Iredell_Well Abandonment_20230825 (3)

WELL ABANDONMENT RECORD Por Internal Use ONLY:
4 ,
1.Well Contractor Information: WELL ABANDONMENT DETAILIS
Adam Wilcox 7a.For Geoprobc/DPT or Closed-Loo'p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on histher property) well construction1depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4396-C wells abandoned:
NC Well ConimctorCertification Number rj; ` � 7b•Approximale volullic of water roll ainhtg ill Nvell(s):
Yadkin I v FOR WATER SUPPLY'*YELLS ONLY:
Company Name "AUG 2 5 20 7c,'1 ypc of dlisinfectaut used:
2.Well Construction Permit#: t
List all applicable well construction permits(i.e. ifknown
alrt?)� 7d.Amount of disinfectant used:
3.Well use(elleck well use):
Water Supply Well: 7c.Scaling materials 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 ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Nan-Water Supply Well: 19 Bentonite Slurry ❑ Other(explain under 7g)
IMMonitoring ❑Recovery I'
Injection Well: 7f.For each material selected above,"provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer-Test ❑StorniNater Drainage
❑Experimental"Technology ❑Subsidence Control 7g.provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Healing/Cooling Return) ❑Other(explain under 7g) The well was filled to the top with a
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/OwnerNnme PacilityID#(ifapplicable) 8.Certification:
5066 Harmony Highway Hamptonville NC 27020
Physical Address,City,and Zip Signature ofCertifred%Vell Contractor or Well Owner Date
I rendell 4884111953 By signing this form, 1 hereb},certify'Mat file wetl($) was(were)abandoned in
County Parcel Identification No.(PIN) accordlance frith 1 Sit NCAC 02C.0100 or 2C.0200 Well Construction Standards
and thal a copy of this record has been:provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well(letails:
36.050572 IN -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.
CONSTRUCTION DETAILS OF NYELL(S)BEING ABANDONED SUB\,IITTAL INSTRUCTIONS
Rliaclnrellconst•uciiarrr'ecord(s)ifarailable. Farrnrillipleiiyecriorrornar-u•alersupplya•ells
0jVLY id1h the same constrtrctirnr'ahnndamrrexi,}•oar can submit one form.
10a. For All Wells: Submit this foRm within 30 days of completion of well
6n.Well 1D#: RW-1 abandonment to the following:
Division of Water Resources,information,Processing Unit,
6b.Total well depth: 67 1617 1-fail Service Cetite'r,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in t0a
6c.Borehole diameter: 8•25 (ill.) above, also submit one copy of this forin within 30 days of completion of well
abandonment to the following:
6d.R'aler level below ground surfacer Unknown (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centcr,iltaleigly NC 27699-1636
1. !
6e.Outer casing length(if knon•n): NA (ft) foe,Tor Witter n ter Sunily&blieeflon ells: 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 lalown): Unknown(ft) abandoned.
i
6g.Scrceu length(if lalowu Unknown): (ft,)
Fonn OW-30 North Carolina Department of Environmental Quality-Division of Water Rcsouroes j Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Cottrac(o•Information: WELL ABANDONMENT DCTAILIS
Adam Wilcox 7a,For Geoprobe/DPT or Closetl-Loop Geothermal Wells having the same
Well Contractor Nnmc(or well 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
NC Well Contractor Certification Number f+ 7b.Approximate volume of water•I.landuling En well(s): (gal,)
GENE-D I
Yadkin FOR WATER SUPPLY WELLS ONLY:
Company Name AUb L
7c.Type of disinfectant used:
2.Well Construction Permit#: .� r
List all applicable,rell catslr»char penults(i.e, raunl} 7a( wr r c,etc.)Onoun
� 7d.Amouutofdisiufecfaulused: !
