Cleveland_Well Abandonment_20240311 (4)

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WELL ABANDONMENT RECORD For biteriutltheONLY;
This foim can be used for skittle or r multiple rsiells I
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1.Well Contractor Informations- WELL ABANDONMENT'DETAII!S j
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Stefan Smith 7a.Number of wills being abandoned::
WcllCanliaetor Name(or welt aura mortally abandoning%tell.an I iker property) For uiirtrlpk njeatote or ryirl-trier supply wells ONLY oath the lane
cmisfrucnrdyubbwrdanninertf,iron can snbrsuf aiefiJrnr.
3576-A . I 1
74.Approximate volume of water remaining in Well(s): - - (n1.)
NC•WellConimctorCertlfi5tllotiNorther i I
SAEDACCO FOR WATER SUPPLY WELLS dONLY:
damn*Name -7e.Type of disinfeeta(t used: . 1_ , __ , _•
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2.Well Construction Permit 0:, , •
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LtM tell hpphinfrle ell permits(i.e.Cdejnly,Sline,Parlance.Lrjectian,,elc!ifbuten 7d Antotlnt of tllslnfecraut tsetl:
3.Well use(ehed.well use):
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WaterStipph Well; .7.0.Sealing materials used(cheek all that apply): .
CDAgricultitnt ' OMunicipallPublie- DI Neat Cement Grout ' Cl Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) • j7Rcsidential Water Simply(single) ❑Sand Content Grout ; . ❑Dry Clay
❑Ii dustrialfCommcreial ❑Residential Water Supply(shard) Cl Concrete Grout ', •O Drill Cuttings
-CIieigation _ _ ❑Specialty Graut I. CI Gravel .
Non-Water Supply Weitt - ❑BentoniteSiurty ❑Other(explainunder7g)
hMaaitoring. DRecovery. .
Injeetioli Well: 7f:For cash material selected above,provide amount af.eit;itcrials laved:
❑AquiferRecltarge ❑Griiundrt:aer.Reitedfution Neat Cem.:471b ,Wti:4gal.' Sand Cem.:lb ,Wtr:gal. •
OAquiferStonige and Recovery OSa1inity Barrier
Bentonite.:lib ,Wtr:gal. ,'
O Aquifer Test ❑Stomn�,iter.Dntiriage __ � - _� - __
OEc-perintental Techttolotr�s' CSubsidetxe Control 7g.Provide a hrief descr(ptian of the abaadnomcnt procedure:
❑Geothen»al(Closed Loop) 0Tracer • •
Mixed drum of grout (3751b Portland cement 51b bentonite
©Geothermal(Heatinv/Coaling Return) ❑Other(explain under 7tt) -
powder and 28 gal water) then tremie grouted wells.
.
4.Date well(s).ahandoncd:2726-2024 I
• {a.Well location: 1.�*1`.4:4'; r : t f"'.,a
White Tire Center I, - '
.11.Certification; INK 1 2024
Facility/CW.1 r Name Fxility IDy(ifupplicable) AKA ,. ,
�r '� 7.4. lntoti'r.^ v 2/29/2024
2715 Fallston Rd. Lawndale, NC 28090 , Yr t r_.- ��^.
• ':ram-:g
Physical Address.Eby,and Zip • S_.(Inge::.Certified Welt Contractor or V1i wat30G --4m
Cleveland - - • Bo signing this farm,f herby cel•tifv That the well(s)was(were)abandoned in
Canaiy Parcel Idcnllftr i W u No.(PIN, accordance with 1M AC:1C 02C.0100;or 2C°.0200 WGell:Construction Standards
and that a copy of this record hanbe6.provided to the well olmer:
Sh.Latitude and longitude In(fegr-ectilinimites/seennds ordeeim,'al degrees: I.
(tar tan rarlit,one ItatI1nit is s dncicd) 9.Site diagrmt or additional well details:
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35.474260 81.510389 You arty use the backof this.page to provide additional.well site details or well .
N W ,abandoinnent detaiils. You may also,attach additional pages if itecessan'-
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CONSTRDICTION DETAILS OF WELL(S)BEING ADANDONED 5.URAfiTFAT.INSTRUCTIONS
:tooth odd cvrwxlrarc7iart n oaks/of available. •Fier nnrfhpk ilafeaiiar:'ar no/minor supply - - I
Hells ONLY with the mime cosraen Iion'ehaudnriaere.jou con ubmiI are jonrs lOa.Fur All Wells: Submit-thiss font. within 30 days of completion of well
Ga.Welt IDO:Mr4-1 abandonment to the folloning:
Divisicinof WaterRmiturci,Infurrn:ition-Praces§ing Unit,
19 1617 Mail Service Center,Raleigh,NC 27699-1617
• 6b.Total well depth: (ft.)
lab.Far.fnieclion Wells: In addition,to sending the foam to the address hi lOa
Gc.Borehole diameter:2 • (iu.) above-also subudt ono copy of this',form within 30 days of cornptetion of Well
abandonment to the following: 1 '
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fid.Water level below 13 Divistott of Witter Resounees,Underground injection Control Frogratu,
ground surface: - (ft.) 1636 Mail Service Cc.tdr,Raleigh,NC 27699-1636
Ge.Outer easing ism h(if latatva): (fL) tad,•irar Water Sjrrtjtiv infeetign Wells: In addition'to sending the form to
the address(es) above. also submit Brie copy of this font within 30 days of
completioti-af well abandonment col the county health depattntent of the county
fitInner ca.in;/tuh(ag-tengtir(if brawn): _ (ft.) what:abandoned.
