Iredell_Well Abandonment_20230825 (2)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Info•nnalion: SWELL ABANDONMENT DETAIL`S J'J,
Adam Wilcox 7a.For Gcoprobe/DPT or Closed-Looli Geothermal Wells having the same
Well ContractorNa ne(orwcll owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4396-C wells abandoned: I ,I
NC Well Contractor Certification Number 71).Approxinnn(e volinue of water reLaiuing in svelt(s): (gal.)
Yadkin TOR!WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit 0:
List all applicable well canstrucaopernnus(i.e.UIC,County,State,Variance,etc.)tfknaun
7d.Amount of disinfectant used:
3.Well ntse(check well use):
Water Supply Well: 7c.Scaling materials used(check nil!hat apply):
[]Agricultural ❑Nlusicipal/Public ❑ Neat Cement Grout ❑ Benlonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Saud Cement Grout ❑ Dry Clay
❑Industrial/Commercial• ©Residential Water Supply(shared) IN Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 9 Bentonite Slurry ❑ Other(explain tinder 7g)
Alvionitoring ❑Recovery
Injection Well: If.For each material selected above,Iprovide amount of materials used:
❑Aquifer Recharge ❑Ground-Ater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of qne nbutdwmnent procedure:
oGeotherinal(ClosedLoop) []Tracer The well was filled to the top with a
❑Geothermal(Heating/Cooling Return) ❑Other(e air iP e 7g�f' i _
�-t-3entonite and concrete grout slurry. A tremie pipe
a.DaIC�5'CII(S)aball(lOnCd: 4/24/2023 AUG 2 5�2023 was utilized to assure proper application of
Sit.Well location: r ormabicft Procwr.4P4 tithe slurry.
Cain, Anne E DWOMOG
Facility/OwnerNarne Facility lDM(if applicable) 8.Ccriilieation: ® e-
�.5066 Harmony Highway, Hamptonville, NC 27020 A ,�i /, •2`;20.?3
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953
By signing this form, I hereby certify that the well(s) was(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 provided to the well owner.
56.Lalihrde and longitude in rlegrees/sniuutesJsccouls or decimal degrees:
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
36.050572 N -80.755154 W You may use the back of this page to,provide additional well site details or well
abandonment details. You may also attacks additional pages if necessary.
CONSTRUCTION DE,rA1LS OF WELL(S)BEING ABANDONED
Aunc/n+•ellconslracdonrecanl(s)ifaral/able. farunnhipfei++/'ecriararnan-rrnrersrrpplyutlLr SUBi••IITTALINSTRUCTIONS
I
ONI.Ynrlth ilia save carstrnetton!abarrrlonntern,you can sabrnit one fora. r
/I 10a. For Wells:ells: Submit this fotin within 30 days of completion of well
6a.\Yell IDll: M W-11 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6h.Total well depth: 45 (ft.) 1617 Nlail Service Center,Raleigh,NC 27699-1617
10b.For f election Wells: In addition, to sending the form to the address in 10a
6e.Borehole di:uneter: 8.25 (in) above,also submit one copy of this fonn within 30 days of completion of%veil
abandonment to the following:
6d.Water level below ground surface: Unknown (ft) Division of Water Resources,Underground Injection Control Program,
1636!-fail Service Center,Raleigh,NC 27699-1636
6c.Outer casing leugilt(if known): NA (ft.) 10c.For Water Simply&li ieetion Rlells: 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
Er.Inner casing/tubing length(if known): 30 (ft.) abandoned.
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6g.Screen length(if known): 15 (ft.)
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Fonn GW-30 North Carolina Department ofEnvironmenial Qnality-Division of Water Resources I Revised 2-22-2016
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WELL ABANDONMENT RECORD For Intental Use ONLY:
1.Well Contractor hlformadon: WE, AIIANDONMENT DETAIL IS
Adam Wilcox 7a.For Geoprobe/DPT or Closed-LoYop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on Lis/lier property) well constnretion/depili,only 1 GW-30 lslneeded. Indicate TOTAL NUMBER of
4396-C wells abandoned: i II
NC Well ContmctorCertification Number 71).Approximate volume of water reimiining in well(s): (gal.)