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(cheek allltha(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 ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑irri ation ❑ Specialty Grout ❑ Gravel
Not-11'ater Supply Well: 19 Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery j
Inicction\Yell: 7f.For each material selected above,l provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Gcotfrertnal(Closed Loop) ❑Tracer
7g.Provide a brief desct•iption of the,abaudournent procedure:
The well was filled to the top with a
❑Geothermal(llcating/Cooling Return) 00ther(explain under 7g)
bentonite and concrete igrout slurry. A tremie pipe
4.Date ivell(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#(if applicable) 8.Certification:
5066 Harmony Highway, Hamptonville, NC 27020
Physical Address,City,and Zip Sibnmture of Certified Well Contactor or Well Owner Date
Irendell 4884111953 By signing this form, I hereby certi,Widt Ore wells) was (mete)abandoned in
County Parcel ldentificntion No.(PIN) accordance with 1 Sit 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 degreeshnimUes/seconds or dechnal degrees:
(if well field,one hat/long is sufficient) 9.Site diagram of 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.
CONS•I'RUCTION DETAILS OF WELL(S)BEING ABANDONED
�ltraclnrellcanstr»crlonrrcarrl(s)/faratlanle.ra•n»rniplettlectla,ra,rta»-„arerxrrppryire!!.c SUB\EIT'I'ALINS'IRIJCl'iONS
ONLY wit/r 1lte same carslrnetiarabar»la»ntenl,you can submit are farm.
10a. For All Wells: Submit this form within 30 days of completion of well
Ga,Well IDN: RW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb.Total well deptli: 69 (ft.) 1617 IN
Service Center,Raleigh,NC 27699-16I7
lob. For Iniectiou Wells: hr additionito sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
Ge.Borehole diameter: 8.25 (in.) abandonment to the following:
Unknown Division of Water Resources,Underground Injection Control Program,
Gd.1\Ater level below ground surface: (ff.)
r�t 1636 Mail Service Ccntci•,Raleigh,NC 27699-1636
Gc.Outer casing length(if known): ,VA (ff.) IOc.Tor Water Supply&Infection WI ll§: [n addition to sending the form to the
address(es)above,also submit one copyyof 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 laioea): Unknown(ff.) abandoned.
nt
I
6g.Set-cell length(if known): Unknown (ft.)
Fonn OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Reviscd 2-22-201G
I

Ii
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: \YELL ABANDONI•IENT DCTA S
Adam Wilcox 7a.For Geoprobe/DI'T or Closed-Loop Geothermal Wells having the sane
Well Contractor Name(or well owner personally abandoning well on hislhor property) well construction/depth,only I GW-36 i i needed. Indicate TOTAL,NUMBER of
4396-C wells abandoned:
NC Well ContractorCertiGcation Number RECEIVED 7b.Approxintale volume of ivaler remaining in well(s): (gal.)
Yadkin AAA— 9 5' 023 FOR WATER SUPPLY\YELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit t: ln,`0fXAVi:n r'r�t �Una
t» i
List all applicahle a•e11 construction permits(I.e.UIC,C'ourrty,Stat,I ,•r 1ree,etc.)rf known �
7t1.Amount of disinfectant used;
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(Cheek alfthat 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 El Residential Water Supply(shared) 19 Concrete Grout ❑Drill Cuttings
❑irri ation ❑Specialty Grout ❑ Gravel
Non-Wrtler Supply Well: H Bentonite Shtrry ❑Other(explain under 7g)
111 ivionitoring ❑Recovery
Injection Well: 7G For each material selected above;provide amount of materials used:
❑Aqui fer Recharge ❑Groundwater Remediation
❑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(CoolingReturn) ❑Other(explain under 78) The well was filled to the top with a
bentonite and concrete'grout slurry. A tremie pipe
a•Date well(s)abandoned. 4/24/2023 was utilized to assure proper application of
SR.Well location: the slurry. !,
Cain, Anne E NA
Facility/Owner Name Facility[DO(if applicable) 8•Certiticaatio�n: - ®
5066 Harmony Highway, Hamptonville, NC 27020 _E%�� r
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
lrendell 4884111953 By sighing this forte,I hereby certtf',that the well(s) was(here)abandoned in
County Parcel Identification No.(PIN) accordance ivith 1 SA NCAC 02C.0100 or 2C.0200 Nell Construction Standards
and that a copy of this record has been provided to the well ou-ner.
