Burke_Well Abandonment_20240311

WELL ABANDONMENT RECORD crnal Use ONLY. . .
Titis form can he used for single or multiptewells 7
I.Well Contractor information:' AS WELL ABANDONMENT DETAILS ,
Robert Miller . •
7a.Number of wells being ahandaned:,3
WIConuactor Name(or well racer rmnatt rbtamto twit onhisri r r en For nadnpie infection or rna-leaver supple wells ONLY with the some
a Y' Pot?• 9) consrnrcooniaboadenment.maccotsrrbnut'vaejbrin•
2675-A
NC MU Carlltagort cnifeealioii Nno bcr 7h.Appt'nrimate volume of tester ftiierining in Well(a): (;,ill.)
SAEDACCO FOR WATER.SUPPLY WELLS ONLY:
Company Namc 7e'NM of disinfectant used: .
2.WellConsttuctiun Permit 0:, , wi0100707
•
1,114l nppl bode trell permitslitt away,S71,11e.'Pariafse:lnzertiorr,.elc:k lJkwun 7d.AttiDtlne of dhInfeCe:lnt used:
3.Well use:(eheelotell use):. I -
Water Supply Well: 76.Sealing materials used•(cheek all drat apply.):
IJAgricnitrnat- ❑Miraicipd/rublic• , El Neat Cement Grout , ' tE Bcntonite Chips or relicts
l7Gcotlicnnal(HeatinCooliag Supply) ORcsidcntiat Water Simply(single) '❑Sand.Cetttent Grant 1 El Dry Clay
❑IndnstrialiComnurcial ❑Rcackntial Water Supply(sluiced) El COIICri•te'Grout. O Drill Cuttings
❑irrigation.. —
El S' ts�Grout 1 El Gravel
_ -- • _ - Pmal_
Non Water Supply Well: - ❑Bentonite Shiny Cl Other(er'plainunder 7g) •
❑Manitorine. I:Recovery . . •
Injection Welt: • 71.For each Material selected above proside amount of.Materials used:
['Aquifer Recharge. SiGredulwater Remedintion
. l7Aquifer Storage aisi Recovery OSalinity Ranier •
Bentonite.:251b ,Wtr:gal. ;
❑AguiferTest • ❑SlonnuaterDrainage --
t7EiperinteutalTecltnoioev ❑Subsides Coattui 7g.Provide a brief description di the abautlnnmeatprnecdurm
ElGeodnonal(Closed Loop) ❑Tracer ;, ,
Pulled tooling and abandoned injection boring w/ granular
_®Geotllenual(Heating/Cooling Return) ❑Othertexplain under 7e)
bentonite. it „-,
4.Date wcll(s).ahandoncd: _ j\
` " r
5a.Well location: • RAH 1
1 �n24
Former Foothills Service Center g;Ceiti[ication: trlitrtr«;uen 1pr.,..r
Facility/ih'ncrNamc FacilitylVor01npplicablc)• . , •"U
• 312 E. Union at..Morganton, .NC 28655 "4 2/27/2024
Physical Address.City,and Zip 5icp_ahr.:f)r..;;r• 3e�'-,;:j.4:�' ' 5 +an:r bau.
Burke By.vgulrrg this form,1 hereby certify that the well(s)was(were)abandoned in
Coiuni Parcel tdentifii shoat No..iPINij accordance nil!:at t.tC/C 02C.0100.or 2C:021.10 rya Cott sfrttction Standards
mid what a copy ofthis record has beenprovided Io the well owner.
56.Latitude and longitude in dcgircestm mites/seconds ordeenu l•degrecs: • I
OI
wensad,air 410011g is Siiircicm) 9.Site diagram or additional well dils:
You maY use tie back of this page to.provide additional'well sire details;or sell -
• N N abaiidotunaiitdetails..You may also atlach additioatl pages if necessary.
CONSTRUCTION DETAILS OF%VELUM,iIEING ARANDONED s1.1B1SR7TAr.iNSTRUCT'IONS '
:hind,aell consirtictimt recordist t)'mailable. :Far mu/oplc ityectimi or innnrater supply ' - -
'Dells DNL1 nit/i dre same evtisorxtlon$rbaJuhrrineru,ion can buGtrih one jonrz 10a:For All SVc11r. Submit this Corot Within 30 days of completion of tsnll
6a-Weil ID4:
A-i - A-5 abanm
ndoent to the following: '
• Division of Water Resp •
ptrm,tnformatiun-Proct ing Unit,
•
30 1617 Mail Service'Center;Raleigh,NC 27699-1617
6b.Tetal.well depth: Te.)
1Oh.For In[Mimi Welts: he addition to sending the form to the address in Ica
above:also submit one tom'of this form within 30 days of completion of Well
.6c.Borehole diauteter:1.5 (in.y abandonment to the following:
j.
•
i
fid.Water teed bcfmv ground surface: • qt.) i)ivisiott of Water Resources;Utidergrouud Injection Control PrOgratn,
1636 mail Service Ce itcr,Raleigh;NC 27699-1636
Ge.Outer casing Ica lh(if lantva): ( ) 10e Foe-Wirer Sunnis.&lniectina Wells: In addition to.sending the form to
the addresses)above. also subnuti one copy of•ties form within 30 dais of
completion•of well abandonment Co tlie county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where alxtndortcd
6g Screen length(if known): (ft.)
