Iredell_Well Abandonment_20240119 (2)

WELL ABANDONMENT RECORD
For Internal Use ONLY:
i
1.1Ve11 Contactor Information: WELL.ABANDONMENT DE•I'A�I S
RANDY OWNBEY
7a.For Geoprobe/DPT u•Closed-I L Iop Geothermal Wells having the same
Well Contractor Namc(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW!30 is needed. Indicate TOTAL NUMBER of
3214A wells abandoned:_- _
NC Well Contractor Cc1•tification Number 71).Approximate volume of water ren)ajning in well(s): tl.)
AIR DRILLING INC `g'
FOR WATER S[1PPLY WIs1,LS;ONLY:
Company Nnmc
2.Well Construction Permit 11:
2023-40485 7c type of disinfectant used: HTH
List till applicable well construction permits(i.e.U1C,County,Sta
3.Well use(check well use): �:rle,Variance,etc. 1 known 2 CUPS
7d,Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply):
Municipal/Public ❑ Neat Cement Grout ❑ Bentonile Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(Single) ❑ Sand Cement Grout
❑ Dry Clay
I-AndustriaVCommcrcial ❑Residential Water Supply(shared) ❑ Concrete Grout
❑lrri+ation I-] Drill Cuuings
Non-Water Supply Well: ❑ Specialty Grout ❑ Gravel
❑Monitoring ❑Recover ❑ BC1)tonite Slurry Other(explain under 7g)
injection Well: y
7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediati°n 150 LBS HOLEPLUG'
❑Aquifer Storage and Recovery [:]Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed loop) ❑Tracer 7g,Provide a brief description of the abandonment procedure:
❑Gcothernal(lleating/Cooling Return) 00ther(explain under 7g) POURED 150 L B S' H O L E P L U G
12-8-23 -'�= --r L 'k,/
4.Date well(s)abandoned;
Sa.Well location: JAN 1 9. 2024
STUTTS RD INVESTMENTS,LLC
!n"-.rt r ^c1 :•v.?� Fri'
Facility/Owner Namc �:b '�`�•4a
Facility lDtl(ifpiplicable) 8.Ccrl' tion:
405 STUTTS RD,MOORESVILLE,N.C. 28117
Physical Address,City,and Zip _ _ 12-8-23
IREDELL 4636611334 Sjgnatureof Certified Well Contractor us-"Well Ow•ncr t)atc—
County IJp signing thisJoint, I hereby certrjy than the 1ve11(s) was (were) abandoned in
Parcel Identification No.(PIN) accordance with 1 SA A'CAC 02C.0100 or 2C.0200 Well Construction Stan((arels
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a col)),g0his record has been provided to the well owner.
(if well field,one lut/lo0tng is sufficient
35° 33.0$4 ° 9.Site diagram or additional well details:
N 80 53.457 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 WFLL(S)BEING ABANDONED
Attach Nellronstrurnanrerorilt)/fava(lable. I'armititipleifilerl(nnaYaali-Ivalers'lippt)•wells SUBMiTTALINSTRUCTiONS 1
OA'L I'Wth the soda'colls7ruciioldahali(Innlnelu,Pall can sithni t nne jhrni. '
lost. Far All Wclls: Submit thisi form within 30 days of completion of well
6a.Well ID11: abandonment to the fi)Ilowing: ,
70 Division of Water Resources,I. Information Processing Unit,
fib.'Total well depth: (ft.) 1617 Alan Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in IOn
Gc.Borehole diameter: 2 (111,) above, also submit one copy of this Pori) within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: (ft) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Ccu(er,Raleigh,NC 27699-1636
6c.Outer casing length(if known): (ft.) loc,For Water Supply&Injection 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 cotuity health department of the county where
GC Inner casing/tubing length(if know,,): (ft) abandoned.
i
I
I
6g.Screen length(if known): (ft.)