6g.Screen length(if!mown): - (ft.) '
Fono GW-30 Noah Carolina Department of Environment and Natural Resonrccs-Division of Water Reso.0 of Revised Aap st 2013

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WELL AB: . u..®NMENT•RECORD For Internal Use ONLY;
This form can be used for single or muldpte wells
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1.Well Contractor information: WELL ABANDONMENT DETAILS
Stefan Smith 7a.Number of wells being abandon Id: 1
WetConk:ado:Nome(or nett owaxpusonallyal0nIaI llb non Onhicdlerproperty) Fa rinrlspie frjL't&ur or urns-litn0.r supply wells ONLY 'iveti the Some
consaircrie,'abmrc airn.mf,)tm ear s.,lawik wu*J6rnt,
3576-A f
NC}Veil,ConimgorCerlifiu�Uon Minter '
• 71r.Approximate s•nlumeofvratra-remaining inwetl(.r•): (g:el.)
SAEDACCO FOR WATER SUPPLY WELLS OWN:
Company Name 7e.Type of disinfectant used: 1• .
2.Well Construction Permit 0:r f
Lai all appideoly o uellpermns(i.e..Cont,Srck,i'aria ce,i rjOrfiarl,ctc)iJfir,arra 7d.Amount of disinfect:int-used:
- 3:Well use(cheek well use):
• Witter Supply Welb . . 76.Scaling inutcrl: 51.'0 i(cheek-all chat apply):
' 1jAgrieulturat bMtinicipal/Ptiblic• ID NcatCcntcnt.Gttout • 17•lcntonitcCltipsorPellcts
Dt cothemlal(HcatinrJ'('.00lingSupply) I:Residential Water Supply(singic) •❑Sand:Centent Grunt ❑Dry Clay
❑h dnsirial/Comntcicial CIRcsidential Water Supply(stared) L1 ConeretC Grout . • O Drill Cuttings
❑litigation__—__v._._ .�._._ _. _ - _.• 0 Specialty Grout Gravel
Non-Water Supply Weft: Cl Bentonite Shiny Cl Other(exploit'under 7g)
®Mariitodne . I:Recovery .
injection Well: - - 7F For cacti material selected above,provide amount of.ntntetiats used:
❑AquiferRecharpe OGrounduatcrRemedi:ition Neat Cem.:47lb ,Wtr:4ga1.;• Sand Cem.:lb. ,Wtr:gal.
DAgrtiffr Storage and Recovery ❑Salinity Barrier
Sentonite.:llb ,Wtr:gal. • •
❑AtinifeiTest OStonuwaterDrainage —� ��_ �..___ •
DExperinierital Teclnuoloav. : ❑Subsidence Central 7g.Provide a brief description of the abandonment procedure: .
. . DGeolhennal(Closed Loop) ' 17Tracer
Mixed drum of grout (3751b Portland cement•51b bentonite
®Geothermal(Heating/Cabling Return) ClOther(explain under 7e)
powder and 28-gal water) then tremie grouted wells.
4.Datecrell(s)abandoned:2-26-2024 -
5a.Well lecithin: :o. Lf I.- i ,r"'� *I .
• White-Tire Center , • . •
8:Gertlttcntion: ' '' MAK 1 z024
Facilityithstw Namc Facility 1As aapplicable) i.
2715 Fallston Rd. Lawndale, NC 28090 ?
tilt f �.r ri7?.it2;1 r..,. 2/29/2024
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Physical Address.City.and Zip • �5 iC CxrtiriedWeltGemstetororWell'p-ir•n:f31PYr..v';�'J(� ai
Cleveland • By signing this form; 1 hereby cartify'.tlrat tire well(s)was(werel abandoned in
County Parcel la:allEarnitNo.(PIN) occordtmce with 1SA NCAC 02C.0lCO.or 2C.0200 Well Cansirucfion Sianthrris
and drat a copy oflhis record lras bent provided to lire well owner.5U,Latitude and longitude in degrees/minutes/seconds or decimal:degrees: 1.
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Owen nerd,one latfloirg i,iyt r,cierti) 9.Site diagram or additional well details:
35.47426081.510389 You tuary�:the the•bacl:of this page to provide additional Well site details or well
N W abandoiunent details. You may also atlach additional lrages if itecessaty.
CONSTRUCTION DFTAIL.I OF WELL(S)BEING ABANnciN
ti CLIBM1iTTTAi.iNSTRI)CTiONR
:Wade tegli roriwruerieui reizrrdlsl u'av llabld. Pa multiple I lee irm'rrr rrun•uttlyr apply - - I,
trek*OV1.)'trotthe.mug truiurrwn rvililanrla9wntioueonudrmhareAtm 10a.For All Wdlr: Submit-this fonu within 30 days of completion of well
6a.Well(D€l: -2 abandonment to the following:
Dipistin of WaterResaulrcr ,Infonnation•ProcesSing Unit,
19 • 1617 Mail Service Center,[Weigh,NC 27699-161.7 •
6h.Total well depth: OL)
•- lob, or inaction wens: _Itf addition j to sending the form to the address in lWa
de.Borehole dianutcp:2 (lu;} above.rasa submit one copy of this font within 30 days of completion of Well
• abandonment to the following;
Division afWaterResuuni es,Underground injection Control Pregra i,
6d.Water level below ground surface:13 (ft.) 1636 Mail Service Ccietcr,Raleigh.NC 27699-1636
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Ge.Outer casing length(if[mown): (tt:) 10e.FnrWL . r�m criv •inl tin .f Div: In addition to sending the form to
the addresses) above, also submitherie copy of this form within 36'days of
completion of well abandonment to th�county licahh department of the county
6f.Inner'easing/tubing length(if toruwn): (ft.) where abandoned,
.6g.Scrim length(if known): (ft.)
