Iredell_Well Abandonment_20230825 (4)

WELL ABANDONMENT RECORD For Intent aI Use ONLY:
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1.Well Contractor Information: WELL ABANDONMEN'I'DETAILS`
Adam Wilcox 7a.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the seine
Well Contractor Name(or well owner personally abandoning well on his/lier property) well construction/depth,only 1 GW-30 1s needed. Indicate TOTAL NUMBER of
4396-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water re]Inaliaing in rvell(s): (gal.)
h
Yadkin It OR!PATER SUPPLY WELLS ONLY:
Company Name I
7c.Type of disinfectant used:
2.Well Construction Permit M.
List all applicable urll constrtrcllon permits•(i.e.IIIC.County,State,Ya•larce,etc)if bimm
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublia ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout f ❑ Dry Clay
❑itadustrial/Commercial . ❑Residential Water Supply(shared) a Concrete Grout i. ❑ Drill Cuttings
❑Irri alion ❑ Specialty Grout i ❑ Gravel
Non-1'Vater Supply Well: d Bentonite Slurry i ❑ Other(explain under 7g)
MMonitoring ❑Recovery 1.
Injection Well: 7f,For each material selected above,iiwovide amount of materials used:
El Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer'I'est ❑Storinwater Drainage I.
❑Experimental Technology ❑Subsidence Control !'
7g.Provide a brief description of theinbarrtlmamcnl procedure:
❑Geothermal(Closed Loop) ❑`Tracer l'
LiGeotherinal(HeatinglCooling Return) ❑Other(e— he well was filled to the top with a
'15entonite and concrete'grout slurry. A tremie pipe
d.Datewell(s)nbandoned: 4/24/2023 AUG 2 5'2023 Was utilized to assure proper application of
sa.Well location: lnft(t�,atcn Proc uOe slurry.
Cain, Anne E NA DW0113OG
Facility/Owner Name Facility ID#(ifapplicable) 8.Cerlificati0u:
5066 Harmony Highway, Hamptonvilie, NC 27020 41—
Physical Address,City,and Zip Signature of Certified Well Contmetor or Well Owner Date
Irendell 4884111953 By signing this form, !hereby cerlfy�lthat the arell(s)it-as(here)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 yrovided to the well owner.
Sb.Latitude and longitude in degrees/minutes/sceontls or tICC1111AI degrees:
(ifwell field,one fat/long is sufficient) 9.Site dingrnen or additional,.vell details:
36,050572 N —80.755154 Rr You may use the back of this page tojprovide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
I'
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBi irl'AL INSTRUCTIONS
Attaclnrellcoastrucliottrecotzl(s)ifm•ailable.Parin+dtiplebjectiotror•tray-uwterstipplyu•ells
OtY1.1'n'ith the saarc carst•udiotdabaadoaareat,pori car suborn ate forat. 10a. For All 1Ve115: Submit this form within 30 daps of completion of well
y AS-3 abandonment to the following:
Ga.Well IDN: �
I
Division of Winter Resources,Information Processing Unit,
Gb.'I'otal well depth: 60 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: Ili addition,to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in.) above,also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6r1.Water level below ground surface• U n known (ft) Division of Water Resources,Underground Injection Control Program,
1636 Nlail Service Center,IRnleigh,NC27699-1636
Ge.Outer casing ICllgtlr(If known): NA ft.) 10c.ror Water Sunnh'&Iniection Wells: In addition to sending the fonn to tine
(
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
Unknown abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen iength(if limowil): Unknown
Form GNV-30 North Carolina Department of En ironmcntnt Quality-Division of Water Resources Revised 2-22.2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONNIENT DETAiLSII
Adam Wilcox 7a,For Geoprobe/DPT o•Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/herpropetty) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4396-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water renlnaluhng ill well(s): (gal.)
Yadkin FOR WATER SUPPLY WELLS ONLY:
Company Name j
7c.Type of disinfectant used:
2.Well Construction Permit M
List all appllcahle well construction permits(i.e.111C1 Coatry,Stare,Variance,etc.)tf knotrn
7<h Amount of disinfectant used:
3.Well use(cheek Nell use):
Water Supply Well: 7e.Scaling materials used(cheek all that apply):
❑Agriculturai ❑Municipal/Publie Cl Neat Cement Grout ❑Benlonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial El Residential Water Supply(shared) R Concrete Grout { ❑Drill Cuttings
❑Irri ation CI Specially Grout ❑ Gravel
Non-Wnter Supply Well: N Bentonite Slurry ❑ Other(explain under 7g)
RManitoring ❑Recovery
Injection Well: 7G For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remedialion
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the'abandonnrcnt procedure:
[]Geothermal(Closed Loop) ❑'tracer the well was filled to
�J the flop with a
i
❑Geothermal(Heating/Cooling Return) ❑Other(expl inkti r1 e 7g)
bentonite and concretejgrout slurry. A tremie pipe
a.Datewell(s)abandoned:4/24/2023 AUG 2 5.2023 Was utilized to assure proper application of
58.Well locaflon: InlIG'M-AiC01 n1.
