Mecklenburg_Well Abandonment_20231024 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Mike Tynan y 7a.For Geoprobe/DPT or Close-d1-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G;Z30 is needed. Indicate TOTAL NUMBER of
2725-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of orate remaining in well(s): <2 (gal.)
IET FOR WATER SUPPLY WELLS ONLY:
I
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: WM0301320
List all applicable well construction permits(i.e.UIC,Coun(y,State,Mariance,etc.)ifknown none
3.Well use(check well use):
Meek SIP 70003164 7d.Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout I ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry �' ❑Other(explain under 7g)
Clvlomtoring co�er}� -- -- --- - —— — — — —` �—-- — --
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation —250lbs Hole Plug
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed 10 feet of 2" casing. Filled well from bottom
to the top with bentonite (Hole Plug).
a.Date well(s)abandoned: 10/13/2023 Resurfaced ground with soil cuttings.
5a.Well location:
Residential/Agri Property
Facility/Owner Name Facility ID#(if applicable) 8.Certification: ( T 2023
14720 Brown Mill Rd, Huntersville 28078 /•/_ 10/17/2023
Physical Address,City,and Zip Signature of Ce e .d Well Contractor on Well Owner(]'.;;:;�Riri Date
. .
Mecklenburg
By signing this form, 1 hereby certify that the ivell(s) tivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0500 or 2C.0200 Well Construction Standards
and that a copy of this record has bfenI provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35 25 31.112 N -80 55 00.811 �, 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
Artachwell construction record(s)ifavailable.For nrultipleitjectian at-non-water supplvwells
ONLY with the same consb nctionlabandotwrent.You can submit one fortn.
IOa. For All Wells: Submit this form within 30 days of completion of well
TM W-3 abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 34 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
t ,
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.)
8.5 above, also submit one copy of thi'form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 25 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
none 10c.For Water Suaaly&Injection Wells: In addition to sending the form to the
(ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the co sty'health department of the county where
6f.Inner casing/tubing length(if known): 19 (ft.) abandoned.
6g.Screen length(if known): 15
Form GW-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:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werle
it
y7a.For Geoprobe/DPT or 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-304s needed. Indicate TOTAL NUMBER of
wells abandoned:enat't
3344-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.73 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
WM0301315 &SIP#70003159 7c.Type of disinfectant used:
2.Well Construction Permit 9:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ijknown I.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S Bentonite Chips or Pellets
i
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite -10lbs.
❑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
Pull well screen,abandon boring with Bentonite chips and coverwilh cuttings
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
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4.Date well(s)abandoned:
9/27/2023
5a.Well location: '��r �ti
Timothy Fridley N/A r. `' - -�
�
Facility/Owner Name Facility IDI!(if applicable) 8.Certification: OCT I .i 2023
9905 Statesville Road, Charlotte, 28269 at 9 38.2023
,...P �
Physical Address,City,and Zip Signure of Certified I C #tractor or Well Owne€"•:;'_" G uDate .
Mecklenburg 02509209 ';
By signing this form, i tereby cer'fih that the ivell(s) was (were) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latflong is sufficient) 9.Site diagram or additional well details:
35.356269 N -80.842170 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 recor(s)ifavailable.For tntdtiple injection ornwt-waiersupply wells
ONLY with the same con.sn•:rction abmuloi?meirl,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: S B-04 abandonment to the following:
Division of Water Resources,Information Processing Unit,
5.0 1617 Mail Service Gegter,Raleigh,NC 27699-1617
66.Total well depth: (ft.)
10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 3.25 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
J i
6d.Water level below ground surface: 0.5 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suvoly&Iniecti In Wells: In addition to sending the form to the
address(es)above,also submit onelcopy 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): (ft.) abandoned.
f
6g.Screen length(if known): 5.0 (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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h

4 I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW i30i is needed. Indicate TOTAL NUMBER of
wells abandoned:0-0)
3344-A
NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): 0.57 (gal.)
I
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
WM0301315 &SIP#70003159 7c.Type of disinfectant used:
2.Well Construction Permit#: i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
I '
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite -10lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
I
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Pull well screen,abandon boring with benlonite'chips and cover with cuttings
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 9/27/2023
5a.Well location: I 21,n 23
Timothy Fridley N/A
FacilitylOwnerName Facility lD#(ifapplicable) 8.Certification:
9905 Statesville Road, Charlotte, 28269 9.28.2023
Physical Address,City,and Zip Signature of ertified Wel onuactor or Well Owner Date
Mecklenburg 02509209 By signing this form, 1 hereby certify that the ivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.356269 N -80.842170 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
Allaclt well cons/ruction recorci(s)ifm,ailable.I:ol•mulliple isyectian or non-iratersupply bells
ONLY with the some construction!abanclonurent,you can.submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SB-03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
5,0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) p
i
10b.For Infection Wells: In additidn to sending the form to the address in 10a
6c.Borehole diameter:3.25 (in.) above,also submit one copy of this'form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 1.5 -(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): A) 10c.For Water Suuoly&Iniecti In 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
6E Inner casing/tubing length(if known): (ft.) abandoned.
I '
6g.Screen length(ifknown): 5.0
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016