Moore_Well Abandonment_20231006

WELL ABANDONMEN.T RECORD For Mental U ON IA% i
"Iliis fbim can Ge'used for sittgleor multiptetiEellli \ U VLn
I.Well Contractor inform:titO : WELL ABANDONMENT DETAILS.
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Brian Ewing 7a.Number of wells being abandoned: 1
W L erimeMrNenteloir WidlnWedOdWanally:absii4niugwalaritiisl)terprepertyy Fri' raa1opl atteettor or noniorafer lupin), walls .ONLY wan tl i .some
•ctioV necfianfabonithane 1, verc»rr,r&lvnJtaiejfiror; •
4240-B . •
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NC Well ConlragorCoitifu:attarNnil>Sc 7h,Approihnate snlunte of Ffat�'r etnaining in"�rcll(s): („at.)
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SAEDACCO FOR WATER SUPPLY WELLS ONLY;
Company Name7e,Type of disinfectant used:
2:Well Caia traction•Permit ti:, . ' .
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Ltit ddl4.iphroble iilelt pawing(i.t Cuuri?r',•$taro.Val-Jame,ce,fitJ dJbn,,etc!tfd'arorrrt 7d.atinonnt of disinfectant used:
3.Well idle Ohm*.Well use): ._. .
Water.Supph•Well: 7w.Scaling materials used(c1icel611 that apply):
gelgr cultural DMitnicipll/Putilic- N,fieat Ccnieill,Gwnt 0 Bcntoaitc Chips Pr Pellets,
❑Sand Cement GmutF., a -�` ., :i 1 bg`t' v
btl othermitt tficati! Cooli°g Supply) blicsidential Water, ipply.(shig le) ,,�,,. .,r c rt r
❑halustrial/Coninicrcial DRcsidenti,d Water Supply(shared) ❑,Conerete'Gtirut -r Cl Lidilttitings
❑iniwttion • 0'Specivlty gwuf .' OCT 0 6 2O2 gar l
on-Watcr Su pp Iv Well: Cl Bentotute:Slgiay 0 Other(explain under 7g)
®INciuituring-. C Recovery. ,v ,.
injection Wcl(; 7f-,For.each material selected �iaxt<;ji'tri�9de amonntofmaterials used:
❑Aquifer Recharge. ❑Groundviater Remediation Neat Cem.•471b ,Wtr•3ga1. Sand.Cem.•lb ,Wtr•gal.
Cl.r1'qutferSioiitge atxf Reco eiv I7Saliniiv Darner-
❑Aquifer Test ❑Stamm iterDrain Drainage -
❑Experiutental To.hnoio>bf • DSubsldence Control 7g.Pr Side-a brief description of the'abandnnment proeedure-
1:IGeoiherinat(Closed Loop) . OTt:net
tremi from the bottom to surface
.ClGeothermat(iimtting/Cooling Return)' ❑0thertep lain uuder7a) .
4.Datewill(s).ah;indoned 9-12-23
Sa.•Well Fixation:
Matthews:Market
Facilitpncr}into F cililylIia(lupplicablal • &cerlutiealioi0 .