Fenn GW.1r Nona Carolina Delntnteta of Environment and Natural Rcsoruecs-Division of Water Resources Revised Aqua 2013
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WELL ABANDONMENT RECORD . For lmcntal•usvONLY; -
This foim can be used for single or nttiliipte wells
1.Wet!Contraetor information: {,b'E.LL A RAN DON MENT_DETAILS
Stefan Smith - 7a.Numberofvvellsheiny)abandoned:l •
Well'ContractorNante(ormrllottvffpi:tsanallyabaftignin;ecll.anIdsllrerpiupcny) For multiple. tulertlar or Trott-nnt�r' supply wefts ONLY with the .swni •
axisfn NJrcn, abandon lent,pit!rmr snbttrlr ei Itrst,
3576-A: 1,-1 •
NC'\}'c11 CanlrAttorCenlfi lion Nnn:6et 7b.AnproxinlntelYiInnie of watt remaining m�aining in well(s) (gaL)
SAEDACCO - • FOR WATF.RSUPPLY WELLS ONLY:
Company Name •7c.Tyre of disinfectant Used:•
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2.Will Construction Permit 0:, , ; •
Laiidlullplluiddaurllp%rnritr(i...:Cuci.0%.Si ii.i'urianc'.lnfetharr.,rtei fktmrsn
. Id,Amount of disinfectitnt rued:.
3.Well use(checkn'ell use):
Water.Supply Well: .76.Scaling inatcrials:nsed(check all that apply): •
I:Agricultural CIMunicipsl/Pilbiie- " 111 Neat Cement Grout • 1 ci Bentonite Chips.or Pellets
OGeothernial(Hearin/Cooling Supply) IJRdsidential Water Strpply(single) O Sand:Ceiiwnl Grout i• : ❑Dry Clay
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. ❑Indnslrial/Commercial " IResidential Winter Supply:(slutned) Cl Concircw Grout , - O Drill Cuttings
bri tion t7 O Specially Grant i Gravel
Non-Water Supply Welt: Cl Bentoldte Slurry Cl• Other(explain:tinder 7g)
' 1)1Moniloring. 1Recovery. . . . - ..
injection Welt: - - - - - • - '7f,For-loath material scieetell'above,provide amomntOf"Materials used: • -
I:AquiferRecharge • OGreundn:nerRentediatian, Neat Cem.:471b ,Wtr:4gal., Sand Cem.:lb ,Wtr:gal.
OAgnifcr Storage airs!Recovery - OSalinity Barrier -. -
Bentonite.:lib ,Wtr:gal. ;
-OAgniferTest OStonn aterDrainage. —� _
❑Experintetuttl Technology C Subsidence Control
7g.Purvis:a brief in scription Of the aha:Wonmcat perecedure:
ClGeotltemtal(Closed Loop) ClTracer
Mixed drum of grout (3751b Portland cement 51b bentonite
®Geothermal(Heating'Coolinst Return) ClOthertexplain under 70
I
powder and 28 gal water) then tremie grouted wells.
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4.Date well(s)abandoned 2_26-2024 ,$i t G'�..7.,"1.
.^y
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Si.Well Location: a r�•' •}x, ,
White -Tire Center ' VAR'' r 1 2p24
Fac 1 t 19tittcr Nnroc Facil'v 1Dd+ tfn limbic) .8.Certification:
2715.Fallston Rd. Lawndale NC 280904 l avJC`:, "` 421942024
Physical Addicts.City,and Zip " S ahtre CcOired Well Conuaaaror Well o sn:r Date
Cleveland • • fly signing this fwm,1 hereby certify that the well(s)was(were)ahmrdo,ed III
Conuiy Par el Idculiliealbu No.(PiN) accordance with 1 it\CAC 02e,01(10.or 2C:0201 Will"Construction Standards
and digit a copy oftlris record hav becit Provided-to the well owner,
56.I atihrde and longitude in dcgrccslminirtcrfseconds or decimal;degrees: ,
(if ttell r`ald,one tat/long is snineiari) 9.Site diagram or additional well details:
35.474260 81.510389 • You may,use the beekof thi§.page ai.provide additional well site:details or well
- N . W - "abaidoinent'details..You may also attach ariditiotratpages if necessary.
('ONSTRITCTION.DETAILS OF WELL(S)BEING ABANDONED SURMrrrJT.INSTRUCTIONS
Math Veit cvnrixirucIfort ncvrdrst If available. For trrultiplc injection'or rmn.u•al r supply - - I ' ,
ur11cONLYtrlt1Wrstmtucwratnulnmvabanthanincnu.ygaCanarbmlt(ateflue. 10a.-'Far All Wells: Submit- is fontsWithin 30 days:of completion of well
Ga.Well IDfI:DW-1 abandonment to tbcfollowing;
Division of Water Resogrcix,Information�"Procersing Unit,
50- - -1617 Mail Service Center,Raleigh,NC 27699-1617
6h.Total well depth: 0i) I
110b.For fnlectlan Wells: In addition to sending the fotut to-the address ht.lOa
•Gc.Borehole dLttnteter:2 Um) abandonment
also subunit one copy of Ihis'.fonit within 30 days of completion Of vietl
abi ndonmeitt tothe following: ,
Division:of Witter Resources,'Undersrouud injection Content Program,
6d,Water level below ground surface: 19- (ft.) 1636 Mail Service Ccutcr,Ralcigiy NC 27699-1636
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10c,For Waiter Snpnlv.0 infection Wens: In addition to sending the fort to
6e.Outer casing length(if larown): • Aft.) the address(es) above. also submit One copy of"tins fotmt within 30 days of
completion of well abandonment to(hi:county health deptulnterd of the'robotyc
6f.Inner casin,Jtubinglength(if itnuwn): (ft.) where abandoned..
6g.Screen length(if iniown); (ft.)