DV,'Q!8'3G t e slurry.
Cain, Anne E NA
Facility/Owner Name Facility ID#(ifopplicable) 8.CcHifca/tiol_:
5066 Harmony Highway, Hamptonville, NC 27020
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953 By signing this ornt, I hereb,cerli that the :cells iras mere abandoned in
Count Parcel Identification No.(PIN) c S S f } 11 (Jr (were)
Y ) accordance with ISA iVG�IC E►2C.0700 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 wail field,one IaUloug is sutlicienl) 9.Site diagram or additional Nell details:
36.050572 Nr —80,755154 ", You may use the back of this page toiprovide additional well site details or .veil
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUMMITTAL INSTRUCTIONS
Aitachtrellconstrrteiiourecotct(s)ifm•ailable.Porntriitlpletajectionornan-tratersuppli,u•elis•
ONLI'u-lth the scone construcriwt!abarulourneut,pair can suhurit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDH:AS-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb.Total well depth: (ft.)
60 1617 Nfail Service Center,Raleigh,NC 27699-1617
L
10b,For Iniectiot Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in.) above,also submit one copy of this form
rm within 30 days of completion of well
abandonment to the following:
6d.11odor level below ground surface:
Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
163E Nfail Service Center;Raleigh,NC 27699-1636
i1
Ge.Outer casing length(if lnuovn): NA (ft.) 10e.Tor Wit ter Sunnly&Injection\ti'ells: In addition to sending file form to the
address(es)above,also submit one copy of this form«thin 30 days of completion
of well abandonment to the county; health department of the county where
Gf.Ill er easing/tirbirg length(if taroun}: U n known(ft) abandoned.
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6g.Screen length(if known): U n kn own M)
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Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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III
WELL ABANDONMENT RECORD For Internal Use ONLY:
li
1.Well Contractor Infor•ntation: WELL ABANDONMMENT DETAILS '
Adam Wilcox 7a.For Gcoprobc/DPTorClosed-LogpGcothermal Wells having the same
Well Contractor Name(or well owner personally abandoning;well on bis/Iher property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4396-•C wells abandoned:
NC well Contractor Certification Number 7b.Approximate volume of grater renjaiihing it lvell(s): (gnl.)
Yadkin TOR WATER SUPPLY WILLS ONLY-
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.(11C,Cmtno,,State,Marlance,etc.)i(,htown
7d.Amount of disinfectant used
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heatiog/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Watev Supply Well; M Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery '
Injection Well: 7f.For earls material selected above,provide amount of materials use(]:
❑Aquifer Recharge ❑Groundwater Retnediation j
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control I
❑Geolltermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
The well was filled to the top with a
[]Geothermal(Ilealing(Cooling Return) ❑Other(exp ain,,,ndg
d.Date well(s)abandoned: 4/24/2023 U ntonite and concrete grout slurry. A tremie pipe
AUG 2 5' 2023 was utilized to assure proper application of
5n.Well location:
ir,�l , �rt slurry.
Cain, Anne E NAl DWOMY'ka
Facility/Owner Name Facility iD#(ifapplicnble) S.Certification: �
5066 Harmony Highway, Hamptonville, NC 27020 Ale- eel-
Physical Address,City,and Zip Signature of Certified well Contractor or well O%v ei' r Date
Irendell 4884111953
By signing this fornn,I hereby cer'Iify,'Ilia/1he well(s) eras(hvere) abandoned in
County Parcel Identification No.(PIN) accordance with 15A MCAC 02C.0100-or 2C.0200 If-'ell Construction Standards
and that a copy of this record has been provided to fine well ou-ner'.
5b.Latitude and longitude in degreeshuhuUcs/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional nvcll dell its:
36.050572 N, -80.755154 11, You tuay use the back of this page to provide additional well site details or well
abandonment details. You may also athich additional pages if necessary.
I.
CONSTRUCTION DETAILS OF WELLS)BITING ABANDONED SUBMITTAL INSTRUCTIONS
fiiiaclt welicanrtructlan records)tfat ailable.lbr tatdtiple h fecilon orvton-a-ater supple trells
OAIM'u-Ith the saute eoustritettoalabamlamtent,you can submit one form.
10a. For All Wells: Submit this fenu within 30 days of completion of well
6a.Well ID#:AS-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 60 (ft,) 1617 Nlail Service Canter,Raleigh,NC 27699-1617
I.
lob.For lidecliom Welis: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in.) above, also submit one copy of this form«Rhin 30 days of completion of well
abandonment to the following: fl
Unknown Division of Water Resources,Underground Injection Control Program,
Gd.Water level blow ground surface: (ff.) 163614ail Service Centelr,'Raleigh,NC 27699-1636
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Ge.Outer casing length(if lo►orvn): NA —(ft.) 10c.For 11'aterSunmh•&lrniectiorr lyells: In addition to sending the form to the
nddress(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
Gf.Lutev casing/tubing length(if lmonnth); U n known(ft) abandoned.
Gg.Screen length(if known Unknown): (ft.)
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Fonn Gw-30 North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22.2016