Fern,GW-30 Carolina ion Carolina ep.mmcm of Enviroonunt ant Natural Resources-Division of Water Resources •Revised Auk 2013

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1 1
WELL ABANDONMENT RECORD For Intermit Use ONLY: j
This form can be ilsed for single or multiple wells - • i
1.Well Contractor Information: • WELL ABANDONMENT DETAILS'
•
Robert Miller 7a.Number rif wells being abandaned: 5
Well eortaetor.Nanie(or b}nllon=N,isonallyulianioning well unLsllerpropeny) For undopie injala1 or ton-irnre>1 supply wells ONLY with tL+e .same
crltstnretiw,•vbandonment,}an can s,fwurale form,
2675-A I
71r.Appntzimatc vnluim of watrr remaining in*ell(s): .. • • (aL)
NCfidlCoitimetorCvnificalloitNumber { '' .
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
i
Cancan).Name
de Type of dL,infiet rnt used:
2.WeltConstruction Permit 8:, , W10100707
Let ull eppliroble well purtniry(l.e.Courtly,Brine,Variance.Injeclion•.elc:1 IIJkwwo 7d Amount of disinfectant-Itself:.
3.Weil use(check well use): -
Water.Snppiy Well: 70.Scaling materials used(check,ill that apply):
G7Agricnttntal 1]MankipaUPublic El Neat Ccnicnt Grout i • 61 Bentonite Chips or Pcilets.
• 17Cicothermrl(Hcating'CoolingSupplyi Oltcsidtminl 1VatcrSltpply(single) '❑Sand:Cement Grout D Dry Clay
Dlndnstrial(Com menial [Residential Water Supply(shared) ❑ConcieleGrout 0 Drill Cnlliuge
•• ❑irrigation - [7 Specialty Grout 0 Gravel •
Non-Water Supply Well: CI Bentonite Shirty : Cl Outer(explain under 7g)
• ❑fulotdtotine.- DRecoren
Injection Well: • - • • - 7f.For'cach material scleeted'aboyr,!pioride amount of.Materials,used:
DAquifer Recharge. 11Gtmtndwater.Rentedia1km i
OAquiferStonrgdatxi Recovery OSalinity Barrier • J .
DAguif&Test . fStonm)atert)ntinage '
Bentonite.:251b ,Wtr:gal.
•
❑E.eperimeulal TecImoiog_r• CISubsidence CoflimI 7g.Prnride a brief description of die•altaudonment procedure:
❑Geothermal(Closed Loop) ❑Tracer • I.
Pulled tooling and abandoned injection boring w/ granular
®Geothermal(Heating/CoolingReturn) ❑Other( plain under 7g) _ • 1_. "u
t ' -$--
bentoaite. :; r�; ��
4.-Daterrelt(s)abandoned: ' Muk 1 1 2024
$a.Well location: • • • I,
Former Foothills Service Center t l3+f'r'{�•� ' UAt
Facility./Onncr Name • Facility IP (iluppliwble) $•CeniRen on:
• 312 E. Union St. Morganton, .NC 28655 • /��f 2/27/2024
•Physical Address:City.,and ZipSisralr t,:cs! . :' ):..4', A '-`:'s+nr r Doi
} �
Burke _ ily signing ibis farm,1 hei iby certify chat the'relies)wits(icere)abandoned in
Cawsiy Itreel liimaifreitinu No.(PIN) -ccorrlance with MI.\CAC-02C;010')or 2C.0200 Well Cansliatetioc Strand zrils '
and Aria a copy oflhis record has beenprovfdedtoihewell owner. -
Sh.Latitude and longitude in degas eslminutcs(sceonds or decimal degrees:
(ifsiell[aril,Otte l;ttiloiigissiifciet>t) 9.Site diagram or additional well details:
You tua,use the back of this.page to Provide,additional well site d tils or sell
N W abandonment details. You may also nitackaclditio Inc pawifnecessary.. . .
CONSTRIiCTION IW.TARLS OFWELL(S)BEiNC ABANDONED SURM lTA1.INSTRUCTIONS
Aired,WI rostruicdiuu ncvri!(s1 if ovoiloble. Far multiple injection or brbn•n'l r supply . i
•
weltsOVLYmiltthesank;crntiorbe(lo,ttdhaink,nr.teiuivustunsubitiitOrefwnc 10a.roe All.Wells: Submit this mini milnin 30 dais of ccnnpktaon of well
s-i - s-5 abandonment to the folloiving: I
6a.Rell 171gs
•
Disiskin of 1Vatcr Resou rests,(nformatiotn Proces .ng Unit,
• 1617 Mail Service Cent Raleigh,R ti NC 27699-16T7
6b.To tat;Welldepth: 30 0i) " '
{Ob.Fri r7nlectinn Wells: -In addition to sending the fornn to the address in Ida
6c.Borehole diantcterl•5 (in.} above,also submit one copy of this'foirn within 30 days of completion of well
abandonment to the following:
fid Water level hero*ground surface:. (ftJ Division of Witter Rest:Io nics,Underground Ifnjeetion Control Pregr•atn.
T636 Mail Service Center,Rale1,1i,NC 276994636
Gc.Outer casin ism (if I.vrrrrn): ( 10c..For Water Snrinly Silnlection Welist: In addition to sending the form to
1; ) the address(es).above.'also submit one copy of this formwithin 30 days of
completion of well abandonment to lide.county health department of the mangy
6f.Inner casing/whit:1 length(i£imown); (ft.)
where aixtndoncd.