Yadkin FOR WATEIt SUPPLY WELLS ONLY:
Company Name
� 7c.Type of disinfectant used:
2.Well Constructionbleirelc Permit 0: cr i
Llst all applicable well construction permits(f. l)lG, rot t ty`, e,l'arla+ce,ex•.)if knmrn
7d.Amount of disinfectant used:
3.Well use(check well use): AUG 2 5 2023
Water Supply Well: tom!^ r+tl tl.'* 7e.Sealing materials used(check all!that apply):
❑Agricultural lwq u t�et � ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout j El Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
iNom-\Yafer Supply Well: d Bentonite Slurry D Other(explain under 7g)
A Monitoring ❑Recovery
Injection Well: 7f,For each material selected above,',provide arnotint of materials used;
❑Aquifer Recharge ❑Groundwater Remediation
I •
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storm%ater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of tlic;abandonnient procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
The well was filled tg ;the top with a
Bentonite and concrete Igrout slurry. A tremie pipe
a.Date well(s)abandoned. 4/24/2023 was utilized to assure proper application of
5a.Well location: the slurry.
Cain, Anne E NA
Facility/OwnerNamc Facility lDII(if applicable) 8.Certifi!ca�lioll:: p �/
6066 Harmony Highway, Hamptonville, NC 27020
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953 By signing this form, I hereby certl �that the wells was were abandoned in
} g g f � f; () l >
County Porcel identification No.(PIN) accordance with 1 SA ArCAC 02C.0100 or 2C.0200 Well Construction Slanda•ds
and that a copy of 11tis record has been provided to the well owirer.
5b,Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 9.Site diagram or additional well details;
36.050572 Nr —80.755154 ", 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.
i
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED I
SUB\•IITTAL INSTRUCTIONS
Allaclnrellconstrnclioarecacl(s)jarailnble. 1%or nrrrtfiplehfectinnavron-�ratarstrpplywetts f
OM I'irith the sane can submit one form. I
1l It 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDN: MW-12 abandonment to the following:
Division of Water Resources,btformation Processing Unit,
61).Tolal well depth: 50 (ft.) 1617 Dlail Service Center,Raleigh,NC 27699-1617
10b. for Injection Wells: In addition to sending tine foam to the address in 10a
6e.Borehole diameter: $'25 (in.) above,also submit one copy of this form xvithin 30 days of completion of well
abandonment to the following:
6t1.Water level below ground surface:
Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 l4ail Set-vice Ccntl r,;Raleigh,l\'C 27699-1636
NA 10e.For\\rota'Sunnly&Lricefion Wells: lit addition to sending the form to the
Ge.Outer casing ICItg1I1(if Ii1r051'll): (ft.) 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
6G Inner casing/tubing length(if known); 35 (ft.) abandoned. I
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6g.Screen length(if known): 15
Fonu OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONNIENT DETAILSI
Adam Wilcox 7a.For Geoprobe/DPTorClosed-LooplGeothermal Wells having tile same
Well Contractor Name(or well owner personally abandoning well on hisgrer property) well construction/depth,only I GW-304is needed. indicate TOTAL NUMBER of
4396-C wells abandoned: II
NC Well ContmclorCertification Number --q 'i� f 7b•Approxhnatc volume,of water re i talining in well(s): (gal.)
Yadkin „ !! FOR WATER SUPPLY IYELLS ONLY:
Company Narne AN 2
7c,Type of disinfectarri used:
2.Well Construction Pernilt M �r V�
List all applicable n•ell construcann perarirAQr. i1V i rru l riance,etc.)ifkrtou'n
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(clieck all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Content Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout D Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: 9 Bentonite Slurry ❑Other(explain under 7g)
IRMonitoring DRecovery
Injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Reniediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer i
❑Geothermal(Heating/Cooling Return) ❑Olher(explain under 7g) The well was filled tq the top with a
bentonite and concrete grout slurry. A tremie pipe
d.Dale well(s)abatidoited: 4/24/2023 was utilized to assure proper application of
5a.Well location: the slurry. �
Cain, Anne E NA
Facility/Owner Name Facility 1DN(ifapplicablc) 8.Certification:
5066 Harmony Highway, Hamptonville, NC 27020 A4-- �i�iLt�r
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953 By signing this form,I hereby cerlifj lhaf the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100.or 2C.0200 DWI Construction Standards
and that a copy of this record has beenprovided to the well owner.