3196 Vass-Carthage Rd. Whispering Pines, NC -28327 •BFI,a f E.VY I fl. 9/21/2023
Physical;Address;City,acidZip SiuiilnrnorC¢itl0Cd1WeliCeittrd;lciJ n-r'.ilDwoer Dine
Moore Ltv vigniiig MO Jfrrm,.1 he 4v cei•tffy.thnt the ivell('s}wa..):(wore)abruidoned at
Count) . - rPdo el lckniifiCiUairNO.(PINS accurrintice wilts 15.4'.\C4C(12C:,01110 or 2C.0200 Well Cofi,tractiori Slartdk rds
and that a copyaftis record hes,heen pro ided to MCI:veil ci nen ''
S1t.,1 atitudeand loagitaeee-in.degrces(nitnutcslscennds or dedin'rl.degreess I
Or welt lktd Om Git1Io1l1'is suilictra) 9.Site diagram or additional well'details•
You uia use the back of this page to preside additional well.Sim details or well
- N - • - - •W abandonment details. You may also:attach additional pates if necessary. '
Ct)NCTRI1CTION.DETAiLS OF WELL(S)BEING ABANDONED .SUBM 1I AT.TNSTRUCTiONS
:math tf:efr corwirilditirr ritivritts)be uirilIdle_ lvir multiple itljrittrue nr ism-wetter supply I
ireils ONLY with the lamer nstrortioniaruvrdkl,xstnit,tart raw utbirnt oreAno. Ian.•Fur MI Wells Suhmit this farm Within 30 days of completion of well
Ga.Well m0:MW-4 .abandonment to the following: 1
Dhvistiin of Water Resourets,Info rmatien•Pr gassing Unit;
Gb.Total well depth: 10 ((L. 1617 M:ail-Senice'Cetitcr,•Ralcig;h,NC 27699-1617
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1l0h.For inlccihe;Wells: In.addition to sending,tho form to the aadross in i0a
' Ge.ilorehole diat<etew 1 above,also subntit.one copy.of tttis.fora within 30'days of eomptetiou'of well
(hi.) :abandonment to the-fallowing: '
DMsion of Water Rdsourees;Underground•injection Control Ptrogram,
rid.Waterlevet.bclow ground)sutrfaee (ft.) 1636 Mail Scnvice'Centcr,Raleigh,NC 276994636
10e.-Far Water Sunnis.&Tiiiettion Wells: in addition-to sending the form to
6e.Outer casing length(if known); , . -_(ft.) the:address(esl'abode. also submit.one copy of this fbtm Within 30 days of
completion of well abandonniene to the county health department of the county •
61.tuner easing/tubing length(if!,'grown): (ft.) *here abctirdottcd,
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. 6g.Screen length(if lawnn):5 ,(flt.)
Form GW-30 Nonh Carolm Degumneai of Envlronotent aril Natural Desolates-Division of Water iRe owns Revised Arrpusi 2013

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WELL ABANDONIVIEN.T RECORD Fat Internal OW ONLY: ; 1
Mils fornicaiiheused.fer single-of inultiPlemellS •
I.Well Contractor Informatitin: IVELL ABANIM)MMENT"DETAILS
Brian Ewing7a,Number of wells being abandoned:1
. tu W411eUrirai*Mariti Or'w411tist. lt kfskinally:ab..aixifitiLuig uell.ciu lifsht&tittitictly) Frir muttipk tn./await or mul oruff r sitiq...(3. wens. °Amy 1,,,m/ me smile
ainitriretwalizbauddifinott,pm Our.wthigit OtolArnt.
4240-B i .
7h.App.iiiiittrate•valume of Wetn'.retitaining in Will(s) ktal-)
NC Well CantraetarCertilicationNumbef •
SAEDACCO
FOR WATER:SIMPLY WELLS ONLY:
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Company Name 7e.Type ofdisinfectant Used:
I Well Construction Petnilt if:/ , .
hit oil opplklitrle tivl!peiirtiig 6:4L'ethudy,Slam.riiiierce,hijecito° oL)?flototi,o-
7d.Atimunt of:disinfectant USed:
3.Wial Ark(ebeek 1,i'cil DOI ,. .
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Water Snpph Welk .7e.".'Staling materials-used(eke&all that apply):
1:1Agricultural " Ijkfitaicipal/Public. 5d,Neat Conant:Otani 0Rerapnite Chips or PelletS.,
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aCieollicmul(Hcatitig/Cooling SuPply) • bitcsidet?tlid,Water Stipp!),(sitig1u) 1:1 801d;CHWrkt arp.tP i77:1---:E:,1 prD1-.e11.1,Y
i . 1.;__i,,,11,..... ;, gi, PE • - „
DIndustrialiCommereial DResiciential Water Simply'(shated) • -b.C°.11Fivtt Grout' - rill' ullings
Ellnigation - • b:Specials:Grout OCT 0 6 208. tav"5i
Nop-Water•SOpply Well:. ' • . ' Cl Beakiaite Shim ' Cl Oilier(egplain under 7g)
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Milkiltinlloring-, . , . Elltec,ovet)„'_ Irr41-4?..:nt pr:.7,7,:-..-4,4t2i7.-g UM
ir.stjeeti9p WO:. " . • 7f.For each material selectOkal)4%erskjide antountat materials used:
. . DAtiutfoytcharge ET(inimithi-ato Rntkdkiiidit e
• - Neat Cem.:471b ,Wtr:3gal., Sand.Cem.:lb ,Wtr:gal.
likrinifer StOnige ard-ReCovery OSalinity Barrier
ElAitinfa Test- EISttimmeter Drainage . • .