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Fenn GW-30 Nanh Carolina Dcpannxnt ofEnvlrantnent mit Naiuml Resources-Dlvisien,of Water he ur ct Revised Antos'2013
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WELL ABANDONMENT RECORD For linertul Use ONLY;
This form can be used fdr•singte of muliipte wells
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I;WeliCentraetur Information: WELL ARANOONMENT•DETA11:,S
Stefan smith 7a.Number of tills being abnndoncl+l:l
• %YettCodtallorNonie for stett owner sonatly:.tiaaronfig wort.onlifcAierpiepeny) For eirlrtpk. nfeeltar. or. taseirtf r supply wells (ONLY WA') the Smite
crnuttuefoonloboidoiitr ent,you CUR sr+BNrtt 614jhrrtr,
3576—A i
NC Wcl1 ConuagorCerlificailaii Number '711.Apprnz(mate within ufrfater rant ieiag in ivcll(.v)t: (OW
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SAEDACCO •FOR WATF.RSUPPLYIVHLI SO'Ni:Y:
Company Name' 7 ,Type Of.dlslnfcctant used: • .
2.Welt•Constructian Permit its. ,
lditt l rtpptk bhrwellparaniN(Le.C.aitly,Stab[,-Yurlur,•re.Irrj0ctinra,rhil(fF wley m 1'
• 7d;.atnounrufdislnfcctiuf`ttscd:
3.Well use(check well use);
- Water.Supply Well: 7c,Scaling materiels used(cheek all 1tliat apple):
C1.4gricultitrrt 0Municipal/Publie: 6l Nat.Ccmcnt.Otv•ut I, . CI Bentonite Chip§orpclets
DDfscotlicmia[(Heating/Cooling Supply) pkcsidential Water Supply(singlo) O Siinrf Centg)0 Gmut I Cl Dry-Clay .
OlndnstnalICoinntercial • ORasideutial Water Supply(shntecl) Cl Concrete Grout. Cl Dnll Cltttings
❑iideation O Specially Grout Cl Gravel . •
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Non-Water Supply Well:
p! CI Hentoltite5luay ❑;Other(explain tinder 7g)
$Motittonng.. . . 01Recovery . . .
- . Injeetiaf Welt: . . 7f.For each Material scicetcti•abore peorideantmriatdl.tit;ite.tialsrrsed:
CAquifer keelrargt? OGmundwuler Retnediatian Neat Cem::471b ,Wtr:4ga1. Sand Cem::lb ,Wtr:gal.
. cAquiferStontge and Recovery • 17Salinity Raeder
Bentonite.:llb ,Wtr:gal. : '
OAguefer.Tesi DStonmcaterD.rirfliage — •
.CExperinteuhll Technology OSubsiderne Coidnrl 7g.Frttvidc a hricf'descr•iptian of the'ahantinnment procedure:
C1Geotherinal(Closed Loop) -. IiTtacer • "• .
Mixed drum of grout (3751b,Portland cement 51b bentonite
.f3Geoihennal(Heatinitt'Cooling Return) ElOther(cglain under 7g) .
•
powder and 28 gal water) then tremie grouted wells,.
J.1)atc eU(s).abandmlcde 2-26-2024 ir••� �.,
Sa:Well location: n,; -_-)
White Tire Center ��r.ti
Facility/O .
acilit}1Qrvtur Nine • Facility IDH(fappli>cable) 8.CertlRciitlon: ?024
ntc,-,7r^,; •.
2715.Fallston Rd.- Lawndale, tic'28090 f--" j', , j) ,•;' :(2ai,Z024
Physical Address;City.'arid Zip limo: Ceolited Well Continuo tor WeltO in:r D;ur.
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Cleveland . o fin a lhts farm; 1 hernh ecru ,that the reel!a was([deed)abandoned•irt
Cotroty Parcel Idaiitittcallou Na,(PIN) a ivory/tin re with 15rt:.CAC 02C 0101)or 2C:02•70((fell Causlrrlction Stimike-4
and that a cvpy of11w,regard leaf been..pravided to the well(inner.-
SIi;Latitude and longitude in dcgrccsfminut'esfscennds orilecimllydegrees: 11 • •
(lrst'eli Field,one Iat/laiig is s,itncient) .• - 9.Site diagram or additional Well details:'.
35.474260 81..510389 You may use the back of this.page to'provide additional.is�ll.sitedelails.or wail
N w' Abandonment details,.You may alsal aback tidditiowat pages if necessary. '
CONS'rRl1CTioN DETAILS OF WELLS)RHINO ARAANntiNEn - StiBmtrrAL INSTRUCTIONS I
' Mock ii eft errnstrncrinrt nilt,rde-sJ 41 available. .For rmdripie atprincel•Ov cvsn-uwtir strpp!1 '
welts ONLY iritlt adr mate cwistrariintda tWulnv:iertt..yua am salmi[pneAnn. 10a:For All Wills: Submit this faint Within 30 days:of completion of well
6a.Well 1D4:MW-3 •abandonment to the following: I.
Dhision of WalerResinerSas,Information_Prece sing Unit, •
20 1617 hfail,Sei�ice'Ccntcr;Raleigh,NC 276999-1fi17
'6h..Total well depth: (11.)
lab.For inleelkiri Wells:'In addition to sending Ilk font to ttie address in:1(a
:hotter iiiso•submit one Copy of this Conn within 30 de s of'completion of well
Ge.Borehole diameter:2 - (in.) abandonment la the following: ; y p
Division of WiuerResorirsees,UtIIderground 6tijectlmr contrul Pregram,
6d.Water level below ground surface:.12. . (fr.) 1636 Mail Service Ccuter;(ialeigh,NC 27699-1636
Gc.Outcrcasin Ic (if linowu)•• 10e.•For•Water-Sunnh�;S Infection WI Ils: In addition to.serrdin the fort to
easing (ft.) .the,address(es) alroce,•also submit atiei copy of this foutt within 30 days of
completion of well abandonment tb the-Founty health department of the county
6f.Inncrcasing/tithing length(ifloiown): . (ft.) tylrsrcabamlorlcd,.