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees: i
(ifwcll field,one[at/long is sufficient) 9.Site diagram or additional well details:
36.050572 N -80.755154 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 SUBIWITTAL INSTRUCTIONS
Amacln+ell conslrrrcNar records)tf m•ailable.I%nr nudriple it Jecttam ar nna-n•auersupp!}nrldr
ONIA'irml+tbe same cvnsnucuto+r'nhmulaunenr,you con subudloneform, 10a. For All Wells.• Submit this form within 30 days of completion of well
6a.Well IDU MW-1 3 abandonment to the following:
Division of Water Resource's,Information Processing Unit,
6b.'rotai well depth: 53 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in) above, also subunit otie copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: Unknown (ft) Division of Wafer Resources,Undl rground Injection Control Program,
1636 Mail Service Centel r,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.Ton•Water•Sm)niv&Iniectioii Welis: In addition to sending the form to the
address(es)above,also submit one copy of this form writhin 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if luiow•n): 38 (ft.) abandoned.
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6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of 1Vater Resources Revised 2-22-2016
1 !

I
WELL ABANDONMENT RECORD For Internal Use ONLY: i
i �
1.Well Colhracto•Information: WELL ABANDONNIENT DETAILS
Adam Wilcox 7n.For Geoprobe/nPT or Closed-Lofop Gcollicrmal Wells having the same
Well Contractor Namc(or well ownerpersonally abandoning well on his/her property) well construction/depth,only I GW-36 is needed. Indicate'rarAL NUMBER of
4396-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volantc of n•ater renitiining in wcll(s): (gal.)
Yadkin �V i IrOR WATER SUPPLY\1rI;LLS ONLY:
Company Namc 20��
2.Well Cons(ructiol Permit ft:
AUG 2 5' 7e.Typeardisittreefanfased:
List all applicable well constnrcban permilr(i.e.UIC,Cot mr Slsrla�f e rrCn (c�i ll�(prrrr
Irr4�+ 7d.Anlount of disinfectant used: I
3.Well use(check well use):
Water Supply Well: 7c.Scaling nmtcrials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ! ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial OResidential Water Supply(shared) H Concrete Grout ❑ Drill Cuttings
[Irrigation ❑ Specially Grout ❑ Gravel
Non-Rater Supply Well: R Bentonite Slmry ❑Other(explain under 7g)
JyMonitoring ❑Recovery j
Injection Well: 7C For each material selected above,'Orovide amount of materials used:
❑Aquifer Recharge ❑Ground%vater Reinediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStortnwater Drainage
❑Experimental Technology ❑Subsidence Control j
7g.I t ovidc a brief description of the nbnntlonmcnt procedure:
❑Geollierntal(Closed Loop) ❑Tracer The well was filled to the top with a
❑Geotiternial(Heating/Cooling Return) 00ther(explain under 7g)
a.Date well(s)abaullellell: 4/24/2023 bentonite and concrete grout slurry. A tremie pipe
was utilized to assure proper application of
Sa.Well location: the slurry.
Cain, Anne E NA
Facility/Owner Name Facility]DO(if applicable) 8.Cerfiftcation:
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 form, 1 hereby cerlJ&that the u•el!(s) was(rw•e) abandoner!in
County Parcel Identification No.(PIN) accordance with 15A A'CAC 02C.0100 or.2C.0200 If'ell Construclion Slandards
and that a copy of this record has been provided to the well owner,Sb.Latitude and longitude in degrees/ntiuules/seconds or decimal degrees:
(ifwell field,one latilong is sufficient). 9.Site diagram or additional well details:
36,050572 N -80.755154 \\, 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.
CONS•I'RUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Altnclnrel/callskrrcviatrecord(.r)ifm•nflable. harmmrUiplehfcctionaraan-unlor.trrpplyu•ellr �
OA'LP with the same cwrsn action nbnmclorament,you can submil one foray.
lost. For All Wells: Submit this forin within 30 days of completion of%veil
6a.Well IDII: MW-14 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well deptlu 50 (ft) 1617\Mail Set-vice Cotter,Raleigh,NC 27699-1617
10b. Eor lulection Wells: In addition1to sending the fonn to the address in 10a
6c.Borehole diameter: 8.25 (bra) above,also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: Unknown (ff) Division of Water Resources,Underground Injection Control Program,
1636 IN-fail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) loc.For Water Supply&Injection Wells: In addition to sending the fonn to the
address(es)above,also submit one copy of,this forni within 30 days of completion
of well abandonment to the county icalth department of the county where
6f,Inner casing/tubiug length(if lalown): 35 (ft.) abandoned.