II I
Form GW-30 North Carolina Departmcot of Environmental Quality-Division of Water Resources
Revised 1.-7.2-20 I G

)i)l E1,I. AIIANDONMI'N d' RECOI21)
Fur Internal Use ONLY:
L Nell Contractor lnl'm•nlalion:
\YI?L1,AI3r1+\I)ON!\1li\'I'Uls 1'AI�,S
CHAD HARTNESS
7a.For Geoprobe/DP'I'or Closed-ll o pp Geothermal Wells having lllc wale
Well Coau'uclur Nunte(or well uwncr personally abandoning well on his/hcr properly) total consh•llt601tMC11llt,only I O1'11-k is ncedcd, Indicatc TOTAL NUMBER ill'
2901 A wells abandoned:.______
NC;WelI ContractorCertilicalion Number 7b.Approximate volume of wale•J,etlnaining in n'cll(s):
AIR DRILLING INC FOliven,r.IZSiJI'Pl,vwl':,,,$ )NI.Y:
Company N:nne
2.Well Construction Permit Ili
27969 %Type of disinfectant used: HTH
List ell upplivablr it-ell aou.rnrtrc•liou pumice(i.e. U/C,C'otulq.,.S'tntc. Vurlrnu•r,rrc•.J r•'/'knnu•n 2 CUPS
p
7d.Amomll of disinfectant used:
3.Well use(check well use);
Wafer Supply\\re11: 7e.Senling nultet•(als used(clieek all chit apply):
f Y):
LlAgriculnual LlMunicipal/Public 1:J Neat Cement Grout LI Rcnunlite Chips or Pellets
IJGeothermal(Healing/Cooling Supply) HRcsidenlial Wllcl-Supply(single) IJ Sant]Cement Grout k IJ Dry Clay
( IlndusU'irll/Cununercfrll I:_IResidealial Water Supply(sliared) 9i C011CIVe Cn•out I) Drill 011611ga
! ilrrigutiuu I
I I Specially Grout I_i Gravel
Non-Water Supply\Vell:
I I�'lonitorin!
I'IRecovcry I; )ientonite Slurr)' I ! Other(esplaiO undCl•'il!)
L~
Lt)celton Well: 7f.For each material selected abo4,provide anunurt of ur:uerirtls used:
LlAquil'er Recharge CAGroundwater Rennediation 2 1/2 YARDS
ClAquil'cr Storage and Recovery rlsalinity Barrier
I IAquifcr'fcst FIStormwater Drainage
CIICxperimcntal'1'cchnology HSubsidenceContr•ol
lJGcothcrmal Closed L.00I) l,Ilrttel 7g.Provide a brief description of ific abandonment pprocedure:( ]eating/Cooling Return) POURED 2 1/2 YARDS OF CONCRETE
f 1Gcuthcrmal 0L_)Olhcr(explain under 7g)
d.Dale well(s)abandoned: 23
,.
Sa.Well location: —
DAVID PARKER ' -
ln��,;;
P:tciliry/Owner Naas Facility IDI/(inapplicable) 8,fcy-f'IicaIiot
155 PARKERTOWN RD,MOORESVILLE,N.C. 28115 � l '
Ph �-, ..-...., .._.,.,.�.,_,.6-20-23
Physical Addross,City, %it) -- ..------ -----.--_-- .-...__
Si)nauuc ol'Ccrtilicd Nrcll(.'unlramar or�t1'dl Owner Date'
IREDE_LL 4659-24-1163
IIP.\'il;ning ihie/irrm, /hrnrht ceril/i•r/rrrl the ur//(:\y n'rr.c Aver'r) flAuldn+rr•rl ill
(0101) Parcel Idcutilieation No.(PIN)
crc•c•a•dunce with /,Srt n'C.;AC.'ll?C.117t711 ur'C'.11'ill F1''rll C'un.+•lrurriun.S7unrlurdc
5b.Latitude;Old longitude in degrees/minutes/seeontls or decimal degrees: unr/Thal a cu)�r of lhia rc•c•ord has bcicn prnr•itled in the n•c'l1 on•lier.