6g.Semen length(if Imowm): (tiP.) 1
i
Form GW.30 'Wont:Carolina Department of Environment and Natural Rcsou.•ccs-Division of Water Resoafos Resiscd August 2013
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is
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' WELL ABANDANMEN.T RECORD Poi infernal(Ise ONLY: 1
Ttiis form can lie used for single or ntuhiplewells
I.Well Contractor Information WELL ABAND(1NMEN' PDE TAILS
Robert Miller 7:t.Number of wells being abandonedt 5
We L eat-A anor Mine(or well owner odisonally ahsmionln oell on lusiter property) Fite rnidaple (I Jeciios or non-uw(eri suppn, wells ONLY with lie .sole .
constrrrc(ion'abmrchrnmersr,inn cwr ssilmii(one Ann,
2675-A 6
NC Wcll ConiradorCcnil utifoti Nmii,cr 71►.ApprnrLnate roluine ofwater tYnt:nning in wdl(s): (gal.)
SAEDACCO FOR WATER.SUPPi.Y WELLS ONLY:
Constant Nano • 7e.Type of disinfectant used: -. .
2.Well Construction Permit a:,• , R10100707 I , .
lid 0up/thimble well permits(i.e..Coonry,Srata,Variance.1nJectiur;,etc)(Allow! 7d:Atn.Oun t of disinfectant-used:
3:Welt use(cbcdcwell use): •
Water.Supply Well; 7e.Sealing m:ltctisls:rised(check all that upplY):
17Agricuititral. DMrmicipaliPnblie• _ El Neat Cement Grout - 11113cntonite Chips or Pellets,
ECJcotiietmal(licating/Cu©ling Supplyy Ctilesidcteial Water Supply(single) ❑Saud_Centerit Grunt ❑Dry Cl iy
❑lndiistrial!Commercial ❑Resideniial VaterSuppiy(siinrcd) ❑,Coutiete5Grou[ 0 DrillCutdngs
Mitigation - . - ❑Specialty.Grout ❑Gravel
Non-Water Supply _ �. . • .IJ•BentottiteSlutty ,
y. ❑'Other(explain under 7g)
. t7Monitoring ' . . . . 17Recovety .. (' ,
Injection Well: - - 7f.Foreaeh material selestcd aboces!pnuvide amount of.Materials used:
❑Aquifer Recharge - InGroundnaier Remeiliation '
'. Oiquifer-Stonige and.itecovery [Salinity Barrier . .
❑AquifcrTest. ❑StonmsaterDrainate
Bentonite.:251b ,Wtr:gal. .
❑Eiperimeutal Technology • 17Subsideta-e Control • 7g.Frnnide a lirfcf description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Pulled tooling and abandoned injection boring WI granular
• • DGeothemial(Heating/Cooling Return) ClOtber(explaiu under 7sd)
bentonite. ;-" '`�: j '
1..� '�i fv9
i:t1V;—:/•:*".11-1
if4.Datcwelt(s)•abandoned: -5a.Well!wailer!:
2024
Former Foothills Service Center into rrr• :Y n?r-1..T�
• 8.Certificatiorn I ' '°�tt':6
Facility 10,Wncr Name Focht[•1Da(rfapplicable) - L'-j i
312 E. 'Union. St. Morganton, NC 28655 . ,/j. 2/27/2024
- Ph}gicalAddres:City,and Zip Signlhf oCr�;r g-T:r;, •'sc::3'''' ito-rrr —DON
Burke Bysigning this/tint, 1 liemby cent fy-rhar the well(s)was(Were)abandoned in
County' . Pagel 1denti lcailauNo.(PINj oc-eordrinx WI 1SA i C11C 02C,01G0,or 2C.0200 Wi'eltConsfitctrwn Standards •
and thin a copy aftbis record lrm•been provided'o thewell owner.
Sb.I.:alitude and longitude in degrccsrminutes(ssconds or decimal degrees: -
(ifricn rvtd,one latilosig ix 5(t11ikn4) 9..Site diagram or additional well dccaiLS:
You ma}ruse the back of this.page to provide additional well site details.or well
. N . W _abatidoinnerti details..You may also attach additions pages if necessary.
•
CONSTRIiCfION DETAILS OF WELLES)DEINC AllANBONED 5SURMm'Ar.iNSTRLtc'fiONS.
:workcell censiructiart nturdts)If ovallable, -Fdr multiple irgecGod ix,-nun-wutir supply . -
wells ONLY with the mot nut ilonrobmubtuneui.pia can subniR one Aria 10a,-Far MI-Wells: Submit this form within 30 days of nonilaiction-of aril
Ga Well ID/3:C-i - C-5 abandonment to the following:
• • Division of WnterResi)urc c,information-Proctssing Unit,
30 1617 Mail Bernice Center,Raleigh,NC 27699-1.617
6b.Total well depth: V*
loth For infection Welts:'In addition to sending the form o the address to 10a
G¢.Borehole diameter;l•5 tin,} above,niso"submit one copy of this form tsit in 30 days of"completion of well
abandotm ent to the following-,
i
fid Water Iercl.bcton ground surface:. (ft) •
1636
of Witter Resaurces;Underground linlou Control Program,
1636 Mail Scnicc Ccncr,Balers,NC 27699-1636
'�t
1Oc.Far Water-Strrtnts&iiticetinri t`eDs: in addition to.sending the form to
lie,Outer casing Icnçh(if Imn a) (ft) tire.addresses) above, also submit bite copy of this form Within 30 days of
completion-of well abandonment to'the county health department of 16e county
6f Inner easing/tubing-tength(if!Mown): (ft.) where abandoned.
•
6g.Screen length(If luiown): (ft.)