IIi
6g.Screen length(If known): . (ft.)
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FomrGW-30 NoithCarolim Department ofEnvironment awl Natural Resources-Division of'Warer.Rcsoincei . Revised August2ul3
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WELL ABAND.OlYMEN.'Y'RECORD. For httamalusoONLY:
This form can be used for single or mtiliiple w011s •
I.Well Contractor Information: WELL ABANDONMENT DETAIL S
•
Stefan Smith 7a.Number dfssellsbeingpbanda I I: 1
liVeliCoPltacrorNanie(or i ltntsnnpe^snnaUynUaseiouingoell.ant;isrlierpioperty) For nrulapk. U1ection or rion-au rl supply welts ONLY with r& some
contra eelor•i,Gardnir neat,,ran cwr.rrfxmdr ewefi,nu:
3576-A
NCWd1.CanimgorCanifs~tiioriNntitbor '7i.Appru lnsttc;vulnaut:ofwaterc aluinginWell(s): .. . (gul,)
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Cenrpany Name I"
7c,Type of.disinfectant Used: 1
2.Well Construction Perrault 0:, ,
Ltst rrfl npidknubre well peortr(is_Cosa%Sato,;briarre,hr,'ectiorr,.etc:►if born • 7d:Auioutit of disinfeetuut'used: "
3.Well use(cheek well use): . .: . .
Water Supply Well: 7e.Scaling materialsuscd(check all that apply): .
0Agriculturat ❑Mttnicipal/Pubtic• • IR!Neat Cement Grout Cl Bcntonitc Chips ort'cilcts
ClOcotliennal(Hcatiii ICooling Supply) is Residential Water Supply(single) In Sand Centeut Gmut . I. Cl Dry CL7y .
❑hidnslriallCorrintcrelal " OResidcrohtlWnter Supply.(stitircd) • Cl Concrete Grout ' .i7 Drill palings
.Oirrigation D Specialty Grout Cl Gravel
Non-water Supply Welk:- � .C Bentottite Slimy . i 0 Other(explain under 7g) •
• i:Moniitoring. • DRecovety.
Injection Weil: • - - - - - - if.For each tuaterhd selected above,provide amount of:nuiterials used:
°Aquifer Recharge, OGroundnnter Rentediation . Neat Cem.•471b ,Wtr•4ga1.I Sand Cem.•lb ,Wtr•gal.
EiAquifer Storage and lieeovely L)Salinity Barrier - .
AgniferTest DSlonnaaterDfihage Hentonite.:ib ,Wtr:gal. j
O
- lb --
• I
' DEsirerintetual Technology DSubsideis a Control • 7g.Preside a brief description of tlnc abandonment procedure:
DGeochennal(Closed Loop) °Tracer .
Mixed drum of grout (3751b Portland cement 51b bentonite
OGeothenuat(Heating/Cooling.Return) 17OUier(explain under 7R) . i,
powder and 28 gal water) then tremie grouted wells.
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4.DatcsseU(s)"ahandoncd:2-26-2024 J t__o I"" , •
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9f�, i� a k...t" V t
Sac Well location: p'
White Tire Center MAR 1 1 2024
• ti:Certification:
racilityKhrncr None Facility tam(ifappiicable) I
_ Into--rov 7;orr,�e,
2715 Fallston Rd. Lawndale,, NC 28090 _ ram".,:;)
yl '. Lam!`/ 15flre � 9/2029
Physical Address.City,and Zip' . S6aeihue Certified Well Contractor or Well(hair Deus
r
Cleveland ily stgntrrg this/Omni I herby certify-burr the well(s)rise(there)abandoned in
. Conuiy Parcel litctul(160iikNo.(PIN) ' accordance with ISA:t:CHIC•02C.010(I.ar 2C.0200 Well Cons/hidtun Standards
' • and that a copayofthis record has been provided to the well owner; •
5h,I ltitude and longitude hi degireestntlntitestscconds or decitnal"degrces:
. Otto!!facial,one latllung is nimdcra)" - ' 7.Site diagram or additional well details: •
35.474260 81'.510389 • You may use,the back of this.page to provide.additional mil site details-er well .
N W abandoiunent details..You may also atiaclr additional pages if necessary. •
CONSTRIi(LION"DETAILS OF WELL(SilEING ABANDONED 4URMiTTAT,INSTRUCTIONS , -
:ittntlr weal roofrnclioo necurllsi I)'armllable. Fur tmrhrpk i,Jection'f,r rate.utiau'supply -
nrtls ONLY with tl,o smw raistrutrtoni6ci rdouiaeru,)on con subuift err fume. tOo.For All Wells: Submit•this fame s►ithin 30 days of•completion of%loll
6a.Well ID4:Mt4-4 lbtfndoumcntto thcfallossing:
Diyixitin of WatcrResourcts,information Processing Unit,
20 1617 Aiail,Service Center,Raleigh,NC 276994617
61r.Total well depth: (i 4 1
loh.For inieetion.Wells: In addition to sending the fornt_io the addtesi iu"10a
6c,6arclhole diatneter:2 (in.} above.also submit one copy of this own within 30 days of completion Of well
abandonment to the fallowing:
. ll •
Division of WaterResourecs,Underground Injection.ConlrolProgram,
Gil,Water fuel below gr and surface: 12 - (IL) •1636 Mail Service Cenrter,Raleigh,NC 2769 9-1 6 3 6
Gc.Outer casing Icn,�th(if hvrawn): (ft.) toe.Far Water Strunk'4,inicstirt i Wells: in addition to sending the form to
the addivss(es) .above. oho submit one copy of this•form within 30 days of
completion of well abandonment to ihcicounty health department of the county
6f.Inner easing/tubing length(if known): (ft.) where atnndencd,
'6g,Screen length(if known): (ft.)