(illvell field.one Itellong is sufficient)
35° 38.351 ° <9.Site diagram o addilional well iletails:
N 80 50.380 \V You may list:the batik Or Ibis pageilo provide addiliomd \\•ell site cicudls Or\rel:
abandonment details. You may also attach additional pages il'neccsS:uy,
CONSTRUCTION QET,lI S OF WFI 1 tS)BEING ABANDONED
:Innrhnr!lrou.cirurtronrccorrl(,c)i/nvuilaGk', hru nraltipk•brjerrionru nun-rrntcr.rupp(t trelLt' SI113M1T7'AL INSTRUCTIONS
` ONLY with dre.ronrr c•nna•lruelion/nbruulnnnrrnl,)'nu run avrhnr/I our:%arm.
10a. For All Wells: Submit this'fornl within 30 days of completion of well
6a.Well ID/h abandonment to the('ollowing:
1 '
Division of Water Rcsoui cos,Information Processing]Jail,
Gb.'I'olal\roll depth: 20 (ff 1617 Mail Service Cehnter,Raleigh,NC 27699-1617
101). For Inicction evens: In addition to sending the lino it)the address in IOU
6e.Borehole diameter: 24 (inns) above, also submit one copy of fill irrm within 30 drtys or completion of\vrll
abandonment to the following:
6d.Water fevel below ground surface: (rt,) Division of Water Resources,Underground Injection Control I'rugraun,
1636 Mail Service Center,Raleigh,NC 27099-1636
i,
6e.Oufer casing length(il'known); (ft.) file.For\Valor Supply S Inicction Wells; In addition to sending the Ibrnl to the
addross(eS)abo\'c,also submit one cbliy of INS fot•u)within 30 clays ul'eumpletion
of well abandonment to the cuuuty, health department of the county \ahem•
01'.Inner casill0libing length(if'known): (rt.) abandoned. �
t
6;,+.Screen lengtfl(if
Form(MI-30 North Carolina Department orj.11\•ironotcntal Quality-Division of Water Resources
k;\iscd:._r!_
......,
t 10

IT IJ"i 111311LINDUINIV11(NT RECORD
For Internal Use ONLY:
I. "'Ill Cnnlrslctor Information; WELL A13ANllONMLN'I'llF
NEILL PARDUE TAIi.S
-- I
--- 7a.For Geoprobe/UPT or Closed-ILoop Geothermal Wells having the salnc
Well('nmracwr Name for well owner person:llly abandoning well on his/her properly) well canstruclionidelAlt,only I Ci -30 Is needed. Illdicalc TOTAL NUM 131 R of'
2609A wens abandoned: I fl
VC\\ell('antraclar(:crtilic;uinn Nwnl,ar 71).Approximate volume of'tvalell•r�enrllnnng in well s):
AIR DRILLING INC ` _._(gal.)