•
Form GR430 Nonh Camtim Department of Emtirunment awl Niutnat Resources-Dh iston of Wow Res ouic s -Revised August 20 t3
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I �
• ' WELL ABAND.ONNIENT RECORD For lniern ltiseONLY:
Theis foim can be used for single or multiple atlls
I.Weft Contractor information:' WELL ABANDONMENT DETAILS
Robert Miller 7a.Number of netts being abandonedi 5
‘Vol e-on cforName(lira'etionncrp isonanyabawidnln.,„egansisn rpropc,0) • For mdople. UJL•rtion or won-water i sirpplj• wells ONLY 'with the •.3ajta .
citshrrifiwi'abmnfoionent pot con aulniotoit for,G
2675-A 1 II
70.Appmximmate volts*Of waterrent:aining in vvell(s): - - (0L)
NC.Welt(bnirastorCerrifcailon Nmubcr
SAEDACCO FOR WATER SUPPLYWELLSONLY:
• Company Name. I
7e Type nl'dlsiufictaut used: ,
2:Well•Constructlott Pevtlt ft:, , WI0100707 1
•
List all applkulle•weirpermks(i.e.Cuvrfi'.Smta,Faria ce Itrfertia •etc)if,Giawn 7d;stmouni of disinfectant used:
3.Well use(cheelt.ell use): 1 '.
Water_Supply Well; .7c.Scaling matceiats used(chat:alltioat apply): . `
OAgricnittirat OMttnicipaUPohlie- ❑Neat Cement Grout. I: NI Bcntonitc Chips.or Pellets
' • DC othsrmat-(Hcalingg/Caoting"Supply) Ottcsidcndal Water-Supply(sin5ic)' ❑' and-Cement Grout - 1 Dry Clay •.
❑Industrial/Commercial ❑Rcsidct>tiat Water Supply:(shared) ❑Concrete Grout • i CI Drill Cuttings •
❑urination 1]Specialty Grout 1 '. ❑Gravel
Non-Water Supply-Well:- .0 HentoaiteSlui'ly ❑Other(es--plain tinder 7g)
OMoniloting-.. . . IRecovera . . I. "
• Injection Well; - - -- - 7f.Forreacb material scictted above,provide amount of titatetials used:
UAyrdfer Recharge . INGriiundnater Rentediation I •
•IlgniferStorage and-Recovery . .IJSalinity. Barrier . i .•
.. ❑Aquifer Test . ❑StonnwaterDrsinagc
Bentoaite.:251b ,Wtr:gal.
°Experimen1u_l Technoloev 17Subsidetrce Conimul
7g.Prosvide a brief description of the nbandoomcat procedure: •
• ❑GeaUtemtal(Ctosech Loo))) ®Tracer Pulled tooling and abandoned injection boring w/ granular
UGeothennat(Heatina,Cooling Return) C1Othcr( plain under 7n) . . . • f.r ,— •
bentonite. 1 1,y?7(1\__.� PA,.,rip -
c s 5
J.Datc.wdl(s).abandoncd:
. Mvtir; 1 1 211
'24
. Sa.Well location:
Perrier_Foothills Service Center . . rttrc.'rr.^rc<:l �••'- �F •.)I
Pecility/Or ner Narc Facility Ws erapplicablc) •
RA
.8.Ccrtiucatioit: : DWtii G -
312 E. Union St. Morganton, .NC 28655 . 2/27/2024
•
Physical'Addm.E,Cily.mid Zip SignerN.r.lt n:; :" = ►aria Dale .
i
Burke By.signing flits form,I lremby certijy't of the wells)wins(Were)abandoned it:
Camay Parcel& idlri anon No.(PLN) acconlam,e With Lit I i\C.IC 02C.8180.or 2C:0200 Welt Canaliuclion Standards
' and that a copy oftlris record has been:provided to the well owner.
Sh Latitude and longitude in dcgr'ces/minutos/scconds ordecirnatdegreesi• •
Orwell Fold,one tm/loitg is Srttrieicry) 9.Site diagram or additional well details:
You inn use the_back of tliis.page to;provide additional nett site details or well. - N • W .abatuloiwteni details.-You may also attach additional pages if necessary_.
('oNSTRIiCTiON DETA11 S OF WELLS)IWING ABANDONED SURMEITAr.iNSTRUCTIONS
:Math tali wsuirselulrt recvrdtsJ if available. •For,mdtiple-in,ecean'ur ma iiirti7•wippip '
wells ONLYw•ithMe'svnrecaestnrerio,ciabtardarttent.100cnnsubniitare/Orrr 10a.•For All•Wells:' Submit-this feint Within 30 days of completion of well
D i - D-5 abandonment Mike following: 1
63.Well ID/1: - , I
Division of Water Resourt s,Informatioo•Pipcesi`ing Unit,
• I617 Mail Seitiice Center,Raleigh.NC,27d99-1617
65.Total well depth: 30. (R.) 1
lOb.For Injection Wells: .In addition to sending the form the address in EOU
Ge.Ilorcholediantetea:l•5 (in above,also'submit one copy of this Coins within 30 days of'completion of well
.} abandonment to the following:
I- .
Gd.Water level bcltiw ground surface: (ft.) Division of Water Resourres,Undetgrvund Injection Control Pnior•atn;
1636 tvfail Service Carer,Raleigh;NC 27699-1636
Gc.•Qutcr casinglength(if tunwn): (ft) IOC.Far Water Snooks&tulectinn Wells: In addition lo.sending the form to
the addresses) above.also submit one copy of this fort within 30 da,s.of
comptetion:of well abandonment to Ith I county health department of the county
61.Inner easing/tubing length(if larmrn): ({ ) where abandoned.
.
6g.Screen length(if blown): - ((Y.)
