Iredell_Well Abandonment_20231113 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary S imcox 7a.For Geoprobe/DPT or Closed-Coop 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. Indicate TOTAL NUMBER of
2944-B wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
S&ME, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(checkall that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cemeri rout c" `s P-1 'N,Bentonite Chips or Pellets
4F�--4-d Dry Clay❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) ❑ Sand Cement Gtou " ?&"
❑Industrial/Commercial
❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
NOV 1 •� 2023 g
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonitd6tu7ry: t;pbOther(explain under 7g)
v �.�`•....J
RMonitoring ❑Recovery
" Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 65 I bs
❑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 Removed concretes pad and protective cover.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Filled well casing with bentonite chips to surface.
4.Date well(s)abandoned: 10/30/23 Hydrated bentonite.
So.Well location:
Nest Communities
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
640 Shinnville Road, Mooresville, NC
11/10/23
Physical Address,City,and Zip Signature of Certified Well Contractor of Well Owner Date
Iredell B signing this form,I hereby cerli that the wells was were abandoned in
Y grt g f Y .f'� () (were) .
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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 39r 02.68° N 800 48r 05.99rr �, 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well construction record(s)ifavailable.For multiple injection or non-watersupply 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#: M W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 4`�'`8 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (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: Dry (ft.) 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 Supply&Iniectio I 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.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I
f

P
WELL ABANDONMENT RECORD ForintemalUseONLY:
` 1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
!
Gary Simeox 7a.For Geoprobe/DPT or ClosediLoop 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. Indicate TOTAL NUMBER of
2944-B wells abandoned: I�
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): .2 (gal.)
S&ME, Inc. FOR WATER SUPPLY WELLS.0NLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
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):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement GKout !Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gfodt•'_ �r �1 ��2-fl bra Clay
❑Industrial/Commercial ❑Residential Water Supply
( ) ❑shared Concrete Grout y Drill Cuttings
❑Irri ation ❑Specialty Grout N Q V ! ���-❑ Gravel
Non-Water Supply Well: ❑BentoniteSlur�y-- - ' ' 7� ( p g)
RMonitoring ❑Recovery li:`1 ' +dth�r explain under 7 —l _
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 65 I bs
❑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/CoolingReturn) ❑Other(explain under 7g) Removed concrete pad and protective cover.
Filled well casing with bentonite chips to surface.
a.Date well(s)abandoned: 10/30/23 Hydrated bentonite.
5a.Well location:
Nest Communities
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
640 Shinnville Road, Mooresville, NC 11/10/23
Physical Address,City,and Zip Signature of Certified Well Contractor ors Well Owner Date
Iredell By signing this form, I hereby certify that the ivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0'100 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: I i
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 39' 01.49tt N 800 48t 08.72tt 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
Atiachwellconstructionrecord(s)ifavailable.For multiple injection ornon-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#• M W-3 abandonment to the following:
Division of water Resources,Information Processing Unit,
6b.Total well depth: 43.2 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: 42.19 (ft) 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 Sunnlv&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 coun� health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i

1
WELL ABANDONMENT RECORD ForIntemal Use ONLY:
r.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Simcox 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-30 is needed. Indicate TOTAL NUMBER of
2944-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water j remaining in well(s): (gal.)
S&ME, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout: -u!~ ?_7 " .❑-My,Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout " "`' lr o Del:Cuttings
❑Irri ation ❑ Specialty Grout NO V 202 Gravel
Non-Water Supply Well: ❑Bentonite Slurry G LI Other(explain under 7g)
RMonitoring ❑Rec_ov_ery
Injection Well: 711 For each material selectgd above;p 7ovrd albint of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 75 l bs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater 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 concrete ;pad and protective cover.
Filled well casing with bentonite chips to surface.
4.Date well(s)abandoned: 10/30/23 Hydrated bentonite.
5a.Well location:
Nest Communities
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
640 Shinnville Road, Mooresville, NC 'zl�_— 11/10/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Iredell By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has be in provided to the well owner.
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
350 38' 58.52" N 80° 47' 46.88" `1 You may use the back of this page io 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 weUconsiructionrecord(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construclion/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
69.Well ID#• MW-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 52.5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
1
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (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: Dry (ft.) Division of Water Resources,U iderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Sunhly&Infection(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.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016