FOR WATI'sR SUPPLY WILLS ONLY:
Compam Name
7c.Typeordisinfeclalll used: 1 ,TH
2.Well Construction Permit I/:
/.Al rill up/divable,rrll emisin/0in11 permilx(i.r•. UIC,C'oun/r•Stale. Variance.etc. i 6 illi'll 2 CUPS
7d.Amount of disinfecinal uscd:'L
3.11'rll use(check t,,ell use):
1-'a(w.Supply Well: 7c.Scaling malerials used(cheelc all that apply):
lAgricullursll LIMunicipal/Public Cl Neat Cement Grout
A 13cnloni(c Chips or pellets
i ICicolhcrntal(liuuintt/Cooling Supply) I.IResidelitial Water Supply(siuglc) LI Saud Cement Grout
I I Dry Clay
9 Ind list rial'ConllncrcillI "Residential Water Supply(shared) (.I Concrete Grout
Ilrrin:dion
f_1 Drill Cullings
I [:1 S cciall Grout
P' y L I Gravel
Non-Water Supply 1\'ell; '
1-1 13enionile Slurry I-1 Other(explain under 7g)
IMonilorilit` I:IRecovel•y
Injection Well: 7C.For each material selected above,provide amount of inalcrials used:
Ayuiler Racharr,c 1-1Ciroulidwaler Remediation 75 BAGS
i IAgiuidi:r Slorage:[fill Recovery FISalinily l3all•icr
IAquil'ur'rest I ISutrniwater Drainage ; —
il:xperinlcnlal'I"cchnolov.y 11subsidmice Control --
I Kivolhcrnoll(Closed HIPS POURED) r:er Loop) 7g.Provide a brief description orille ab:uun lonlcn e l procedure:
l I:I
IGaxhcrnittl(I Ic:iling/Cooling Return) I.I0111Othcr(explain under 7!7) 75 BAGS BENTONITE C_
that �1=
d.[):Ile Well(s)abandoned:
06-01-2023 '' 1
JAN 1 9 2024
ia.Well location: ,
SPIVEY CONSTRUCTION S--- URN
.a
Fariliq•%thrncr N;urtc Facility II)8(il'applicablc) R.Ccl'lili ratio D°:uj:5Ls +
167 LUGNUT LANE,MOORESVILLE,N.C, 28117
J
I'hyshmI r\ddress.Cily,;,,,(I rip _ _ _ 06-01-2023
I RE D ELL hand •n -el l-e•-- -
['ounty ,:•• 13P signing(his.ia•117, I herehP ceiYiljr 1/dal Me ivell(s) was (were) abrrnrloneet in
I -ccl Identilic:nion No.(PIN) aevorelanc•e with 1511 NC}IC,'02C.'.0100 o,-2C,'.0200 I'Vell C;onsll•ur.'tion 5lruulrarLv
ih.Latitude and longitude in degreeshninules/sccontls or,decialld"degrees: and that a ca/ry afrhis 1•ecorrlhas/teen provided to the lve//owner.
(if'well Iield,one Ialilonl!.is suflicietil)
35 0 0 9.Site dingrtutt or additional well.details:
33.916 80 54.302 W You may use Ole back of this page to provide additional well site detalls of-well
oban(louulcnt details. You may also attach additional pages irnccessm.y.
CONSTRUCTION p]';1':11I.S Ol'b\rF1 I (S)]3FINC'Al3A1N'DONI')
:lurnlrn•rllr•nno•u•rrrnun,•r:cor•r!(.,yr/nrni!«hle. l•ilrnudlipleinlerrionoruall••u•rucre•rrpplvmellr SUI3MI'1'"1'r11.1NS'1'RI)C`170NS,
ONLY uirh thu sun«•r unsa'r«riorr4rhundrmulenl,Iv1u hula,,«hall"n1«:Jor«r. �,
IOa. For All Wells: Submit this lbrnl within 30 (lays of completion of well
6a.\Yell IDI{t abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb.Total nett depth: 305 (,.t) 1617 Mail Service Center,Raleigh,NC 27699-1617
101). For Infection ells: In addlition to sending the form to [lie address in lot,6c.Borehole diameter: 6 W
(ill,) above, also submit one copy of Luis;form within 30 (lays or colllplelion or well
abandonment to the following:
i
6d.Water level below grouad sal-race: (Iy) Division of Water Resources,Uui(lerground Injection Control Program,
1636 Mail Service denier,Raleigh,NC 27699-1036
6c.Ouler casing length(il'known): 01.) 10c.For Water Sunl)ly&Iniceli Ia Wells: In addition to sending the form to the.
address(es)above,also submit one bogy of this rorill withill 30 days of completion
79 GALV of well abandonment to the county' health department of the county where
6r. lane"casing/tubing length(if l(nown): I'I, abandoned.