Form GW-10 Nonh Carolim pejummtn of En lioimicn oust Naluml Rcsoiccs—Division of Water Resources Revised August 2013
t
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' 'WELL ABANDONMENT RECORD the ONLY;
This form can be used for single oe nlultipt wellsi '1
1.Welt Contractor information: FELL ABANDONMENT DETAILS
Robert Miller 7a.Number o n fwellsbcigabandonl I: 5
WO]fCmlrsefor Manic.(orwellouc isicOatlyninfri ninossell,onkis+llerpropcny) For rriufnpie injection or rein-rraier'I supply wells ONLY with the some
co nrctia,/tha,rdthrmwif,,torn can 50tnitiatej6nn.
2675-A -
iJEWell.Contractor Cetliftratioit Nnn her rt 7h.Approximate rolume of Watt* nctining in rvell(.r'): . • (,tL)
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Con>gany Name 7c.Type of disinfectant used: '
2:Well Construction Permit d:, , WI0100707 •
PLf on appllrvble well permlis(ici Cuardy,Stele.YurJarce.Infection,,eke j if Ammo 7d zlttnlnnt of disinfectant-used:
t.
3.Wet!use(diedcwtl use):
•
Water Supply Well:- 7e.Sealing materials used(cheek all that apply):
❑Ag.ricnhttrtl DMtinicipalipublic• CI Neat Cement Grout pa Bentonite Chips or Pcllcis
DGeotherna1(Hcating/Cooling Supply) pResidential Water Supply(single) ❑Snd:Centetu Gtnut 0 Dry Clay
❑Irtdtistrial/Comnwreial ❑Residential Water Supply:(shined) D.Concrete Grout C Drill C Hint
• ❑iitigation ❑Specialty Grout ❑Gravel
NenWatcr Supply Well: ❑Bentonite Shirty ❑Other(explain tinder7g)
. ❑Monitoring. l7Recovety
Injection Welt: • • • 7f.For each material selected above,provide aototuit af.nt:Walalsused:
❑Aquifer Recharge, lSGiaundttaier Reniediation 1' ' .
°Aquifer Storage and Recovery OSalinity Bonier i'
Bentonite.:251b Wtr: al. ,
❑AquiferTest CISlonnwater Dratnaec g
DExperintetilal Technology ❑Subsidence Control 7,Provide a lirief'descriptian of the abandonment pmecdo r:
❑Geothermal(Closed Loop) ❑Tracer ); '`
Pulled tooling and abandoned injection boring w/ granular
.❑Geothenal(Heating/Cooling Return) °Other(explain under 7g)
bentonite. 4'. -i
4.Datewell(s).abandnued: _ i ASi/kli
5a,Well location: -
4G24
Former Foothills Service Center • • trJs�"r 'Cn �._ 1,
PaciliirfOrawr Nano Facility ina(i appliwbls)
$.Ceiiification: D r't`t,:;��
312 E. Union St..Morganton, NC 28655 2/27/2024
Physical Address.City.and Zip - Signlr, c?rF.,.•r.'::%:' s- t a•r>:r Dan:
• •
Burke By signing this form,1 hereby certO•that the well(s)was(were)abandoned in
County Parcel IdzndGcathm No.(PIN) accordainc willt!j>I«4C Old.01Q4.gr 2C 0200 Wei/Constiruction Stirnibirds
and that a copy of this record has been'provided to lire well owner.•
sb;Latitude and longitude in d l' '
cgnsc9/tttintttes(sccnnris or decimal'iicgrccsc
(ifWell t`rold,one La/Ions issntlicicri) 9.Site diagram or additional well details: •
You may me the back of this page to',provide additional Well-site details or well
N. W .abaudoinnetu details..You may also attach ridditiotntlpag ss if necessary.
CONSTRIleTION DETAILS OF WELiAS)BEINC ABANDONED i)BMI1TAi.INSTRUCTIONS I
Mucktor!/cvnstractrurt trevrd(sl Jj ovW(0Wld. Fir innlople byectimi or tavn.rrulu•strlryily ' I
welts ONLY irioi the some ewrseucao,'iorrcharrmeru.ion con submit cvre:Wm. 10a.For All Wells: Submit this foist within 3'0 days of completion of well
Ga.«'ell IDg:E-i - E-5 abandonment to the fattening:
•
Division of WaterRtsuurcet,Information Processing Unit,
1G17 Mail Service Center,Raleigh.NC 27699-1617
Gb.Total'tvcll depth: 30 (ft.)
lob.For Infection Wells: In addition to sendintg the fonts to the address in IOa
6c.Borehole diameter:1,5 (iu:) above,also submit one Copy of this form within 30 days of completion of tell
abandonment to the Cottoning; IF
1
Division of WaterRcsouries,Utidetgntund Injection Conitvl Pni'r:uti,
fid.Water Iced below ground surface: (fL) 1636 Matz Service Ccntl r,Raleigh,NC 27699-1636
6e Outer caging length(iLrlmnr�n): (ft) Inc.Fne W;iter•Snrnniv&ln(eetion Wells: in addition to.setnding the form to
the addresses) above. also submit One icopy of this form within 30 days of
completion of welt abandonment to die county health depannicnt of the county
•
6f.Innereasing/tubing length(iflarnwu): (ft.) where abandoned,
6g.Screen length(if drown): (ft.)