I
Porn GW,30 NoahCaroUna Dcponntetn ofEmlronntenl my.]Nnrural Resources-Division of Water Rao aucee Revised August 20t3
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WELL ABAND-ONNLENT RECORD For InternalliseONLY; ,
This form can be used for singlebr multiple wells
I.Weti Contractor Information: YELL ABANDONMENT DETAILS
Stefan Smith 7a.Number OCtr ills being abandonld:ll
wen'Cot:tmefor Nellie(or uillnscrcrpeianultyatianianhi.eI1ontrisilicrproperty) FOP undopie. hfee+far or lion-mfi Isirpply wells. ONLY with the .sous
emufrnchcxi/aloridiutttmrtt pre con salmi(otiesform;
3576-A
NC.Welt ContractorCegllicadoti Narita
r lb.Appro home v e of
water� oiniug in w eIl(s):; . . (gut
,)-
I. '
SAEDACCO FOR 11rATER SUPPLY WELLS ONLY: '
Gonrpany Name 7c.Type of disinfectant used:
2.Well Construction Permit(1:r , 1•
LW tell ttpphctthieWillpl rune(i.e.Comb,3tcto,harJosi,hr t lion„eta)Prowl •
. 74 Aittount of disinfectant used:.
,S.Weil use(elieek well use):
Water Supply Well: • 7d,Sealing matcria4.0scd(check alt¢imt apply):
I7Agriculturat - ❑Mttnicipal/Public ill Neat Cement Groot CI BentoniteChipsorPellets
ccotliennnl(Henlingtooling Supply) . ❑Rasidential Water Stipp!), D Sand Ce
c tttent Gttiul ❑Dry Clay
. ❑hutnstriiUComntercial ORcsidentttal Water Supply-(shared) 0 CooceiaGroui- El Dull palings
Eller ttian 4. -_... . . 0 Specialtycraut ' ,❑Gravel
Noo-1VaMrSupplyWell: 0 Bentonite Slurry El Other(explain tinder7g)
®Moriitoritag . l2Recoven•
• injection Well: - . _' - • . 7f,For each material selcetcd above;provide amountof t:M(0 0s used:
DAquifetRecharge. -OGroundnalerReniedi:ilian Neat-CeM.:471b. ,Wtr 4gal. Sand Cem.:lb ,Wtr:gal.
°Aquifer Storage and Reeovety °Salinity Barrier • •
Eentonite.:llb ,Wtr:gal. ;' .
❑Aquifer Test DStonnwater Drainage.
-
pEaperitnettml Technology °Subsldetrcr:Cot►ttul 7g.Provide a brief ifeseription of the;abandonment procedure:
°Geothermal(Closed Loop) . DTracer V .
Mixed drum of grout (37511Y Portland cement 51b bentonite
DGeothemial(He atinglCooline Return) • 0OIher(aplain.under 710 ,
powder and 28 gal water) then tremie grouted wells.
d,Datcvrdt(s)ahandoncd:2-26-2024 --- -
5a.Well Location: kl, �;`N,,''„
t�
White Tire Center. i' �.�' iRi.� ,, "`
S.Cctiiflialiau: AA/'L
Facility/Ow der Nnntc Facility 10o rifupplicablet 1:'V dry r, I 1 ?QZ42i29iz024
2715-Fallston R . Lwndale, NC 28090 ' . , • , 14Pi►tfCt.. ,,;�
Physical Address.City.grid Zip . tm.. Certifud WO Contractor or Wel(a5 7rc-r D;tac
Cleveland - . By signing this farm, I hereby certtfyi't11at the tie!is i vas(were)abandoned in .
County •Parcel lil:rull"r&ition Na,(PIN) acconlance with 1S.1:17CAAC 02C.0100.or 2C.0200 wen.Cartstniciion Standards .
and that a copy oftlrir record thus beeiil pirovided(o(lie well orrtacr,
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal-degrees: I.
Orwell fmlrl,one lat/luitg is t)tttliicttl) V 9.Site diagram or additional well details:.
35.474260 81.510389 You-nay'use the back of titis.page to;provide additional well site details or well
N . W _abaudoimtent details. You may also attach additional pacts if'tiecessarY.
CONSTRIiCTION DETAIL.0 ON WELL(S)BEING ABANDONED LiRbti7'i Ai.iNSTRCTCTiONC.
Moth u'pll evu.arudhirt rr xsrdisiU'oVollabie. For irrulhple iirjedion'or raaa•nutw supply '
uv/lyONLYfriththesaneearshuchanio0orthirwreril.warnwansrrbrrih(...ieJgrm. . 10a.For MI'Wells: Submit this fain.within 30 days of coui(ilction-of well
Ga.Well ID€1:MW-5 abandonment to the following:
Uii•iskinof Water Rrsonrccr,Information Processing Unit,
6b.Total:well depth: 20 (O,) . 1617 Mail.Service Center;Raleigh,NC 27G99-1617
i, .
• lob.For.fiticclian Wells: In addition to sending the form to the address hi l0ii
Gc.Borclrole dlantcter:2 (ht.) •
above.also Submit one Copy of this form within 30 days of completion of Well
abaridounietri to the fallowing: , 1
Division of Water Resources,Unldeiground injection Control Pregratu;
fid,Water level below ground surface:.12 (ft.) 1636 Mail Service Ccntci knleigh,NC 27699-1636
I 1
Ga Outer casingten (if lvnwn}; (th} IOc.Far Wirer Infection WeIls: In addition to sending the form to
'( 'the,addresses) above, also submit one copy of this'font within 30 days of
complclioti-of well abandonment to thie,eowrly health department ofthe county
61.Inner Casing/tubing length(if larow n): (ft.) where abandoned.
