WI0600071_Well Records_20130607

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R_ELL CONSTRUCTION'RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
CRARI-E -ERRy
Well Contractor Name
Nt C Wf_ 4 ► 92-- B
NC Well Contractor Certification Number
�I EjC i C. ,
Company Name
2. Well Construction Permit N�(M.aml,
List all appficable hell catrstrucaon peState, Marionce. era)
3. Well Use (check well,use):
❑Agricultural
❑Cieothennal (FfeatinJCooling Supply)
❑ industrial/Commercial
❑Irrisation
Non -Thaler Supply Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer T•cst
❑L•xperimentel Technology
❑Geothermal (Closed Loop)
❑MunicipaVPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
groundwater Remediation
❑Salinity Barrier
❑Starmwater Drainage
❑Subsidence Control
❑`f racer
❑Other (explain under fi21 li
4. Date Wells) Complctcd:s Ib i3— Weil iDitJ_yV — 1 to I W —HF
5a. Well Location: 15 2 t G 3
Facility/Owner
aNFwn 1ti�o.R CL GR3.R9aG Uu�".ta�vD (if1p)lie ab1c)
titft-1NSi : )�y Rtt�Si3Ul�C 6�G 28352
Physical Address, City, and Zip
SCOTLAK) b
CO11°t>" Parcel Idaui(ication Nu. (11IN)
ib. Latifude and longitude in degrees/minutes/seconds or decimal degrees:
tirwell field, one lal•'Inng is sufficient)
t4 36f7a 9 a— N S58 3'Z W
6..is (are) the well(s): 131"ermanent or Cyll'emporar'
7. Is this a repair to an existing, well: ❑Yes or 531u
IOUs is a repair. Jill oat know: sell construction information and explain the minor o% the
repair under :..21 r entarkr section or at, die back
of iltis 1brnr.
S. Number ofivelis constructed: 1 J
For narbiple irlecrion arson-uaersopplr trellt' OVLY with the sauce construction, rmr cart
.nrhnlit a,t;%orm.
9. Total well depth below land surface: LJ 9`
rot multiple it -ells list all deptim (t dfili retry (example-1 a;_5on' and ? rnl afl')
r
10. Static water level helots top of casing: _ lO (ft.)
lfuoterlerel is above casir(,, itse "="
11. Borehole diameter:' (���J (in.)
12. Well construction method:
fi.e. anger.. rotary, cable, direct push, Cie.)
FOR WATER SUPPLY WELLS ONLY:
13a. field („ pm) Method of test:
13b. Disinfection type: Amount:
for Internal Use ONLY:
414320
fL ft.
ft.
i ft. i ft. I in, i
ft. I f. I in. I
ft. fL I in.
fL fL
R. ft.
ft ft.
ft. ft.
22. Certification:
.'i�nalure of Certified l c raclor � ale
i{iP N(wdog thisTorm, l here4v cert((i, drar the uell(s) ens (wea) corcrtrncted in accordance
with lid A'GI C 02C.010(1 no, lid 1%(.4(: WC.020(1 11"ell C.'onsnvction Standards and that a
capr n%rhrr wcord has been pr nt•ided to Me, er/l ovrer•.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or %veil
construction details. You may also attach additional pages ifnecessan.
SUI3iiI=AL iNST'UCTiONS .
24a. For All Wells: Submit [his limn within 30 (lays of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center„Raleigh, NC 27699-1617
24h. For Iniection Yells: In addition to sending the form to (he address in 24:i
above• also submit a copy of this firm within 30 days or completion of* well
construction to the following:
Division of Water Quality, Underground Injection Conti -of Program,
1636 Mail Service Center. Raleigh, NC: 27699-1636
24c. For Water Snnnly & injection NVells• in addition to sending the firm to
the address(es) above, also submit one copy of this form within 30 days (it'
completion of well construction to die county health department of the county
where constructed,
Form GW.I North Carolina Dep:uunent of Environntcut and Naniml Resources — Division of lyarcr Qualiy Rcriscd Jan. 20l?

WELLCONSTRUCTION RECORD
This form can le used for single or multiple wells
I. Well Contractor Information:
C +AR LE ERR
%Yell Contractor Nam,
NC V�I�'. A-1 P,2-- U
NC Well Contncter Certification Number
Company Nnmc t�
2. Well Construction Permit #: I JA
List all applicable lull constrileliat pe1•nlits #.eJ Comm; Slate, Irarianee, etc.)