•
Foot GW.M1 Noith Carolina Dcpsomem of Environment and Natural Resonmes-Division of Water Rcsoum a Revised Angus 2013
I

1
1
• ` WELL ABANDONMENT RECORD For lntcmal Use ONLY;
This form can be used for single or multiple wells
I.Well Contractor Information: -WELL ABANDONMENT DETAILS I
Robert Miller . Tu.Number(if wells beingaltandnncvll:'5
Welltot/racierNamelorwellow=persanal1yattarionlnowen.on*herpropcny) For rtdtipc nieettar or :ton-51uk. ',supply wells ONLY with for sane
cnnstntcfrc,i,'abardoiument,!,on car svbniut a'10 fsi si
r"
2675-A '
NC R'cU ConlradarGciliIi lio t Nmimhcr 7b.Approximate volume of water rein:riniug in well(s): . . („aL)
SAEDACCO FOR WATER.SUPPLY WELLS ONLY:
alimonyName _- 7e.Type of ditiufeeetant used: 1
2.Welt Construction Permit 0:, , WI0100707 •
Lst 01 pphcuble twit p rmiir fi.e..Ccrtra}t Stt<te,Par)attir.brrectiam.et i tffita5Wn 7d;AIttOnnt of dlslnfec(nnt'use*l:
3.Well use.(check well use):
•
Water.Supply Well: 7e.Sealing matcoi.tls•used(cheek all tiiat apply):
(]Agricultural bMunicipal/Puhlic• Cl Neat Cement grout 1 It l3•cntonitc Chips or Pellet's-
El(eother nal(Heating/Cooling Supply) ORcsidetttial Water Supply(Single) l7 Sand Cement Gmut j ❑Dry Clay
❑IndristriallCommcrcia_1• ❑Residential\Vatec Supply.(shared) O Concrete Grout. I • ❑Drill Cuttings•
Ohl-Madan . . 0 Specialty Grout O Gravel
Non Water Supply Well:- El Bentonite Sluny ❑Other(explain puler 7g)
13Motiitorine 1Recoveiy
Injection Well: - 7f.1For'eacbinateritd scicctcd'abote'iprosidc amount of.drtitccialsa-"sed:
OAquifer Recharge, EIGrounduater Rentediation
. OAquifer Storage and Recovery OSalinily Barrier
• ❑Atimfer.Test ❑StonmraterDrainmge
Bentonite.:251b ,Wtr:gal. '
•
OEaprrinrentol Te{buoloev OSubsideuce Cmrtnml 7g,Peptide a brief description cif the'abandnnntent procedure:
13Geothemtal(Closed Loop) I:Tracer
Pulled tooling and abandoned injection boring w/ granular
.®Geothermal(Heating/Cooling Return) DOtbcr(e plain under 7g) •
bentonite. I•6'T'•' .<�
4.Dafcwci[(s).at)andoncd: __ j.'a
Sa.Well location: lVI,L{K I .�G24 •
Former Foothills Service Center [rito.r .gin ,fir .
-Facility/Owner Sarre Fn:ilitr 1De(itapplicablc) R•CertiRcatloit: ' i DYr L,:, :?n
312 E. Union St. Morganton, NC 28655 . 2/27/2029
Physical Address.City,and Zip' . Si tr.vor,...tirs'i%:' iE4;Ott in•ndr Bale
I
Burke By signing this fiirm, 1 herby certify that the well(s)was(were}abandoned in
Colony Parcel Idenliftcariaa No.(PIN) accordance with 1Sif s, 11C-02C.0100.vr 2C.0200!hell-Construction Standards
and that a copy of this record has bee)i provided to the well owner..
Sl,.Latitude and longitude In degrees(mimntcifscrnndsOrdecirnal-degrees:
(if*ell rvto,ow taiih rig iy pirficiorl) • 9.Site diagram or additlo n:tl well details:
You.may use the back of this page to provide additional tell sire details or well
N W .abandonment details..You may also attaeh additional pages if nee,c aty_
C(7NSTRIIC ION.nFTAt(5 OF WELUS)BEING.ABANfONEtl 15i1BMITrA1.INSTRUCTtON1
Mad,Well co ntruelrap rrwrd(s)4/uwsi!s rite. For multiple infection or n-mnuter strpply ' '
i s!Le ONLY with the somerwrsavrdoreiztiarrtloymerab ioa eta subnili are film 10a.For All Wells Submit this form within 30 days of cotriplction of well
6a Well mg:G-i - G-5 abandonment to dm following:
Division of WaterRessources.Infor•�mation•Prucessing Unit,
66.Total well depth: 30 (it) 1617 Mail Ser%ice Center,Raleigh,NC 27699-1617
IOb.j:o Ink lion Wells: In addition to sending the form w the address in Ella
fie.Borehole dlatttctcr 1.5 Om) above.also submit one top:of this form within 30 days of-completion of well
abandounteiu to the fallowing: 1'
1
I
•Gil.Water let cl.bc[aw Division of Water Resources;Undergnnmd Infection Control Pnigrtm,
ground surface: (ft.) 163E Mail Scnice Cci ter,•Raleigh,NC 27699-1636
II
Ga Outer casing length(if'mown): ( .)• Inc.For Water Sunnh•.St Inieetinri W{�ells: In addition to sending the fora to
. the addresses) above. also submit one copy of this form within 30 days of
completion-of well abandonment to the county health department of the county
6f.Inner casing/tnhing length(if 6nuwn): (ft)
where abandoned,
I
6g.Screen length(If(mown): (ft.)
Form GW-30 Nan!)Carolina Deponn:m of Environment aril Natural Resources-Division of Water Re of es • Revised Auk 2013
i

I,
• ' WELL ABANDONMENT RECORD For Internal the ONLY: '
This form can be used felt single or null i,te wells
1.Wen Contractor informations WELL ABANDONMENT DETAiL.