6g.Screen length(if Icnolvn):
Form(I\l ;n North Carolina Ucparlmeut ol•Environmemal Quality-Division ol'Water Resources)
Rei'iscd:?-''''"'ll IA

I
WE1,I, ABANDONMENT RECOR1)
hor I nlcrnn l lJsc ON 1..1':
� I
I.Well Contractor Information: WELL ABANDONMENT I)ETAl1,S
NEILL PARDUE 1 1
7n.For GeoprobeMp'['or Closed-Loop Gcollierinal Wells having the same .Well Contractor N;nne((it well owner personully abandoning\veil an his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER oC
2609A wells abandoned:__.--,.___
se \vcll Comru lnr Cersilicatino Numhcr 71).Approximate volume of water remaining in ivell(s): (gal.)
AIR DRILLING INC
-- FOR WA'1'F,R SUPPLY WELLS C)NLY:
c'nngruw N�nnc i
7c.'I'ppc of disinlect:utt used: HTH
2.Well Coasu•uclion permit/lt
List all upplicable trc:(/c•ons•Muction permits(i.e.UIC.Colour,State,Nuriance,etc.)r kaown � CUPS
�' I n C
7d.Amount of disinfectant used:
3,Well use(check hell use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
1!r\gricultural L1Mtsnieipal/public IJ Neat Cement Grout I
-) 13entonitc Chips or pellets
i icolhermal(heating/C:ooling Supply) RResidential W:IIL'I'SuPPIy(Single) CJ Sand C.enietl GrOnl i l_I Dry Clay
1 lad uslria I/C onll nercial I-(Residential Waler Supply(shared) f'1 Conerelc Grout I_i Drill Cuttings
i Ilrri aU°rs I•I Specialty Grout F1 Gravel
Non-Wale-Supply Well:
f 1 llentonite Slurry CI Othcr eX plain under 7?1 Ii\4onitorinh I�If2ccovcry ( •I �)
Injection Well; 7f.For each material selected above,provide amount of materials used:
! Ir\yuilcr Recharge IDGroundwater Remedialion 120 LBS
((Aquifer Storage and Recovery 17ISnlinity Barrier
I IAquilbl.Test 17Storntwater Drainage
I Ilixperimcnlal Technology LISubsidence Control �!
I IGcothermal(Closed Loop) I:I•l)-neer 7g.Provide a brief(lescription of tiic abandonment procedure;
(i,•nllior al(Ilealintt/cooling Return) L101her(explain nnder.710) 120 LBS BENTONITE CRj I.PSAPC)URGD� .
4.Dale well(s)abandoned: 06-01-2023 _.
ia.\fell location:
LAKEVIEW BUILDING GROUP r::l^-�r rr�" "''g UnN
1n��r.;
Facility/OwncrName 1'acililylDt!(ifapplicablc) 8.Certi it' o
131 STUTTS RD,MOORESVILLEXC. 28117 _ 06-01-2023
PIrvsical Address,(:!tv,and Zip --- - ---— _ —
ig f er mturootilicd Well ContractororlWellOwner
IREDELL
cC'moly
IJP signing this••%rnr, l her•eblr cerli/ir that the tvell(s) Was (crew) abandoned in
Parcel Identification No.(PIN) accordance with/S.d NCIIC 02C.0100 oi-2C.0200 Well Consh•uctioll Stundur•(&
51).Latitude and longitude in degrees/min tit es/seconds or dechnstl degrees: and dart a copy q/•Ibis record has liven provided to the stall owner.