6g.Screen length(if known): (ft.) ,
Form GW.30. North Carotins Dep tine nt of Ent ironmmcm and Natural Resources—Ditisiom of Water Reiouhts Revised August 2013

'WELL ABANDONMENT RECORD ForinlcrnalvsdONLY; .
This fonn can be used for single or multiple wells.
I.Well Contractor infortnatitine WELL ABANDONMENT DETAILS'I '
Stefan Smith 7a.Number of w'ellsbcingabandanl l: 1 '
We11'Cot1mctor Name(ornell owner personally alianjdning%veil an lifell er pruticny) Fa' arirlhplc mfpcttan Or ra9N-111ter I supply veils ONLY with the sore
Construotto1i'itbadiwunnt,pa nun as ntr?Nirfrnl,
3576—A
NC Wc11 Contractor CO010milion lYnni+cr
7b.Appnlzimate volume of-Water remaining in ivell(s): (has.)
SAEDACCo FOR'AMER SUPPLY WELLS ONLY: •
•
Company Name 7c.Type of diiiufectant used: I'
2.Weil:Construction Permit tit, , ,
Won a piivobla tirkpormitv(.a.County,Stma,-l'urlarce.firrjechnn,etc:!ifknuwri 7d AUiouut of disinfectant-Used:
3.Wdt use(check well use): .
WaterSupply Well: • 7e.Scaling matclials used(check all that apply): .
IJAgrictdtural : (]MtmicipaliVublia El NcatCcmcni.Gtout i ❑BentoniteChipsorPellets
RGeothctmal(Hcating/C.00lingSupply) . glRcsidential Water Simply(single) D Sand Content Gnus i, ❑Dry Clay
❑Industrial/Commercial. • , ❑Residential Water Supply:(shirred) ❑ConcieteGrout. I O DrillCuttiugs
❑irrigation _ ._ CISpechilty Grout. CI Crave!
Non-Water Supply Welk- • —�— �"' E1 Bentonite Shiny ' ❑Other(explain under 7g)
iI Monitoring. ❑Recovety -
Injection Well; ' - - - . 7f,For each Material seleited'above,provide amount Of Materials used:
❑ uifcrRcclrarge ❑Gmundwaler.Rentedi:nion
Aq b Neat Cein.:471b ,Wtr:4ga1.1 Sand Cem.:lb ,Wtr:gal.
OAquifer-Storage and lRecoveiy ❑S linty Darner
❑Aquifer Test . ❑Slonmtatcr©taitwge •
Bentonite.:llb.,Wtr:gal.
❑Esperimenlal Teeltuokier ❑Subsidetxe Control 7g.Provide a brief description of th,i:abandonment procedure:
❑Geothennal(Closed Loop) . . ❑Tracer I ''
Mixed drum of grout (3751b Portland cement 51b bentonite
OGeothermal(Heating,'Cooling Return) ❑Other(explain under 7a)
powder and 28 gal water) then tremie grouted wells.
4.Date well(s).abandnncel:272672024
5a.Well location: ' 4 tom.i:;
•
White Tire Center - - MAR 1 1 /�ryA
Facility/Ott-Mr Name Facility I1)0(ifapplicablc) S•Cet9[Rc etioit: 20L`t
2715 Fallston Rd. Lawndale, NC 28090 ' . - A t I ."t;r»:;2a2 42.024
Physical'Address.City.-and Zip S..,alum•: Certifisvi Well Continaoror Well thyme ''a = Date
1.
Cleveland By signing this form;7 hereby ceriifv that the well(s)ryas(were.).abandoned in
County Perecl ldeniittteitiniiNo.(PINj accordance with Lit KCAC 02C.01d'O:ar 2CA200 ri'e1!'Conslrudion Slmukardls
• • and that a copy ofthis record has been pr oviderl-lo the well owner.
Sly.latitude and longitude In degrceslnitnutestscconds or decimatlydegreess
Orwell Cold,on:latilong is s,dncicet) 7.Site diagram.or additional well details;
35.474260 81.510389 You_lt a use the back of this.page to-provide additional hell site details or Well
N . W abaudoinnertt details. You may afsn attack additional pages if tkcassan'.
CONSTRIICIION DETAILS OF WELLES)BEING ABANDONED SUBMiTYAT.INSTRUCTIONS I -
:toroth weld cpm'rrucllan n'curdrs,If available. Fear arraltipk•itjecrlyn'a•non•n-stir supply ' r
netts ONLY with the ovum consiicactlmr•'izhanwiWwrn.ion con snbmft are runt. ' - 10a, Fur All'Wells: Submit this (briar within 30 days:of completion of men
6a.Well IDfl:MH'_6 •abandonment to rho following:
•
Dlvisian of Water Resilurce.s,info rmatinu•Processing Unit,
61►.Total well depth: M.)20 WOMail,-Service Center;Raleigh,NC,27699-1617
• is
10b.For inleetion Wells; In additioi)to sending the faint to the•addtesi in Ka
6c.Borehole diameter;2 (III.) above.also submit one cope of This'font-within 30 days of completion of well
:abitndonntetrt to the following; ,
Division of-Water Resources,Underground injection Conttvl Puigratu,
fie.Water level,below ground surface:"12 (ft.) 163E Maul Service Center,Raleigh,NC 27699-1636
i
6a Outer casing length(if!mown): (ft.) IOc,For Waticr Slipplt�s i�SSSiot[Svellg:, In addition to.sending the form to
Mc addresses) above, also submit lobe copy of this fomt Within 30 days of
completion of wall abandorunent to the county health department of the county
6f.tunercasing/tubinglength(if Imnwn); (ft.)
where abandoned.