Robert Miller 7a.Nwnheriftrillsbeingahandunc.r- •
RelICorer:MotNante orvrellcos= tsonall ,rlanndoniailwellonLffilher r For rrndnpin ttfceNat or ran-rater supply wells. ONLY with the ionic
( . Ik Y' o t?oP?nY) consanctlar•ulratrdorimatf ion cwr,rabnytonejornr
2675-A I a
•• • 71r.Approuin4te rolniae o f watir ritaining in(rell(r): („aL)
NC WeIl Cont metorCeniftratiotiNnntet v i
SAEDACCO FOR WATFRSUPPLY WELTS ONLY:
Company Name
7e Tic of disinfectant used: . 1
• 2:WellConstruction Permit fit, , W10100707 .
Lid fillrrpplkufr tidipirrulis(i.e.Cy:way pine,Variance.Lfertiorz.elc►I Jantsn I '
• 711:Antount of disinfectant used: • '
3.Well use(ehe.dcvi'ell use): I ' -
• •
Water Supply.Well _ 7c.Scaling materials:used.(chcc tall that apply_): " ,
C]Agricn)tttrat. ' OMtmicipal/Pubtie. ' Cl Neat CementGtmvt • I , Il BentoniteChipsor Pellets
.
CGcodermtl(HGating/Cooling Supply) ❑Rcsidcntinl Water Supply(single) '❑Sanci Cement Circuit ❑Dry Clay
❑lndustrialVComnrcrcial • ❑Resideatiat Water Supply-(shared) ❑ConcietdGrout I .O Drill Cuttings
❑initiation . . . : CI Specially Grout I` ' p Gravel
Nap-Water Supply Well: Cl Bentonite Slurry Cl Other(expiain under 7g)
❑Monitori»g ❑Recovery• .
injection Weil: . - . -- - 7f.-For each uiatctiad selected above;pimide amount of trt.itcrials used:
•
❑Aquifer Recharge. NGraundanier Rantedration
OAq infer Stomgean)Recovery - DSalinity barrier I. ''
❑AgtuferTest ❑Stonmva ternialta ee
Sentonite.:251b ,Wtr:gal. ' •
OEepirintenlal Teehnolog_vr OSubside►rr:Control 7g.Prnt_ldc a brief description of the al►andnnment prncedttre:
CIGeothermid(Closed Loop) t7Tracer ' ' .`
. Pulled.tooling and abandoned injection boring w/ granular
❑Geothemnl(IleaunglCooling Return) -• ElOther(cxplain under 7c) _
bentonite. •
4.Date wells)abandoned: I. .1:,.4: :^. --�
5a.Well location: t ` �..I: 7�7rY
• -. . i' nitro i
. Former Foothills Service Center • • 1. (U24
0:Ceil!Qcatioim
FucilitriChrVrNnmc Facilk•IDW(limilicabtc) tRitI-i.1:,1a .•,.,c
312.E. Union St. Morganton, NC 28655. /��f
C'(•di z::�a,0G2/2-7i*43 12b24
Physical Adairis:City,acid Zip Signakaorj;,,:r....R:•lit;,.1 .tt 7,. atrr Date
Burke By signing Ants form;I hereby certify'that the'relies)was(were)abandoned in
Calmly Parcel kL^ntifi dou No.(PEll accordance wi/k 1541\CAC 0?C.0100 ar 2C.0200 Welt awn-fiction Standards _
and Aral a copy oftlris record has been provided la lheuell owner.•
SI►.Latitude and longitude in degregatininnteslsceonds or decimarlilegrces: I
(ifn•ett''.lit,one Lath nntgis4atlliciert) 9.Site diagram or additional well details:
You tray use the-back Of this page to'provide additional well sire details.or well
N . W .abaudatniteru details..You"may also attach aidditional pages if necessary_
('ONSTRiiCTiON.DETAILS OF WEi.LtS)BEING ABANDONED . SUBMIT,"AT.iNSTRUCTEONS I.
Attach rdll cvrslrtdiuu ncvriltsl if available. -Per multiple#yeciion or non•nutir supply ' I
rolls ONLY trlt/i the saute cwistr eerie dobeudeurterrr.ono cmi submit one fuort. " laa:'For All Wells: Submit this form Within 30 days,of completion of ivrll
Ga.(Nell ID§:F-2 6 F-4 abandonment to the fallen:Mg;
' Division of WaterResoureis,Information-Proces ng Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 30 (lt4
10b.For inlcetinn Wells: In additioq'to sending the form to the address in IOa
Gc.Borehole diantctet:l•5 (in.) •above;also submit one copy of this Bonn within 30 darts of completion of Well
• •abi ridonntent to the following: I,
Division of Water Resouries,Undergr.otind injection Control Paw-grain,
6d,Water lev el.bclow ground surface:. (ft) 1636 Mail Scnicc'Cenin:4 Raicighi NC 27699-1636
Outer rasing Ica BIa►pwo): (ft.) 10c.Far Water Sunnis'Sr inicction1 Wens: In addition to"sending the form to .
Gc
F ( tide address(es) abuse. also submit ode'copy of tins than within 30 days of .
completion-of well abandoiuncnt to the`county health depaitnrent of the county
where abandoned, I •
6f.Inner catsin�g(tuhing tength(if Gnuwn)r (ft) ,
6g.Screen length(if talon♦): (ft.) •
Fonts GW-30 Non Is Carolina DePartmem ofEavironntcet aisl Natural RCsoarces-Division of Water ltcso : Revised August 2013

• ' WELL ABAND.ONNIEN:T RECORD
For Internal MO ONLY: 1
This foim can be usedforsingte or nrultiptewells
1,Wcti Contractor Information: WELL ABANDONMENT DETAILS I .