3, Well Use (check well use):
❑Agricultural ❑MtHlieipal/Ptlblie
❑Geothcmtal (Ijeatin&Cooling Supply) ❑Residential Water Supply (single
❑Industrial/Commercial ❑Residential Water Supply (shares
❑Aquifer Rccharoe
❑Aquifer Stont_,e and Recovery
❑Aquifer Test
01-:xperimental Technology
❑Gcolhcnnal(Closed Loop)
4. Date 1ire11(s) Completed:5
5a. Well Location: 5
wGround% ater Remediation
/❑Salinity Barrier
❑Storm%atcr Drainage
❑Subsidence Control
❑Tracer
Return) []Other (explain under #21
I-3- well [D# I — I to I W-
3
1 fl rl tfd eC,71 FgA_ b cc% St r.- 13 )4.0,
oar tty!OwtiUnnC�,�`.� � Fae�lih• 1DM (ifapplicable)
E R tv O� C Al1�t�1C Lz I-r �-
15( tk . AAA-InASi - LA\) RlOBORG i�G 283S2
Physical Address. City.:md Zip
SWTL�1fJ�
County Parcel Ideiniricalion No. (PIN)
5h. Latitude and Longitudc in degrees/minutes/seconds or decimal degrees:
f ifwell field, wife IaUlone is su0icicnl)
N N I S5'S 3a9
6. Is (are) the well(s): ❑Permanent or Csll"emporan
7. Is this a repair to an existing well: ❑Yes or �tti'o
!/'this is if remin ill our 47101171 inch\ construction it fornrarion and explain. the nature of the
repair under i:31 remark section or oil life back of this farm•
S. Number of wells constructed: 1 5
nor unhhiple hf ecdon or non-umtrsupp¢• urelly ONLY with the scone constructrnt, You call
submit one form.
9. Total well depth helots land surface: L 9 ✓D' (ft.)
rormultiplewrlLslist all depdksifdfj?l reat(example-31,V0,and?at/0h•)
10. Static wafer level below top ofcasing: 10t (ft-)
lfnrterlerelisalwrecasing. use -
//
11. Iiareholc diameler:� (in.)
12. Well construction method
(i.e. mtgcr, rotary, cable, thresh push, etc.)
FOR W V17ER SUPPLY WELTS ONLY:
13a. Yield (gpin) Alethod of test:
13b. Disinfection type: Amount:
r
r Internal Use ONI,Y:
414319
22. Certification:
ff � ) 3
igttanw of Ccrtifi«I lCc1 radon Date
Its signing thisJohvn, / hereby' cergli, that the ie ll(s) was (utrc) cottstrtrcnnl in accordance
with ISd RCAC 03C.01011 nr 1]d NG4C 1)2C.-r1100 Ili•// r.'nnsnvctiau Standards and that a
cant• ofdtis record has heen ph»rided to rile well otraer,
23. Site diagram or additional well details:
You may use fhc back of this page to provide additional %veil site details or %Yell
construction details. You may also attach additional pages ifllecessar•.
SIJRi ll'fTAL•INS'1'UCTIONS
24a. For All Wells: Submit this form within 3o clays of completion of well
construction to the following:
Division of Water Qualify, Information Processing Unif,
1617 X-lail Scl-vice Center, Raleigh, \C 27699-1617
24b, For Injection llrcll+: In addition to sending the form to the address in 24a
above, also submit a copy of this loran within 30 days of completion of well
construction to the lollowim•:
Division (if Water Quality, Underground Injection Conti -of Program,
1636 Mail Service Center, Raleigh, NC: 27699-1636
24c. For Wager Sunnly K Injection Wells: III addition to sending the firm to
the address(es) above, also submit one copy of this form within 30 days of
completion of xwll construction to die county health department of the county
where constructed.
Font Gl\'-I North Carolina Dep:uvnent of Hueirountcnt and Mamml Resources— Division of WatcrQualit%
Re%ised Jan. 20

0
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Q*RLe , ` L R R
Wcll Contractor Natne (or well owmcr persomilly abandoning wall on his/her property)
NfAd(' -q8a-B
NC Wcll Contractor Cenificatfon Number
V IC0N FCC (NC.