6g.Screen length(if known): Aft.) #
Fe MI GW-30 Nonh Carolina Depatimem ofEnriroanicnt atri Niuuml Resources—Division of Water Rca ata:s Revised August 2013
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WELL ABAND.UNNI.ENT RECORD FUTIniana UsaONLY: •
Tfi_is•foitn can be usedfersingle or multiptewellls j
1.,Welt-Contractor information: WELL ABANDONMENT DETAILS
Stefan Smith 7a.Number of wells beingabandu tali: 8 •
WeltConitae1or Name(or well Cantu pasesllly abinlnsdn;aellon liictiicrprepeny) For rrnrfaple h jeet/ae or rron,m rear supply sells ONLY Will .he. savie
covrsrrrrcruuvum5mmlornueot)vrm nor snbrn f rNi3fnrnr;
3576-A 1
NC Well CoairaclorCanifration Emitter •
'7b.Appmzhnatc volume of hate'aimuwing in icell(s):- • (y;iti,)
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
C,onticany Name is Tyjie of dWnfci attt used:
2.Nett Construction Permit d:, ,
List all applhable wellpernrier(Le.Cumrf),Strk,Parlance.hjsdido,,e10(Ammo 7d.AtllUttntUf disinfectant usi.'d:
3.Well use:(eltcclt well use):
• Water Supply-Well;Welt; 7e.Scaling materials used(checit ail that appiy):
EAgriealtttral ElMttnicipaliPublic• Dl'Neat Ccntcnt.Groat ®Rentonitc Chips or Pellets
OC codtcnnal(Hcnting•'Cooling Supply) pRRcsidentinl WaterSuppiy(singic) 1 Satut-Centefil Grout • C1 Oty Clay .
❑hu iistrial/Colnntcrcial ❑RcSidentud Water•Supply-(shatrd). .1 Condole Grout ❑Drill CuH1n
13 htigation q Specially Grout 'E Cuarel
Ron-Water Supply Welt: '.CI Bentonite Shim ; . ClOtiter(explainpnder7g)
•
112hlotiitotine. , EIRecovety .
Injection Went - 7f,For cash material selected above,provide amount Of Materials hoed:
0AgniferRecharge. 17GtOundnateiRemediation • Neat-Cem.:471b ,Wtr:4gal.' Sand Cem.:lb ,Wtr:gal,
OAgntfer-Storage and Recovery ElSalntily 13airier
. Bentonite.:lib Wtr-:gal.
❑Atptifer Test" • ❑Stanmvatcr DtainMe - -- _____ __-__»-_
OEsperintental Technology ' OSubsideltce CottItul • 7g,Provide a brief description of the abandonment procedure:
CiGeotliennal(Closed Loop) . EITracer
Mixed drum of grout (3751b Portland cement 51b bentonite
©Geuthennat(HeatinitJCoolinRReturn) .- [lather(e plaiitunder7g) .
powder and 28-gal water) then tremie-grouted wells.
4.Datewci(s)•abanduncd:2-26-2024 • N T
Sa.Well Incation: et. '" +'L.:i l
White Tire Center . • MA 1 2o• 7A
Facility/Crvn:rNatro Facility lP$Cfapplkab1e) IL Certification
LY
•
2715 Fallston Rd. Lawndale, NC 28090 I nLt.tii4-trvn '?f'^'; ^ r ' >
ji'j� y�ixt.�+ ' w:•a;:''��2�9i�2024
. •, ,` Cerr 'D/3
Physical Address,City',•and Zip S. �ure,:.Certified Well Centrtclor or Well thvn:r a'-; • Datc
1
Cleveland • Ily signs tkrS flint],1 berrby certifydhal the irell(v)was(were)abandoned in
County Parcel Identifie it u:No•(PIN) accordance teeth l 1:1.:C'AC 42C,(ll po,or 2C:0200 Well Cora:ruction Standards
• and due a coP3 of this record has beEA provided(a tire well'owner.
Sb,_I atitude and longitude in degrees/ntinutes(sccnnds ordccimal degrees:
(if well Reid,one latiltuta icutif d 1) .9.Site diagram el additional well details:
You may use the back.of this page to.plovide additional mgll site detnils.or well
35.474260 N 81.510389 • lV abandonment details..You may also atilt adtlitietratkes if ltecessaty.
C'CINSTRIrrrION DETAILS(1F WELIIS}BFiNC:ABANDONED SUBMFiTAL INSTRUCTIONS
' :Wadi ifIrU roe vnraciiorr mivriksi if ovrdlraiik. Ivor rmrlriplr irferrion'rrr rvOn•uarrr supply ' •
welly ON"00 elk''vim'''.rrucstrrr(tos'mock,'gel Tarr care srJlm'l!we AT'. 10a.for All Wells: Submit this fonts within 30 days of completion of well
6a.Well lD :MW-e -abandonment to the following: -
Division of WatcrResources,Infonuation Pruccssing Unit,
GIt.Total melt depth: 20 (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For-Titlecllrtn Wells:';In addition to sending the forne to the address in IOu
6c.Borehole diameter:2 • (In.) above,also-submit one iopy of this'fonn within 30 days of completion of Well
abandonment talk following: i
'ground sttrfaecd 12 _ (tt.) Division of Water Resources,Underground ilidect(on Coutvvl Pndgratu,
fed,Water level.below"
I - - - 1636 Mail Service Center',Raleigh,NC 27699-1636
,
Gc Outer cgsinglcn,�llt(if!mown):: • VC)) loc.-For W. 'r Supni '. Injection tIts: In addition to.sending the font:to
,the address(es)above, also submit one copy of this font'within 30 days of
completion of well nbnndaitment to Idle county health dcpanntent of the county
61.Innercasingitnbing length(if mown): (ft.)
where abandoned, i
6g.Screen-length(if htion"ts): (ft.) ! .
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• Fame GW-SO Nonh Carolina Depann>em ofEnvironment ail Naturist Resources-Division of Water Re auras Eice�i ed Angina 2013
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