5b.Latitude and longitude in degrecs/ininutes/seconds or decimal degrees:
(if well field,one laUlong is 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 attiteh additional pages if necessary.
p
CONSTRUCTION DETAILS OF\VELL(S)BEING ABANDONED SUBI[ITTAL INSTRUCTIONS
Ahach well constnrmion records)tfarailablt. I ornrrdrtple i,jecttorr oreau-wnrersupply+rclts
OA'LI'with the seine couslrrrdlon'nbrordaunenl,you can submit one farm.
loa. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDH: RW-3 abandonment to the following:
Division of Water Resource§,Information Processing Unit,
6b.Total well depth: 70 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1Ob.For Iniection Wells: In addition!i,lo'sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: 25 (in,) abandonment to the following: i l
Unknown Division of Water Resources,Underground Injection Control Program,
Gt1.Water level below ground surface; (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) loc.For Water Sunuly S Iniection 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
Gf.Inner Ca5liig/tltbing 1CngtI1(If iC1nOWtl): Unknown(ft.) abandoned.
I
6g.Serecu length(if lutotti'n Unknown): (ft.)
Foam OW-30 North Carolina Department of Environmental Quality-Di+'ision of Watcr Resources Revised 2-22-2016

. I
WELL ABANDONMENT RECORD 1 Forlutental Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Adam Wilcox 7a,For Gcoprobe/DPT or Closed-L op Geothermal Wells having the same
Well Contractor Nnno(or well owner personally aba rdop;nbwv baryNisJfi� p well construction/depth,only 1 OW-30 is needed. Indicate TOTAL NUMBER of
4396-C E..,1. ` � wells abandoned: i
qq
NC Well Contractor Certification Number AUG 2 5 2�L3 7b.Approximate volume of water•remaining it,well(s): (gal.)
Yadkin I, FOR W TER SUPPLY WELLS ONLY:
Company Name IfM'7i rr �+� e y 1
7e.Typc of tlisinfeclant used:
2.Wall Consh•uction Permit 0:
i.irt all applicable n•ell cwrstnrcilou permits(i.e.UIC,Coran%Slate,Variance,em.)Jknown
7d.Amount of disinfectant used:
3.Well use(elteek well use):
Water-Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
i
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout ❑ Drill Cullings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Wall: 19 Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 711 For each malarial selected above;provide amount of materials used-.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salutity Barrier
❑Aquifer Test ❑Stormwaler Drainage
OExperimental Technology ❑Subsidence Control❑Gcotltertrtal(Closed Loop) ❑Tracer 7g.Provide a brief description of the ahand onm ant procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) The well was filled to the top with a
bentonite and concrete!'grout slurry. A tremie pipe
a.Datewell(s)abandoned: 4/24/2023 was utilized to assure proper application of
sa.Well location: the slurry.
Cain, Anne E NA
Facility/Owner Name Facility IM(ifapplicable) 8.Certification:
5066 Harmony Highway, Hamptonville, NC 27020
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953 B),sighing this form, 1 hereh),certifythat the irell(s) etas (Were) abandoned in
Comay Parcel identification No.(PIN) accordance with 15A rYCAC 02C.0100 or 2C,0200 ifell Construction Standards
and that a cop),of this record has been provided to the,cell owner.
Sb.Latihule and longitude in degrees/minutes/seconds or decimal degrees: �
(ifwell field,one lat/long is sufficient) 9.Site diagram ov 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.