Robert Miller . 7a.Number of wells being abandanealE.'!3
Well CariraetorNanrr(or-tdlaoreri..sonally:ilnuloningssellonhicllrrpropcny) For multiple. enjgrtlar .ar non-war erjsapply wells. ONLY 'with lie same
axierrrretioniabardaiumg,,jut ear?salvirirwiefann,
u ,
2675-A
NC Wd1 CoritnutorCcitifcmtion Nmi>dcr • '76.Approximate colnnre of rioter remaining in Well(v) . (gall.)
I 1'
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Company Marne 1'
7e Type of disinfi�ctant tiled: t
• 2.Well ConstructionPermit f#:, , WI0100707 1'
LW oil iipplhwLle well}A rirrity(i.e Crwntv,-Stele,YUriamce•Grrrrtinn elc:)((hu n f '
Id.Amount of disinfectant um.* ;
•
3:Well uye(check stell.use):
•
Water Sappy°Well 7c.Sealing materials used(dieer;all iliac apply):'
DA;,ricultttril ClMtmicipal/Public: El Neat Cement Grout Bentonite Chips.of Pellets
170cotl1ermal(HeatingIC.noling Supply) ❑Residential WatcrSupply(single) • ❑Sand Cement Grout - 1 0 Diy Clay
❑brriushiat/Comnicreiat • ❑Rcsidentidl\Vatcr•Supply:(shared) ❑_Coittrcti.Grout El Drill Catlin
ID Irrigation . . 1 Specially Grout ' .❑Gravel
Nun-Water Supply Wctt: Ci Bentonite Slurry ' . ; C3 Other(explain under 7g)
OMNanitoring- t7Recovcay ..
Injection Welt: . : . - 7E For cad]Material selected'abeFj pcosidc amount of rit iterials used:
• ❑Aquifer Recharge. EiGriiu idwater Remediation I
. bkquiferStorageatufRecm'ety • liSalinityRanier "
g ' Bentonite.:251b ,Wtr:gal, ,. '
❑ urfetTest ❑$loiunvaterDrsiria"c. --._
❑Experimental Techmotogy .l7Subsidenee Control " 7g.Prrivide a brief descriptinn cif the,abandonment procedure:
OGeothenual(Closed Loop) ®Tracer 1 -1-
Pulled tooling-and abandoned injection boring w/ granular
®Geothermal(HaningiCooling Return). ClOthcr•(explain under 7g)
-bentonite. - i «-' t . . .
• 4.Date wcll(s).abandoncd: • L'; 1 w.�i, s �;-+• "'
5a.Welllocation: ; ' MAK ] 1 Z0ZZ
Former.Foothills Service Center tDr, i�r .^ ''^ L
Freility_/OivncrNamc ' FncilttyIDx(ifupplicable) $:Cettiflcalipit: �+=c 1 ; .,•.x1;c?-^t
DV�Q:25 9.lrtk
312.E: Union St,.Morganton, NC 28655 2/27/2024
Physical Address.Cit•.'arid Zip • 5i glr;�i:of s'w•ts:;%:'rx,a`1:;nt.tc .' L!'` ++w•r>`r Date
} 5
Burke By signing this form:1 hereby certi&1that the well(s)was(were)abandoned in
Courtly Parcel 1itentit" itluuNo.(PiN accordance wit/r 1,5A 2\CIC 0?C.DI60.or 2C.0200 Well Canalnicllon Srondtrds
and that a copy aphis record has beat provided(attic well onaer.'
Sb:Latitude and longitude in degoccslntinntestseconds or decimaFdegrecs: 1'1;
(lfvsetl rim,one la/lo'ngisstilfieicnl) 9.Site diagram or additional tell Malls: .
• You ma);use tbe•hack of this.page to provide additional well site derails.or Well
N W .abandoiutietudetails..You may also attachadditiorcitpagusiftk•eesssary '
CONSTRitCTiON DETAILS OF WELLSS)BEING ABANDONED • SUBMITTAL INSTRUCTIONS '
:toady it'd)crmvirrtdian ncvrdls)if available liar imulnpte injectimi or isin-irailr sapply
wile ONLY idol thheavu1Lcon sense'aSWUAaument.jorecaosubmit;arejiin. 10a:'For All Wells: Submit-this four within 30 days of completion of well
B-i s'3 e s-5 abitudonment to till following: •
6a.Well ID#t -
Dtyititin of Wateril snniem,Information Processing Unit,
16t7 Mail Seitiice Center,Raleigh,NC 27699-16E7
6b:Total well depth: 3°" _ (It.)
10h.For inle ilon Wells; In additioitdo sending the form to the address in 10n -
6c.Borehole diatueter:l•5 nn,) above.also submit one copy of this forth within 30 days of`completion of well
to Ille following: I,
• b ,I •
Division of Water Rrsources,UnderBntund injection Control Pnigratn,
Gil.Water level below ground surface: • (ft.) l
I636 Mail Scrrice Center,Raleigh,NC 27G59-I636
a Outer caxin Ic (it.wrRn);, ( .) We.For Water Surnls'&.inlcetion Wells: In addition tO sending the form to
G
F �( I tlte,address(cs) aboVe. also submit issne copy of"this form within 30 days of
comptetiu ll-of well.abandonment to true;-caddy health depoitntent of the county
6L Inner easingftnhing length(if known): OW where abandoned. ffI
6g.Seen length(If known); _(ft.) I -
1
Fena GR430 North Carolina Department of Environment anti Natural Resources-Division of WaterRcsouna s devised August 2013
I