6g.Screen length(if known): 15
Foun GW-30 North Carolhra Department of fimironnrcntol Quality-Division of Water Resources I Revised 2-22-2016
I

i
l
WELL ABANDONMENT RECORD For Internal Use ONLY: I
hI
1.Well Conh•nctor Information: WELL ABANDONMENT DETAILS
Adam Wilcox 7a.For Gcoprobc/DPT ov Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on histherproperty) well construction/depth,only I GW-30 ii needed. indicate TOTAL NUMBER of
4396-C wells abandoned: I
� fd� !� 76.Approximate vohune ofwatcr rintaining in tvcll(s): (gal)
NC Well Contractor Certification Number " _ V
Yadkin ` `'` FOR WATER SUPPLY WE,,LLS ONLY:
Company Name
AN L 7c.'I'ypcofdisiufcctantused: �
2,Well Construction Permit N: + 9A UM
��� i
List all applicable well construction permits(he, array,1�r !r J'e1a)ifbiou-ir
7d.Amount of disinfectant used:
3.Well use(clicelt well use):
i
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural El Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) B Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 19 Bentonite Slurry ❑ Other(explain under 7g)
M Monitoring ❑Recovery
Injeefi.on Well: 7f.For each material selected above,provide annount of materials used:
❑Aquifer Recharge ❑Ground�tiater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stor %aterDrainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the,abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer The well was filled to the top with a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
a.Dale ncll(s)al,a,ndonned: 4/24/2023
bentonite and concrete;grout slurry. A tremie pipe
was utilized to assure proper application of
5a.Nell location:
the slurry.
Cain, Anne E NA
Facility/Owner Name Facility lDll(if applicable) 8.Certifneatioll:
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 form, 1 hereby cei•tlfy:that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC,,IC 02C.0100 or 2C.0200 lVell Construction Mandmzls
and that a copy of this record has beeniprovided to the well owner.
5b.Latitude and longitude in degrees/ntinutes/secouds o•decimal degrees:
(if well field,one Iaulong is sufficient) 9.Site diagram or additional well details:
36.050572 N -80.755154 W Your 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 1fELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
�tltaclttfullcol+slrtrcltoArecar�!(s)ijmailahlc. Forinuhiplcirjecliaiarani-sratersrrppl�n•ells ',
0A`LY with the satne catslruatiai abnndonntent,you con.rubmit one fork• IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDii: M W-15 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 50 (ft.) 1617 iMail Service Centcr,.Raleigh,NC 27699-1617
lob. For-Iniection Yells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (ill) above,also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: U nknown (ft.) Division of Water Resources,Until-ground Injection Control Program,
1636 A•Iail Service Cenler,iRaleigb,NC 27699-1636
6e,Outer casing length(if]morn): NA (ft.) 10c.ForWater Slimily&Driection Wells: in addition to sending the fonn to the
address(es)above,also submit one copy of this forth within 30 days of completion
of well abandonment to the county health department of the county where
6f.Ironer casing/hnbing length(if known): 35 (ft.) abandoned.
6g.Screen length(if lonovn): 15 (ff,) `
Fonn GW-30 North Carolina Department orCnvironnionlal Quality-Division orWoler Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY: l
I.Well Cont•aelor Information: WELL ABANDON\•IENT DETAILS
Adam Wilcox 71.For Gcoprobe/DPT or Closed-1.o p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/herproperty) well construction/depth,only 1 GW-30[islneeded. Indicate TOTAL NUMBER of
4396-C / D wells abandoned: II
NC Well Contractor Certification.Number ' � 7b.Approximate volume of water re,
e luaining in well(s): (gal.)
Yadkin AUG 2 5.2023 F OR WATER SUPPLY WELLS ONLY:
Company Name
trtr�Vr*jCn Pr icaloom 7c.'rype of dishifectan(,used:
2.!bell Construction Permit/h DWQMOG I;
List all applicable it-ell construction permils(i.e.WC,County,State,parlance,etc.)t(kno+en
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all(,hat apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Writer Supply(single) n Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: m Bentonite Slurry ❑ Other(explain under 7g)
(,Monitoring ❑Recovery
Injection Well: 7f.For each material selected nbove,'provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Sttbsidencc Control 7g,Provide a brief description of the�abandonnncnt procedure:
❑Geothermal(Closed Loop) ❑Tracer The well was filled to the top with a
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder 7g)
d.Date%%eIl(s)abandotrcd: 4/24/2023
bentonite and concrete grout slurry. A tremie pipe
was utilized to assure proper application of
So.Well location: the slurry.
