisiher property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL'NUMBER of
�t-(-73,^4 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining:in weil(s): /0 . (gal.)
Fi�a.t..0 s W eta-- P � ,
��� � t FOIL WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit# AI 1 A
List all applicable well construction permits(i.a.VIIC County.State,Variance,eta)ifknoun
Lo
7d.Amount of disinfectant used: t�-G
3.Well use(check well use):
Water Supply Well: 7e,Sealing materials used(check all that apply):
°Agricultural °Municipal/Public °Neat Cement Grout fCrgentonite Clups'or Pellets
°Geothermal(Heating/Cooling Supply) CNfesidential Water Supply(single) 0 Sand Cement Grout U Dry Clay
°ludustritd/Commercial °Residential Water Supply(shared) 0 Concrete Grout CI.Drill Cuttings .
Qlrrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ''Cl Bentonite Slu
--°Monitoring - - - - --tRecovery- -- ny CI Other(explain under 7g)
%Section Well: ' 7f.For each material selected above,provide amount of materials used:
°Aquifer Recharge °Groundwater Remediation 160 /b.s
C°Aquifer Storage and Recovery °Salinity.Barrier I
i7Aquifer Test 'ClStormwater'Drainage _
°Experimental Technology" tJSubsidence Control
OGcotlterttal(Closed Loop) gTra�r 7g.Provide a brief descriptionn of the abandonment procedure:
QGeothetmal(IleatinglCooling Return) t]Other(explain under 7g) $)oto f y )23, _k s c.1 N P 3 / r1
J 7 .es
�/ p�"-2-3.J J1k a 2023
4.Date well(s) 1�1 !abandoned: 2
Sa.Well location: In`�rr n r,..:.,4,,,��.`
DWQMOG
Facility/Owner Name Facility lmDJ#(if applicable) 8.CertifIcation:
f302.Dent ►.Sa� errtjv; !J iti3 �a,/lrcN1c, z
Physical Address,City,and Zip
Signature of Ceaitied Well Contractor or WellOwner Date
CountyBy signing this form,I hemby certify that the well(s)was(were)abandoned in
Parcel Identification No.(MN) accordance with 154 NC,IC 02C.0100"or 2C.0200:Well Construction Standards
Sb.Latitude and longitude In degrees/infanta/seconds or decimal degrees: and that a copy of this record has been provided to the rcell owner.
(if well field,one lnUlong is sufficient) 9.Site diagram or additional well details:
N "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 fETAILS OF WEL1.4Sl BEING Ai1ANDONED
Moth well canshuc►ionrecord(s)tJatallable.Formulllplclnjectlonornon-water supply wells SUB nTIAI'IN37RUCttUhTS
ONLY with the same conshttetion/abandonnlent,you can submit one fern:,
�A� •
110a.For All We}Is: Submit this form within 30 days of completion of well
6a.Well 1AN: N 1 A abandonment to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: . 'C) (ft.) ' 1617 Mail Service Center,Raleigh,NC 27699-1617.
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter; 2, (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: 3 0 (ft.) Division of Water Resources,Underground Injection Control Program,
j 1636 Mail Service Center,Raleigh,NC 276991636
6e.Outer casing length(If known): / (B,) 10c.For Water Supply.&1piectionWells:In addition to sending the form to the
( address(es)above,also submit one copy of thus form within 30 days of completion
of well abandonment to the county health department of the county where
6E latter casing/tubing length(if known); .it i A (ft) abandoned,
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6g.Screen length(if known): /v)It (tt

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WELL A.IIANDON MI N'I'RECORD For Internal Use ONLY: �, .
1.Well Contractor Information: WELL ABANDONMENT'TENT DETAILS
AA c ( v
! (YL G"C I Fi^a�""C_t S 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
wells abandoned: d
2N?3 f'
NC Well Contractor Certification Number �//� !_� 9b.Approximate volume of�I ater remaining in well(s): ?7'd (gal,)
Fr -%/L C i s (Nell O-/ .1't} tab] , FOR WATER SUPPLY WELLS ONLY:
CompanyNeme P H 1
7c.Type of disinfectant used: `r
2.Well Construction Permit#: /I
List all applicable well`construction pe nils t e.-UIC,County,State.Variance.etc.)ifknotrn 4 G
7d.Amount of disinfectant used: 1
3.Well use(check well use):
Water Supply Well:. 7c.Sealing materials used(cheek all that apply)
°Agricultural DMunicipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
C0Geothennal(Heating/Cooling Supply) °residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
°Industrial/Commercial. ` °Residential Water Supply(shared) ['Concrete Grout Cl Drill Cuttings
°Irrigation Cl Specialty Grout 0Gravel
Non-Water Supply Well: `p Bentonite Slurry0 Other(explain under
- OMonrtoring - - --°Recovery- —
Injection Well: 7f.For each material selected above,provide amount of materials used:
°Aquifer Recharge ClGroundwater Repudiation
OAquifer Storage and Recovery °Salinity Barrier �yar`01-s
°Aquifer Test C IStonnwater Drainage
❑ExperimenW Technology C°Subsidence Control
❑Geothormal(Closed Loop) °Tracer 7g.Provide a brief
description of the abandonment procedure: J
❑Geotheana!(Heating/Cooling Return) CiOther(explain under 7g) 5 E..)(/ ! j �°9 I)r" e Cl.. �CJ-7r`�* 1 l°tl
tt v
CI P-rP®�i�r
4.Date well(s)abandoned: -/�^2' l'
Sa.Well location: JUL : 4 2J
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,r
6t^�d 1,ej rS F l;ply Ufa
tnior :ir-n r'f :aowrrrg to
Facility/Owner Name Pacility'7l)li(if applicable) 8.Certification: DV/Cti90G
-JJ IAA *nolt nya-: 1. 3 .te .AL,Ct.z4S'Id -ley ,, .co - C.-1 Z3
Physical Address,City,.an3Zip Si turn of Certified Well Contractor or Well Owner bate
By signing this form,I hereby certtfy that the wells)was(were)abandoned in
County •
Parcel identification No.(PIN) accordance with 154 NC/IC 02C:0100 or 2C..0200 Well Construction Standards
5b.Latitude and lOD tudcln d and that a copy ofthis record has been provided to the well owner,
gi egrees/minutes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient) 9.Site diagram or additional well details:
N 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:WELLfSI BEING ABANDONED sun
I►9l`ln1>iNSTRITTIONS
4trtach weltconsfruetign recorel(s)ifovallable.l%ormultfple bljection ornon,watersupplyweth
ONLY with the some constntctlon/abandonment,you can submit aneforn).
10a..For All Wells: Submit this foam within 30 days of completion of well
6n.Well ID#: . /V (lam abandonment to the following:
y Division of Water Resources,Information Processing:Unit,
6b.Total well depth: 5-0 . . (ft,) 1617 Mall Service Cedter,.Ihilelgh;NC 27699-1617
10b.For Iniecttop Wells: In addition to sending the fonm'to the address in l0a
6c.borehole diameter: Z 4.4 (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: q 0 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC276991636
6e.Outer casing length(if known): i, ({t,) 10c.For Water Sunnly,$Iptection 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): . tV// ` (ft) abandoned.
6g.Screen length(if known):
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