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litqteiiinental technology 13SubsidenCe Censtml 7g,;Pitividti a brief Osciiptioti of th ..glintiadunment pree.edute:
C.IGeotAertnal(closed Loop) OTracer. -
tremi from the bottom to surface
InGeothermal(ilealing,tooliug Return)' Elbdter(explain under 7g) ., .
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4.Date weli(s).abandoned: 9-1223 ,
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5a.-Well ideation;
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Matthews Market .
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Facility/0mm Name Witty-11)g Otappliza 8.Certlikati
blc)
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3196 Vass-Carthage Rd. Whispering Pines; NC 28327 - .Brian. Ewing
Physical-Address;Ciin•aitd Zip. • Si* rd or Ceitifi4I u/.1!celilli;:kilfir-,,v4iteh•rxr Data
•Moore . . • ' gi,sigphw/*Am,i lierehy.cerdh•dips the 14,144 leas-(were).litiondoned in •
Quint). Vare1 lt.laulirCzioloit Na.WIN) , -Pc.coidante itifit 1.5.4.A.VAd 02e.r,0100.or,?e_0200 Welt ansIntetiori,Startalggs
and.thata copy Pills-record troy,'be'en proyidedfol the.0%11 thrOer;-
51i...tatiludeAild lOngittrild in,degrces"/MinntesIscennds.or dim II degrees: ,. : . • . .
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(t(ik•eli field,ow latiltutOssjittlaken1) , 9.Site diagram or•addItle oat well details:
You.may_use the back of this page to pros additional well site details.or well'
. • N • .- " - - W abaudatunent tietails. You May aLSdattach additionalpagS if neeessaty... ' "
.CONSTRUCtIONRETAILS ON WELL(SV BEING ABANDONED . ,
SUBMIT4.41",INSTRUCTIONS •
Attucli. :ell corzwudiurt tecvrel(s)lf cueiiilallte. Poe multiple Mjialim 6'iztmir.rtiat supply . . .
wells auvi,y1,1.1.th gm MIllte riXtstrpaipit%akurildqigrit.jun Cull 0190 cur e jcint. 10a. Far All Wells: Submit this..form Within 30.days of completion of well
6d,Well ID€11TIV--7 • abandriumcnt to the'following: •!
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' ' Dlyfsinti of Water Resoure .Information.Pencessing Unit,
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. 1617 blailSeniee tenter,.Italeigb,NC 27699-1617
6b.Total well depth: 10 (ft.)'
' fob.For in lerellon Well : In.ad.ditiott to sending the formto the address in'!Oa
above;also submit one tope of ills km within"30 days of comPtetion of well
6c.Borehole dianteter;1 (iu.) itbdti4Onineut to tkfallowing: 1
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.Divisloti.uelkaler ReSuitrieS;;Undergrimild injection Control Prtigratn,
6d.Waierleralorlow ground sirfliceE. - (ti) 1636'Mail Senicel Center,Italeign,INC 27699-1636
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. ICC Far Water Stituilv 4,Cc.hifeetiam Wells: In addition tO sending'the form to
6e.Outer casing length.(if kinwn): . . (ft.) the address(esj abOife. also Stdinlit.one copy of this Than Within 30 days of
coMpletion of well ahandomien to the county healdi'depanntent of the county.
wWrc abandoned.
6f.timer easing/tnliing length 01.110140: (ft.) , , -
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6g.Screen length(If known)i 5 (ft.) .
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Ram GW-30 Noah arollua DCpartirea of Envirouramt and Natural gcsouscrs-Division of Water 114soutres Revised August 2013.