til'well field.Line ha/Innt is surncicnp
I.Site diagram or additional ivcll ilcluils:
50 34.005 N 80o 54.105 `� You cony Ilse the back of this page!to provide additional well site detnils or well
abandonment details. You may also'nttach additional pages if necessary
CONSTRUCTION DETAILS
h1 Far(S(r BEING AIiANsllONI�1)rrpp(r trc(Lr
SiJ13M1'1"I'AI,INSTRUCTIONS
MYL Y n irh the sane rnnah ucrian/ahrrndnnnrd nl,•Imu can submit one•%ornr,
10a. For All Wells: Submit (IlkIform within 30 days of completion of well
Ga.\\'ell IDI/: abandonment to the following:
i
Division of)Scaler itesoui'ces,Information Processing L'nil,
61).'1'olal iccll(lepih: 105 (ft.) 1617 Mail Service Centel-,Raleigh,NC 27699-1617
IOb, For Infection Wells: In uddilioin to striding the lorm to the address in Ion
Gr. Borehole diantcler: (ist,) above, also submit one copy ol•lhi;c form within 30 clays of completion of well
abandonment to the following;
i
Gd.Water level below ground surface: Division of Wa(cr Resources,Underground Injection Control I'rogranl,
1636 1Iai1 Service Center,Raleigh,NC 27699-1636
Il
Gel Outer casing length(if known): 01.) 10c,Ivor Water Supply&Injection Wells: In addition to sending the form to the
nddress(cs)above,also submit one copy of this form within 30 days of completion
of well abandonment to the coutity health department of the county where
Gf.inner casing/tubing length(if I:uoivn): (ft.) abandoned.
Gg.Screen length(if linown): (ft,)
Perm Cr\V-30 North Carolina Dcpm•lnicnt of Environnpcntil Qtrnliiy-Division LiI'IVatcr Resources
Revisc(I 2-22-201 G

WELL ABANDONMFNT IM CORD
for Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT I)ETAff's
NEILL PARDUE
7a.For Geoprobe/IRT of Closed-1,o1 p Geothermal Wells having the s:uue
Well Contractor Name(or well owner personally abandoning well on his/her property) well eonslruclion/dcpth,only I GW 1301 is needed. Indicate TOTAL NUNIBI•:R ul'
2609A wells nbnndoncd:
\C'IVcll ConuactnrCaGfiaahm Number 7b.Approximate volume ol'water'relnaining in tvell(ti): (gall
AIR DRILLING INC
FOR\VATL;I't S[JI'P[,1'
Compliny Name HTH
2023-23929 7c.Type of lfisinrectanl itself:
2.Well Construction 1'elrntit Il:
List all alyAcable trel/cua.en•rrctinn per•micr(i.e.U/C,CoraaR 57rne, 6'ru•iaarc,ere.)i/'knutrn 2 CUPS
7d.Amonnl of disinfcclmri used: ,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials ,sell(cheelc all flint apply):
❑Agricultural DMunicipal/Public ❑ Neal Cement Grout M Bentonitc Chips or Pellets
LIGeohermal(llealing/Cooling Supply) UResidenlial Water Supply(single) ❑ Solid Cement Grout ❑ Dry Clay
0111dustrial/Commercial ❑cNicIC,Iial Water Supply(shared) 1-1 Concrete Grout 1-1 Drill Cuttings
(Ih•rigatioln L'I Specialty Grout F-I Gravel
Non-Water Supply Well:
El Bcntonite Slurry ❑ 011ie"( I ex plain under 7g)
JNIoniloring 1::1Rccovct•y
Injection Well:1JAyuil'cr Recharge ❑Groundwater Rcmcdiation 7f.For each material selected above,provide amount of materials itself:
200 LBS
FlAquifer Storage and Recovery ❑Salinity Barrier
! IAquilbrTest MtormwatcrDrainage
I:11:xperiniental'l'eelanology CISubsidence Control j
':Geothermal Closed Loop 7g.Provide a brierclescription of'lhc abandonment procedure:
( 1) L10tacor POURED 200 LBS BENTONITE CHIPS
:.ICicolhcrnrtl(l lruing!Cooling Return) l:7Ulhcr(explain under 7g)
4.Date„elks)abandoned: 05-15-2023 f~ T'`Y
Sa.\\roll location: '
a n Ni , 424
SPIVEY CONSTRUCTION
In�';t,^:r:'tea e .•.:.:;•.�.:.,v
Facility/Owner Namc Facility IDll(irapplicable) 8.Cerlif i
1273 BRAWLEY SCHOOL RD, MOORESVILLE,N,C. 28117 05-15-2023
physical Address.City,tail Zip -- —_ ^_._ _-- —_.- __-
Signature of Certified Well Contractor or Well(honer Date
IREDELL 4636156655
11P signing this Jbi-in, 1 hereby c•eriil.k tha dy t e tvell(s) ,was (n•cr•e) aharrrlarrcrl is County Parcel Identification No.(FIN) accor•dunct with lSA AIC,,IC.'02C.'.0I00 ur 2C.0200 [Poll C'urravrar•tiau.S7aarhrr•rL'c
gib.Latitude and longitude in degrees/minutes/seconds of decimal degrees: and that a copy of this record has been provided to the nve�ll owner.