Cain, Anne E NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
5066 Harmony Highway, Hampfonville, NC 27020
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953 By signing!Iris farm, 1 hereby certify that llte vell(s) eras (here) abandoned in
County Parcel identification No.(PIN) accordance with 15A XCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a cop},of this record has been'provided to the it-ell orner,
5b.Latitude and longitude in degreeshuinutes/seconds or decimal degrees:
(ifwell Geld,one lat/lor,g is sttfrlcient) 9.Site diagram or additional%yell details:
36.050572 N -80.755154 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 WE,LL(S)BEING ABANDONED SUB\IITTAL INSTRUCTIONS j
Rttncln+e0couslrnelionrzcorrl(sJifnrnilaLle. Forutulllplebjecllonorvrnn-nnlersrtpply+rel/s
0A'Ly uvdr the same consti•ticlion'abaatauaeiit,you can submit one form. 10a. For All Wells: Subunit this fonn within 30 days of completion of well
6a.Well ID#: M W-16 abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total%yell depth: 55 (ft.) 1617 i<LM Set-vice Cen(er,Raleigh,NC 27699-1617
10b, For Infection Wells: In addition'to sending the form to the address in l0a
6c.Borehole din meter: 8.25 fill.) above,also submit one copy of this form within 30 days of completion of well
abandonne it to the following:
6d.Water level below ground surface: Unknown (ft.) Division of Wafer Resources,Underground Injection Control Program,
1636 NMI]Set•vice Center,Raleigh,NC 27699-1636
NA 10c.For Water Sunuh,&infection R'ells: In addition to sending the form to the
Gc.Outer casing length(if!anon n): (ft.) address(es)above,also submit one copy of this form within 30 days of completion
,f of Neil abandonment to the county ;health department of the county where
6f.inner casing/tubing lengtb(if blown):40 (ft.) abandoned.
I
6g.Screen length(if krtowrt): 15 (ftJ
i
Fonn GW-30 North Carolina Department of Environmental Quality-Division ofWater Resources Revised 2-22-2016

f �
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELi.ABANDONMENT DETAILS
Adam Wilcox 7a.For Geoprobe/DPT or Closed-Loap Geothermal Wells having the same
Well CoutractorName(or well owner personally abandoning well on hisnier property) well construction/depth,only I GW-36 is needed. Indicate TOTAL NUMBER of
4396-C wells abandoned:
NC Well Contractor Certification Number _ V. ... 7b.Approximate volume of water r fml ining in well(s): (gal.)
Yadkin - ' lsE,VE
OR WATER SUPPLY WE,LLS ONLY:
Company Name i
AUG 2 5••2023 7e.Type of disinfectant used:
2.Well Construction Permit 11:
Lost all nppllenble well conwrncami ixri)ars(l.a.0 1.0 2wt?17h c .f ttoun
�±�tr 7d.Amount of disinfectant used: 1
3.Well use(clicck well use):
!Cater Supply Well: 7e.Scaling materials used(check 1111that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
I]Geothermal(Ileating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout i ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 9 Concrete Grout ❑ Drill Cuttings
❑lrfi ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: 19 Benlonite Slurry ❑ Other(explain under 7g)
mmonitoring ❑Recovery
Injection Well: 7r rol•each material selected above;provide annount of materials used:
❑Aquifer Recharge El Groundwater Remediation
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonmtmter Drainage
i
i
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of[lie abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer The well was filled to the top with a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
bentonite and concreteigrout slurry. A tremie pipe
4.Date inell(s)abandoned: 4/24/2023
was utilized to assure proper application of
5.1.Well location: the slurry.
Cain, Anne E NA
Facility/Owner Name Facility lD4(ifapplicable) 9.Certtiificaattion:
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 form, I hereby cerlif!,,that the well(s) was(irere)abandoned in
County Parcel identification No.(PIN) accordance with 15.1 AVAC 02C,0100 at•2C.0200 Well Construction Slandards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner,
(iPwell field,one lnulong is stifliciem) 9.Site diagram or additional well details:
36.050572 N -80.755154 W You nnny use the back of this page to'Provide additional well site details or well
abandonment details. You may also alliieli additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Manchu•ell�ar�truclionracard(sJifo•oilnble.Porvmdttpleiijecliwtm•umi-ivrdersupplyu•e/!s I
ONLY iNth the sane rntistrtrctimilabntnlmnuertt,you can submit one form.