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WELL ABANDONMENT RECORD for Intental Use ONLY: I '
This-feint can tie useit.for single or,rultiple wills I- '
I.Well(ontraetor Information: WELL A13ANDE3NMRN1'DETAILS
Brian Ewing . . 7a.Number of nt•11s being abando»cd:.1
weft Coulruc rAfinie(orw01liwneip..iatta11y..at si uln^,nell.onliiIiik prepcnyl Fur nrrritipk ojtea'our or raanioitifrer SIM) waits• OVU WW1 Nee sonic
Mn'sfrrrethWuiahaadontuaif,pirt care awl v Jrif ixrafrrm,
4240-B •
7h.Appinzimateivolume of water remaining in will(s): (gaL)
NC Well ConiractorCeitific tiiou Naat,cr
SAEDACCO ) FOR WATER.supPi,YWRITS ONI-Y:
Cdnlyan):Name: 7c,Type of disinfectant tiled: '
2:Well Canstritction.Permit M:, , '
LESallaJrplktahk cell pnruetts(i.e_Culritl Suva,lurlruaee.lirjecfiort,,rte)if brown 7d .amount of,dl snfectalll used
3.Wcdl use(check well use): .
Water Supply Well: 7e.Scaling inateri.ds used(Cheek all that apply):
0Agricultnntt 1:1httuiicipa7lfitt[aiic 61 Natt Cenicnt.Gr � it,., '', 1{i{ll,3.FIct cnttc Chips or Pellets
• c r ems. ,..c 4..,..r: ;t..m ••,r.
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OGeotIicnu tl(Hcating,tooling Supply) °Residentwt Water Supply'(single) ❑Sand Cement Gmut ■Uty Clay
halusuialiComnietcial' ❑Residential Water Supply(shared) ❑„Concrete Gnmt OCT0 b 20231
❑ Drill Citttings
[lIrrigation .0 Specially Grout 0 Gravel
t,
NOR:Water Supply Welk . — t 1 Bentotple•Slut 3;7r-2 ':J��.�":1Y al&(explain under 7g)
El14fonilatiug- . .Rt:emery G`c-
injection Wcf• 71.For each material selected above,protwido atnottntof materials used:
OAgniferRecharge _ ❑Gromidtialer-Rentediation Neat Cem.•471b ,Wtr•3gal. Sand Cem.•lb ,Wtr:gal.
17Agttifer Storage aryl Recovery °Salinity Barrier
❑Annie Test ❑Stonuwater h7om age — ---------
❑Expetinienlal Technology OSubsidetx a Condail, 7g,Provide a brief description of the abandonment procedure
°Geothermal(Closed Loop) °Tracer
tremi from the bottom to surface
®Geothermal(Heating/Cooling Return) ®Other(esplain under 7g). - - - - - -
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4.D;ttc.well(s)•abantlaned: 9-12-23 .•
Sa.Weil Location:• -
Matthews Market
Facility/Owner Name Facility 1Dd(ifappliatbto) $•.Ce rtiReat ill.
3196 Vass-Carthage' Rd. Whispering Pines, NC 28327 .Brian� Ewing_ 9/21/2023
Physical Addrem;City,aMI'Zip SignatnrcorCeriiiied Wftt f otdr;a.tdr vr'a'.i!t bicn:r 17iae
Moore Hy signing this pro.1 lreltby cern:4541at the u'rllfs)arcs(icezw)abmidaned inr
Cociuty Parcel ldanjificatinitNO.(PIN) ac-wrd ritre with:lad:1 CiIC OZC,0100 or 2C.0200 WritCcanlnw.Iluli Sfauckrcls
ariddrat,a copy of iltis record has'been provided,to the i'e11 owner.
Sb.d ltitude and longitnde:in degrceslininuteslscconds or decimal degrees
(irti;di Acid,orrwlatilunals$,rlttctera) ' • 9.Site diagram oraddltlo oat well details:
You:may.me the back of this page to provide'additional well.site detuils>or•well
N .. . . • .W abandatunent details.'You tea -also attack k additionarpoges if ttecessaty...
CONSTRUCTION.DET.ALL_S OW WELL.(S)BEING ABANDONED SIIKMITTAL iNSTRUCTiONS.