CONSTRucrION DETAILS OF WELL(Si BITING ABANDONED SUBMITTAL INSTRUCTIONS
Atiaclnrell coitsiraction record(s)ifavallahle.I arntrdllpte it jccllon ar ua,raraler s apple a el/s
OrVl.I'uiNrliresamecarslrrrcilouabmtdonnreru,�urrcyansahnrlronejarnt 10a. For All Wells: Submit this form within 30 days of completion of well
Ga,Well ID#: SVE-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb.Total well depth: 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1G17
IOb,For Infection Wells: In addilioni to sending the fonn to the address in I On
Ge.Borehole diameter: 8,25 (in,) above,also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
Gd.Water level below ground
Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
surface:
1636 l-fail Service Centelr,Raleigh,NC 27699-1636
NA 10c.For water Supply&Infection\Yells: In addition to sending the form to the
Gc.Outer casing length(if Iarotvn): —(ft.) address(es)above,also submit one copy';or this form within 30 days ofcompletion
of well abandonment to the county he,ilth department of the county where
6f.Inner casing/tubing length(if lalown): Unknown(f,) abandoned.
Unknown `
Gg.Screen leuglh(if larown): (ft.)
Form GNr-30 North Carolina Department of Environmental Quality-Division of Waier Resources I Revised 2.22-2016

i �
WELL ABANDONMENT RECORD For IntemaI Use ONLY: k
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Adam Wilcox 7a.For Geoprobe/DPT or Closed-L`oop Geothermal Wells havingthe same
Well Contractor Nanre(or well ownerpersonally abandoning well on his/her property) well construction/depth,only 1 GW40 is needed. Indicate TOTAL NUMBER of
4396-C wells abandoned: I I
NC Well Contractor Certification Number l ,tip..������ 7b.Approximate volurne of water remaining maining in tvell(s): (gal,)
Yadkin l IIL.��� FOR 1YATI;R SUPPLY WELLS ONLY:
Company Name
7c.'fypc ofdisinfcclaul used:
2.Well Construction Permit H: t4t'1F? n°sjcn pr.^.-•GSsk9 4 Urd
List all applicable trill constn+clion pennfts(t.e.•U1C,County,Sit+�`,�jr'�ly e7 ere.)if lnrouu
7d.Amount of disinfectant used; '
3.Well use(clieckwell rise):
Water Supply Well; 7c.Sealing niate0als used(cliecic rill that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Healing/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ❑ Drill Cuttings
❑hri alien Cl Specialty Grout ❑ Gravel
Non-\Pater Supply Well: d Bentonite Shtrry ❑ Other(explain under 7g)
!(Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundvmter Remediation
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control❑Geolhertnal(Closed Loop) ❑Tracer 7g,Provide a brief description of the abandonment procedure;❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) The well was filled to the top with a
4.Datervell(s)abarrtlarred; 4/24/2023
bentonite and concrete,grout slurry. A tremie pipe
was utilized to assure proper application of
5a.Well location: the slurry.
Cain, Anne E NA
Facility/Owner Name Facility tDN(if applicable) 8.Certificatiou: t,
5066 Harmony Highway, Hamptonville, NC 27020
Physical Address,City,and Zip Signature of Certified Well Contractor or We1115wne- Date
Irendell 4884111953
By signing this form,I hereby certify drat the well(s) was (were) abandoned in
Connty Parcel Identification No.(PIN) accordance with 15A AICAC 02C.0100 or 2C.0200 IYell Construction Standards
and that a copy of this record has been provided 10 file well otruer.
5b.Lntitude and longitude in degreeshninntes/seconds or decimal degrees:
(if well field,one lattlong 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 Weil site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMI.1••I•AL INSTRUCTIONS
AfrncJl uell coruL•ucrion records)lfarallable.!or u+utlipte lujectfora orvrnn-tralersr+ppJ�•uetls ,
ONL I'with fire same consu•+rctionlabaudaru+e+N,),oil con s ub+nit one form.