10a, For All Wells. Submit this form within 30 days of completion of well
6a.Well ID11: M W—1 7 abandonment to the following:
i
Division of Water Resouces,Information Processing Unit,
6b.Total well depth: 55 (ft.) 1617 Mail Service Center,Raleigh,INC 27699-1617
10b,For Iuicetiou Wells: In addition to sending the fonn to the address in 10a
6c.Ilorchole diameter: 8.25 (ill.) above,also submit one copy of this Conn within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: U nknown (ft.) Division of Water Resources,Underground Irjection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (f(•) 10c.Tm•Water Sunnh•s Iniectioit)'Vells: In addition to sending the fonn to the
address(es)above,also submit one copyt of this form within 30 days of completion
of well abandonment to the county )iealth department of the county where
6f.Inner casing/tubing length(if ltaown): 40 abandoned.
6g.Screen length(if lumvil): 15
Fonn OW-30 North Carolina Department of Environmental Quality-Division of Water Resources { Itevised 2-22-2016

fl
WELL ABANDONMENT RECORD For internal Us,ONLY:
1,Well Contractor Information: WELL ABANDONIVIENT DETAILS
I
Adam Wilcox 7a.For Geoprobe/DI'Tor 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. htdicate'I.OTAL NUMBER of
4396-C wells abandoned:
NC Well Con(raclorCertification Number �' �`�� 7b,Approximate vol(une of water r Imahning in well(s): (gal,)
Yadkin �..•�f �i 6...SS.. FOR WATER SUPPLY WELLS ONI LY:
Company Name AUG 2 5 2023 7c.Type of disinfectant used:
2.Well Construction Permit/t: P tyl1+D�f t;I►rli I,
List all applicable bell construction pennus(i.e.f/ ., omiip, f yt f� ?t i c/o.)if knows
7d.Amount of disi ifectard used: I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials Used(check alljthat apply):
❑Agricultural QMunicipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) X Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well- a Bentonite Slurry i ❑ Other(explain under 7g)
RMotitoring QRecovery
Injection Well: 7f.For each material selected above,l provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Rcmediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test QStormwater Drainage
I-
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer The well was filled to the top with a
QGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
bentonite and concrete grout slurry. A tremie pipe
4.Date well(s)abandoned: 4/24/2023
was utilized to assure proper application of
5a.Well location: the slurry.
Cain, Anne E NA
Facility/Owner Name Facility ID#(ifapplicable) 8.Ceftif ca/flo�ll: / �
5066 Harmony Highway, Hamptonville, NC 27020 /�'_` �i
Physical Address,City,and Zip Signature ofCcrtified Well Con(ractor or Nell Owner Date
Irendell 4884111953 By signing this oian, I hereby cerli .that the well(s)was were abandoned in
� g g f s f. (> ( >
County Parcel identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 We//Consli'aclion Standards
and that a copy of finis recotrl has beeti!provided to the well owner.
5b,Latitude and longitude in degrees/minutes/seconds or•decimal degrees: I
(ifwcll field,one hat/long is sufficient) 9.Site dingram or additional Well details:
36.050572 N -80.755154 „r You may use.the back of this page toiprovide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
11
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBJNJITTAL INSTRUCTIONS !:
Attadnrcllconstruciiarlreconi(s)tfarailable.Forinallipleirlectiarovtar-sratersappl},irells
OALF wiib the same cmtstruclioniabamtoitocnt,you can submit one farm.
10a. For All Yells: Submit this form within 30 days of completion of well
6%Well IDA: M W^18 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total Well depth: 55 (ft.) 1617 Mail Set-vice Cotter,Raleigh,NC 27699-1617
IOb. For Iniection Wells: In addition to sending the form to the address in 10a
60.Borehole dianneter: 8.25 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below o grutd surface• Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Nlail Service Center,iRaleigh,NC 27699-1636
6c.Outer casing length(if known): NA {ft.) 10c.For Water Snnnly&Iniection Wells: 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 county where
6E Inner casing/tubing length(if lwown): 40 (ft.) abandoned.
6g.Screen length(if known); 15 {ft.) I
Fonn GRr-30 North Carolina Department of Eneiromnental Quality-Division of Water Resources Revised 2 22-2016