01'wcll field.one[m/lone is sufficient) 9.Site dingr:an or additional well details:
350
0
33.490 N 80 54.405 W You may Its(.,tile back or this p;tgc,to provide additional well silo details or well
abandonment details. You may also attach additional pages i I'll ecessary.
CONSTRUCTION DETAILS OF WFLI(S)BEING ABANDONED
a uarlr u•un ranru•araan rer•ar•d(.r)(l rrvnnar,le. Fornnrltiple igjecrioa or aou-watersupph'arelLc SU13MI'l"l'AI,iNS'l'12IJC'1'IONS
ONL I';rich the sulne canna rrclinr ahoadanareat,You can submit one fi rat. �
I0a. For All Wells: Submit this,lorm within 30 days of comple(ion ill'well
6a.Well IN: abandonment to the following:
�l Division orWaler Resources,Informal ion processing Uuit,
Gb.'I'oLtl avcll depth: 95 (11.) 1617 Flail Service Cenicr,Raleigh,NC 27699-1617
2 1/2 10b. For Iniection Wells: ]I)addition to sending the Iin-m to the address in I()a
6c.Borehole diameter: above, also submit one copy of this Barn within 30 days of completion of well
abandonment to the following:
i
I.
lid.Water level below ground surface: (11,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ccuier,Raleigh,NC 27699-1636
6e.Outer casing length(if known); Ut,) 10c.For Water Suonly d Inieclioti\Vellr. in addition to sending the lino to the
addresses)above,also submit one copy olthis limn within 30 clays ofcompletion
Of well abandonment to the coutityi health department o1' the county where
61'.Inner casing/tubing lmnglh(if IcnoNvn):_(It.) abandoned. I
r
6g.Screen length(if lulown): (ft.) i
Form MV-30 North Carolina Deparnncnt ol'linvironmental Quality-Division of Wnter Resources I Revisal 2-7.7.-2011,
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WEI.,L A.13ANI)ONMENT RECORD �
Par Internal Use ONLY:
I.\Veil Con11-:10or Information: WELL ABANDONMENT DE1'�I I,S
NEILL PARDUE '1' I
7a.For Geoprobe/DI' or Closed-11oop Geothermal Wells having the salnr
Well Conlractor Name(or well owner•personally abandoning well on his/hcr'propony) well consu'uction/depth,only I G II.-30 is ucoded. Indlcale TOTAL NUMBER ul
2609A wens abandoned: ____ _ ..-. - --
NC well Contnicnn•Cerlificalion Number 7b.Approximate volmue of note Remaining in tvell(s):
AIR DRILLING INC FOR WATER SUPPLY WELLS ONLY:
Cumpony Nine
_2_023-_1_7_0_78 7c.Type of disinfectant used: HTH
2.Well Constroetioll Permit 11: _ _ I
Lisr al/ilip/irahle hell consvr•action Permits(i.e. U/C,coloq.blab, V(triative,etc.)/flaan,u I�2 CUPS
7(I.Amount of(lisinfecl;ntl used:
3.Well use(cllecic well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
i.a:\grieulun';tl LlMunicipul/Public I:) Neal Cement Grout LI Brtionite(.hips or pellets
LlGcotheruial(bleating/Cooling Supply) TAResidential Water Supply(single) lJ Sand Cement Grout ❑ Dry Clay
Lllndustrial/Commercial ElRcsidcnlial Water Supply(shared) U Concrete Grout LI Drill C:utlinLs
1- Irri galimt CI Specially Grout LI Gravel