SUE-2 IOa. 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: 35 (f,) 1617 Nlail Service Center,Raleigh,NC 27699-1617
10h.For Inicction Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (it,) above,also`submit one copy of this fortis within 30 days of completion of well
abandonment to the following:
6d.Writer level below ground surface: Unknown (fl) Division of Water Resources,Underground Injection Control Prograur,
1636 Nfail Service Centcr;Raleigh,NC 27699-1636
NA W 10c.For Water Sunmh,&Inicction ells: In addition to sending the form to the
be.Outer casing length(if known): NA 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.
Gf.Inner casing/hnbhrg icmgth(if lutosrn): (ft.)
6g.Screen lertgtb(if known): Unknown illy
Font GW-30 Nortlr Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

f
WELL ABANDONMENT RECORD For Internal Use ONLY:
II
1.Well Contractor Information: WELL ABANDONMENT Dr TAILS'
lLS'
Adam Wilcox 7n.For Geoprobe/DPT or Close(I-Ij 1)Geothermal\Yells having the same
Well Contractor Name(or well owner personally abandoning well on histher property) well construction/depth,only I GW-30 is needed. indicate TOTAL NUMBER of
r wells abandoned: I
NC Well I 4396ContractorCertification Number ' `EHCE I E*D 7b,Approximate volume of water remaining in Ivell(s): (gal.)
Yadkin AUG 2 5 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name
IftlCiiXi DB�!�G r�Uld 7c.Type of disinfectant used:
2,Well Co list ructiot Permit 0: D 03-00
list all applicable null construction porn ins(i.e.U/C,Conroy,State,Pariance,ere.)tf knoirn I'
7d.Anionut of disinfectant used:
3.Well use(check ivell use):
Witter Supply Well: 7e,Sealing materials 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 ❑Residential Water Supply(shared) H Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specially Grout ❑ Gravel
Non-Wafer Supply Well: 9 Bentonite Slurry ❑Other(explain under 7g)
HMonitoring ❑Recovery
Injection Well: 7f.For ench material selected above;provide antouut of materials Used:
❑Aquifer Recharge ❑Groundwater Remcdiation
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stomiwater Drainage
❑Experimental Technology []Subsidence Control 7g.Provide a brief description of the abandonment procedure;
❑Geothermal(Closed Loop) ❑Tracer The well was filled to the to with a
[]Geothermal(licating/Cooling Return) ❑Other(explain under 7g) l7
bentonite and concrete''grout slurry. A tremie pipe
d.Date well(s)abandoned: 4/24//2023
was utilized to assure proper application of
So.Well location: the slurry.
Cain, Anne E NA
Facility/OwnerNanre Facility ID#(if applicable) S.eerliflcahOn: o
5066 Harmony Highway, Hamptonville, NC 27020 A- moo"
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owae Date
Irendell 4884111953il
By S7gIll7Jg this fOTlff,I hereby certify ll+al the ivel!(s) was(ieere)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA AICAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been:provided to the lrel/owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees;
(ifweil field,one Int/long is sufficient) 9.Site diagram or additional well details:
36.050572 ,N -80.755154 W You may use the back or this page to'provide additional%veil site details or well
abandonment details. You may also atiach additional pages if necessary.
CONSTRUCTION DETAILS OF NVELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach if-ell co»structtannrecorrl(r)ifarailable.For aedifpleiiyecaonornwr-u-otersupplyirells I'
ONLY wilt the sante canstracBarr/ahandatnteni,yarn can subunit one for lu.
SvCM3 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDN: G abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb.Total lvcll depth: 35 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
Ge.Borehole diameter: 8.25 (ill.) 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: Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 flail Service Centi r,Raleigh,NC 27699-1636
6e.Outer casfug length(if l(IieWII): NA —(ft.) I0c.Co•Water Sunnly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this fern within 30 days of completion
of well abandonment to the county;health department of the county where
6f,lnnet•ensing/tubing leligtli(if iclioi%'n): Unknown(ft.) abandoned. 1
6g.screen length(if known): Unknown (ft.)
Fonn ON-30 North Carolina Department of Envirouniental Quality-Division of Water Resources Revised 2-22-2016
I