Company Nanic (c
2. Well Construction Permit #: _N i A
List all applicable- well constn(crion pet naet t.e. Cotmtp, Stare, pm'ilince. etc.) /1lmouu
3. Well use (check well use):
❑Agricultttr l
❑Gcotlhcnnal (Hcating/Cooling Supply)
❑ Industrial/Comnureial
Non -Water Supply Well:
❑Aquifer Ri:charge
❑Aquifer Storage and Recover•
❑AquirLr Tcst
❑Experinunfal Technology
❑Geothermal (Closed Loup)
f Wo
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 15,
ror tareltiple itliection or non -eater 'sapplt' nt'US O:VU 0•illt the same
eonstntcrion/nl.vindonment,,ioneansitbntitonejorm.
7b. Approximate volume of water remaining in well(s): 1�L/ t4 (fiah)
F
WATER SUPPLY WELLS ONLY:ype of disinfectant used:
mount or disinfectant used:
7c ' aling materials used (check all that apply):
7 Recovery
7E Got each material selected above , prove amount of materials used:
idrroundwater Renirdiation
alinity Barrier
❑Stonnwater Drainage
❑Subsidence Control
❑•rracer
❑Municipal/Public cat Cement Grout ❑ Bcntonitc Chips or pellets
❑Residential \Valet Supply (single) ❑ Sand Cement Grout ❑Dry
Clay
❑Residential \'Pater Supply (shared)
❑ Concrete Grout ❑Drill Cultingc
❑ Specialty Grout ❑ Graveli
cntonitc Slurry ❑ Other (explain under 7g)
❑GeOdiennal (Flcating/C'ooling Itcl�uum) ❑Other(explain u7 tinder
4. Date tvell(s) abandoactl:5 I V 13 - 5 02 I ) 13
5.1. Well location:
Pk-ririo-4Er_ (ok 0s-A Srr•E Ijo.
Fta'cflfty/Ownc{{�uFacilf1vlD:!(fl`aprlfcabtc)
lJfv,�(.Lhuryt,r�•ca(s LZc
(eu�: MUST-.����1til�RC t t�IC283�x2
cPi yysical\ATddress. City, and zip
County Parcel Identification No. INN)
5b. Latitude and longitude in degrees/ntinutcs/secouds or decimal degrees:
(if well field, one hUlong is su0icient)
N 3b176;)_q a• N E 1135 uat q, W
CONSTRUCHON Df /'All S OF WFI I (S) BEING ABANDONED
:1(raclr eel/ caustnrcnon recorr/(,c) i%rrrtri/able. 1•�r tme(riplc injeerion ar eon-rrrtrer.aq�plr
url/.t ONL 1' n{th the sjatue consrrnctiad(rbandowncnr, )wtr can submit one form.
6a. WcII 1D& 1 UV - l tD
6b. •Total well depth: U M.)
6c.Boreltolediameler:C2• l lilt,)
6d. Water level below ground surface: Or r Vt.)
6c. Outer casing length (if known): _ tom) I �% (ft.)
t
6F. inner casing/tubing length (if known): ,N (ft.)
6g. Screen length (if Itnown):.5 —M.)
3LBS _ Lars rIIT-E
SLU RV
7g. Provide a brief description of the abandonment procedure:
rcitil IE✓ Q(�E e9 E' 0 klEj
S. Certification: ''DIN I SO 1UOi'3
�f;TCTT% Signtu are o a' ell Comrrc r well RMLCVP4ORMATIOA1 P , v
CE SING . !
41' signing th/s,form. 1 hciehr certt,'li, that the uel/(s) heirs ('were) abantioncd in
accordance with 15,1 ArC,4C' 02C.0100 or 2C _0200 IVc11 C'oucnaction Sr[nalarrLr
and that a cola• o(7his record hits been praritle(j it) rlu• well otrner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandoi meal details. �'ou may also attach additional pages ifntccssary.
SUBMITTAL INSTRUCTIONS
l0a, For All Wells: Submit this Ibrnt within 30 [lays of coniplction of, well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. ror Injection Wells•, fit addition to sending die lonn to the address in 10:t
altove, also submit one copy of this limn within 3o days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 ,,N4ail Service Center, Raleigh, \C 27699-1636
10c. For Water Sunnh' & Infection Wells: In addition to sending file fonn to
the address(cs) above, also submit one copy of this fonn within 30 clays of
completion of well abandonment to the county hllb eta nct�it of due county
where abandoned.
. F
For,"GW-30 North Camlina Department ofGnvironnicurand Natural Resources - Division of WaterQuality
SUN ? 1 Zni3
9 j cd March 2013

WELL ABANDONMENT RECORD
This font[ can be used for single or multiple wells
I. Well Contractor information:
CAt�L e � R R\!