Non-Water Supply Wcll; El 13entonile Slurry J Other(explain under 7g)
L IlMonitoring olzecovcry ;`
Lt•jection Well: 7f.For each material selected abitvo,provide amount of materials used:
,Aquifer Racharlle E1Groulldwater Rertcdiatiolt PORTLAND CEMENT
F!Aquil'r'Storage and Recovery IDSalinity l3arrier
l :Aquifcr'fest LIStorniwaler Dminage
I'lixperinunlol'I'cohnuloL:>' LISubsidence Control �!I_i<icuthcrmal(Cluse(I Loup) lJ'I'racer -
7g,Provide a brief descriptfun uliilhe abandonment procedure:
I_)C;auhcrmal(bl eating/Cooling Retunt) ❑o0ter(explain undcr7g) POURED 51/2 YARDS PORTLaf0_CEMENT
d.Date wells)abandoned: 04-20-23 is �r —
�, JAN 1 9 z024
5a.Well location: s I a
CANDITO CONSTRUCTION
f tcililyiOwucr Name Paeilily I ll(il';tpplicable) R,Cl'rlltl('i On' e
276 TURNERSBURG HWY,STATESVILLE,N.C. 28677
_ 04-20-23
Physical Adch'css,Ciry,and Zip Si, ,uurc ol'Cortcd 11'dl Conuaetor(n\NeW*e D:ue
IREDELL 4745378891
By signing This form, I hereby ee)ldlj,trot the Ive•N(s) r,.as (tre<tsc-/ uhundoiled Dr
County Parcel Idcntiticatimt No.(PIN) accordance with /Sit NCAC.(J2C!0'1*00 or 2C.0200 iPe(i Construction,Standards
and that a eojly(lf ihis•record has been provided to the the//owner.
5b.Lattitude and longitude in(logrces/minutes/seeon(Is or(lecim;ll degrees:
(il'wclll held.one lit/long is sufficient) 9.Site diagram or additional well(retails:
49.077 N 800 52.543 `(, You may use the hack of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTIZLCI'ION DISTMLS OF\1'b:1,L(S)131-ANG r BAN'DONFI) S1113iV11'1"I'rU.iNS'1'11[1("1'10NS Illnr/nrrN ruu.ra urlirunevord(s)ifavailuhle. Flu uar6iplaill%erviun or nun-trarc'rsupplrnclla p
ONI.l'n•/th the same rnnxlrrrrliorl/nhrrnJnnnrelN.Baru ran sithmil nne•form. d
l0a. For All Wells: Submit this lurni within 30 days of completion of well
6a.Well I O: abandonment to the li)Ilowing:
I
,�ll Division of Water Resdorees,Information Processing Unit,
6b.'I Mill,yell depill: 4`t (ft.) 1617 Flail Service Center,Raleigh,NC 27699-1617
I
24ri 10b. For Infection Wells: In add,ilion to sending the lon•m to the address in lira
6c.Borehole diameter: (in,) above, also submit one copy of tliis form within 30 clays of completion of well
abandonment to the following: '
, I
6d.1Ynter level below ground surface: (R.) Division of Water Resources,liJnderground Injection Control Program.
1G3G 1\'Iail Service CenI lm•,Raleigh,NC:27G)9-1G36
6e.Outer easing length(if known); (Iq) Illc,For Rlaler 5ttnnlV S[nieetion�Nlells: In addition to sen(ling the lion to the
address(es)above,also submit orid,c(ipy of this form within 30 days ol'complction
of well abandonment to the county health department of the county ,vherc
lf.Inner ruing/tubing length(if known); of
abandoned. f 1
6g.Screen length(if luiown): (ft.)
I'ornt(M-70 North C:voliou Depiirtntenl 0I'I:nvironolenud Quality-Division of Water Resourecs
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