:Iliad,trill cvragiruclrrin retnrd(s)if aviijlatte. troy muthpk iirj4tian ur ri1n•rrater s imil1
wells ONLY with t e ar aiareorrstreeflgsabatrrMrvuerlt Teri con svbirdl are Jame Ica:-For'All `Veils: Submit this lout within 30 days of completion of well
6s.Well Jj .TMW-5 abandonment tb the following:
Division of Water Resources,information PructNsing Unit;
6h.Total well depth: 12 (ft.) • 1611 Mail Service Center,.Raleigh,NC 27699-1617
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10h.For iitlectIon Well : In.additioa to sending the form to the addiess iu IOU
6c:Buttltolcdiametet 1 du.) above,also snbaill one Copy of this:form wiililit'30 day�s•tif completion of well
abutulanntent to the fallowing: I
.Dhvislott.ofWaterResourrisi;TTuderground 6ijectiun Contr►l Prrogrant,
6d.Water level.belttn ground surface: (ft.) I63G Nail Sersicd i Center,Raleigh,NC 27t0)9-1636
Gc..(lutereasingten lr.(if!Mown): (ft.) lac sending
Fnr Wirer Surntly&Ldcetion Wells: In addition to the form to
the addresses) above. also stilimit.one copy of this fonts within 30 days of
coniph Lion of well abandonment to the county health-depot-intent of the county
6f.Inner casing/tubing length(if known): (ft.)
where abandoned.
6,Screen length(if imotvn):5 _(ft.)
Fern GW-i0 Nonh Carollrn-DepmUmed of Emironmcnt ani Narurat Resources-phis/on of Water Resources Revised Aaguo 2013

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WELLABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: p� I'1��w WELL ABANDONMENT DETAILTicS
;ee, Fa2O ( - 4i4A114.Idi. 7a.For Geoprobe/DPT or ClosedI Loop Geothermal Wells'having the same
Well Contractor Name(or well owner personally abandoning well oner property) well construction/depth,only 1 GW'-30 is needed. Indicate TOTAL NUMBER of
023 73
- ^ wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): Ail (gal.)
G ^'ah Y l•t(.rfi e. Di Leal*:- i Cam® 0,►i,,t,„. az' FOR WATER SUPPLY WELLS ONLY:
Company Name 'l
7c.Type of disinfectant used: ; ! . T
2.Well Construction Permit#: I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known • ¢
7d.Amount of disinfectant used:. / 08
3.Well use(check well use): ,
Water Supply Well: 7e.Sealing materials used(check all that apply)
❑Agricultural ❑Municipal/Public 0 Neat Cement Gr y R '/ 'a bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) !+residential Water Supply(single) 0 Sand Cement Grout ��I++ n 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) it Concrete Grout O C T ® l1 2Q2� Drill Cuttings .
❑Irrigation 0 Specialty Grout . 0 Qrayel
Non-Water Supply Well: 0 Bentonite Slu � i'F"``s"t`.-...-' Other
��s" _Jy, Other(explain under 7g)
❑Monitoring ORecovery — -
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery 0 Salinity Barrier 7-S V R ro�S S
0 Aquifer Test ❑Stormwater Drainage ! '
❑Experimental Technology ❑Subsidence Control I •
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer ,\ 1
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) (.ew aivi t J lArQM r}A .'+rN
4.Date well(s)abandoned: CI l)If,2 323 wave./1�Y t_ `Yto tv/
1V �d' ��t g��� � ((�� ' ' ne I 5a.Well location: �' ^ / �,"� `QMofto�7' �KW �I
(C�► F �r���C9�lr�Qt
D�1 d (flu eNT /V/ ��
Facility/Owner Name 9 Facility ID#(if app icable) 8.Certification: V
a7,p Edge w0 ud e:erae.t 1 West &0, Nc- �L..�c,4 "myr__ �_ - 6/I$,c; 3
Physical Address,An e y,and Zip `, Sr a ofCert of Jr ontractor or Well Owne Date
j'I tOgo - . Ai/A By signing this form, I hereby cert�that the well(s)was (were) abandoned in
County Parcel Identifibation 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. •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
3S.2330 7 q 11 N 7'k 5 L yykyy V 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 INSTRUCTIONS -
___Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells - .
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well .
6a.Well ID#: N/t abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 4 2 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: t�y (in.) 730-r4 w�.t�.. above, also submit one copy of thus form within 30 days of completion of well
abandonment to the following: ,
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6d.Water level below ground surface: f 7 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service`enter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): W�/�f�' (ft.) 10c.For Water Supply&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
6f.Inner casing/tubing length(if known): /�I l ' (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016
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