Well Contractor Name (or well o%%itcr persormlly abnndoniug %yell on histher property)
NICtn(C 14I8a-8
NC %Yell Contractor Certification Number
\1 IRON F>C ' NC•
Company ?sane ff
2. Well Construction Permit ff: N I
List all applicable well eorstntctiorr permnc Iii.e. Connor, stare, I"ariance. etc.) irlwomt
3. Well use (check well use):
water Supply Well:
❑Agricultural ❑NfunicipallPublic
❑Gcodtcnnal (licating/Cooling Supply) ❑Residential Water Supply (single)
❑IndustrialiCommercial ❑Residential Water Supply (shared)
Non -Water Supply Well:
❑lk•lonitoring
01tecovery
Injection Wc1I:
❑Aquifer Rcoharge
`( mundwater Itemcdiat(on
❑AquifcrStorage and Recover•
/❑Sal(nity Ramer
❑Aquiibr Test
❑Stonnwater Drainage •
❑rExperimental Technology
❑Subsidence Control
❑GLothermal (Closed Loop)
❑Tracer
❑Gcothennal (FfealinglC'ooling Itetum)
❑Otber(explain under 7g)
A. Date well(s) nbandoned:J lb
Sa. Well location:
PETIr10,4Et- f&i i+iS -A Strt; /.Iv, •^> E3-000(
Facilityl0+roc y�n facili v Ill l (il`a rablc lic
t;(�lE ljK� � •i7t [ nc<iz, v�1t& C C_ )
LrL . /U A i MST
Physical Address, City. and Zip
Sc. UT1 �1,1D
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degreestminutestseconds or decimal degrees:
(ifwell field, one lavlong is Sufficient)
CONSTRUCTION DFTAI S OF WFI I (S) BEING ABANDONED
.Itlach 'cell construction record(s) irmz,ilable. For nudtiple igjecrtan or non-utlter snppA•
cells O.YL I' with the smnr eoasauctiar/irbandaunertt. run call submit one rnnn.
6a. Well IIV: I W - l tD l w-1 S
6b.'rotal well depth: 50 (ft.)
6c.Borehole dianeter:02•
6d. Water level below ground surface: 1 D/ (ft.)
6e. Outer casing length (if k00%vu):
t t%
6f. Inner casing/tubing length (if known): N 1� M.)
6g. Screen length Of )mown): 5 (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: I
For Multiple h0ecdon or non -[toter .rnpp& wells OA'LP [rill, the some
conrtnrction/abandonatent. Von can subunit onejorM.
7b. Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS ONLY:
7a'fype of disinfectant used:
7d. Amount of disinfectant used:
ing materials used (check all that apply):
Cement Grout ❑ Bentouile Chips or Pcllau;
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grow ❑ Drill Cuttings
❑ Specialty Grout ❑ Grovel
Slung
❑ Other (explain under7g)
7E For each material selected above, provide amount of materials used:
irE-
7g. Provide a brief description of the abandonment procedure:
��iV1 I E✓ �%� �,Lfe� �' RO 0 11(��
IIII%I 9010,
H. Certification:
�- WATER QUAUTY SECTIO I t
RMAT10N PROC i3 Signatu OR;0nifladvell Contras tt Wcll Owner pate
By signing this (orw, 1 herebr,cer10' that the we//(s) was ('here) abandoned in
aecordrrrtce With 15,1 NCAC 02C'.0100 or 2C.0200 Well C'otrsrracrinnr Srcnuhuds
and that a colrr q0h is record hits been provider( to the well owner
9. Site diagram or additional ivell details:
You may use the back of this page to provide additional well site details or %veil
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL
AL iNS'1'RC1CfiONS
IOa. For All Wells: Subunit this Iona within 30 clays of conpletion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells. Ju addit(on to sending the loon to the address in IOa
above, also submit one copy of this lbrul within 30 days of completion of well
abandonment to the lollowing:
Division of Water Quality, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Sunoly & injection Wells: In addition to sending the torn[ to
the address(") above, also submit one copy of this fonn within 30 clays of
completion of well abandonment to the county health department of the county
%ehcrcabandoncd. GEC R—FRC
,UN Z 4 2013
Form G%V.30 North Carolina (hpartruenl of L'[rvirnnttu:nt aril lasso I Resources- Division of Watcr Quality ' 1`ti`Y/ �Q12013