Cleveland_Well Abandonment_20240419

WELL ABANDONMENT RECORD FdrIcdenialU90ONLY;
This form can be used.for singele oe moipte it'eils I'
11 Well C4ntt•acWr Information: �, t,VP.LL ABANDONhiENT`nETAt1..S 1
Scott Hunt, Jr \ 7a.N"berof wells,hciauah:tndonclv1:11
Kre]fGautmelnrNattie ortvcllovvc� troll ttrt nin�vvell.onhis lter ien For nhrlliplc .ftJeetlar or ium-ti-dur i supple yells ONLY. Willi llti smue
cnrasrrrreflora'm5mrd�airrnerrtlrenecursrh�iUraiej6rni•
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NC td1 ConirdaorCcrrlfcaUoirNntitbcr• b.ApprozLnatc volume aNvater rentyining in ivell(sfi
sAEnAcco FOR WATER.SUPPLY WELLS ONLY.
company Nam 7�Type of dislnfietant used:
2:Well Construction Permit 9:,
Ll3trdlaplrl:i»llld.fitifllartreiLr(i.clCwvah Sta.e,i'urtomce,L�rrlir�M.cicitPJGtve�n 7d.Amount ofdiilnfMAnt`used: J
3:Wdl uyr(chcelcn•cll,nsej:. -
�Ifater supptti Well: .7c.Scaling materialsmsed(cocci(all that apply):
pAgricnititml plvitmicipxUPtlblic _ -®Ncax CerlteB(.GWVt ❑Bcruonitc Chips orPcllets
C70rothcm il.(ItcatingiCool(ug Snpplyj pl2c Wntial Watcc S�cppiy(singlcj 13 Sand Cement Grout ❑Dry•Clay
❑9ndtistriallCmm�tcaial pltcsidential Watcr Supply.•(sbarcd) l7 Concrete Groui 0 Drill Ctituings
❑Ini lion 17 Specialty Grout ❑Gravel
Non 1VatcrSupph'.Wctt: ❑Bentotdte Sluay 17-0ther(explaiuuoder 7g)
19Manitorine. ❑Recover v.
Injection Nvcll: 7f;For caeh•uteri."d selected above,provide amount of ntatedals nscd:
❑AyuftRectmilo 1766uiidnalerRentedwon Neat Cem.f941b. ,Wtr:5 gallongalSand Cem.':lb ,Wtr:gal.
OAquifer Storage aiki.Reeoven, OSalilify l3aider
Bentonite.:5%lb ;Wtr:gal. portland Amount:60 gallons
i7Agtrifrrl'est ❑Stoncnt rtecD:rtitiage.
❑Erpa rinrecilul Tahnotoey pStdlsidetrce Cocdtul 7g.Provide a brief descriptian of the abandonment procedure:
❑Geoillmnat(Closed Loop) ®Tracer
Tremie grouted from bottoio to top
❑Geothermal(HeatinmC44fin Retum) 00dicr(221ain under 7t;D
4.Da(ciseu(s).abandoned: 3-15-24
5u.Wen lucation: ;l�..�.�L4,i � !._La
Lewis Service Station APR 1 9 2024
rkilirynvmr Nmm Facility 1Pe(ifappikabic) A Ccrtliicalian;
4733 Fallston Rd: Lawndale, NC 28090 {t1r`3ITf. =A6'%°3VW6A024
Physkal'Address.City:andZip it!trvot•..i•R:fti lWeflCnwractnrorWe110"
Cleveland Hy signing 1hFs form; i lieirby,cerhfydlinl fire tire11(s)rrns(were)mfiondoned he
Coutuy Parcel kkndGc3dan No,(PIN) pt cvtrlcrlice Will,IS;I:4'L'AC 02d.0l00.br°Zr-.0?00(yell Gaisdniclion Stanckinls
mid rlrni,n Copy ofOris iccord hasbeell pruvided to dre is-ell otmer.
5h,R ltinide and longitude in:dc(mscslnrtriut�cP/scrnnds o�ilccim;tl dcgr ccsi i.
(lfnetl fakl,mte Nulling isitjiicletA) '9.Site diagram or addidonat well details:
You tua�use the Uack pf Wis.page to proc�ide-addifioaal)cell site autails tr tse11
N W :abatldoin►terddetatLs.You etul}afro attach aslditiuuaCgcls if rreet�sary_
C.ONATRifrnox.nPutts ON WEL64i DEINC ABANDONED SURbii rm.t111STRUCTfONS !`
:!lrridr n`rll ciirzvirurirort nLxvdls)Jf oirollrarilr Fur itruloptr iitj'rrfiuli Ur ma-n_•ut'w.xupply "
nelGtONLYuiUttlicis�amrxnirsvrrnaeahmrrkrriucgtt irtucansttbnittwte1iinu 10a.'Far All kVctk Submit Ibis fotnr tithin 30 days of eorriplction•of u�11
6a.Well ID4:RW-1 abandoomcitt to the f4i1411'ing: ;
Dkvisian of Water Resources,Infotmation-Practsiing Unit,
Gb:Total crcIl depth: 40 A)
I6171%tail Service Center,Raleiko,KC 27699-1617
10U.rot to IecNaa wells: h1 addition to,setxiittg tl�form o t[tb address In;10a
abom also submit one bogy'of this)form cciWin 30'days ofycompletion of)cell
5c.Borehole diame(er;6 (in:) abindotintent to tW follolvicig:
frd.Water lciclbe[4ty, and surfacce 35 (ft,) DFcistotiaf Writer Resouries,Und rgtrinnd bijectiou d outtal,Mgraun,
�° 1636 Mail Scrticc Center,Ralcigh,NC 27699-1636
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Gc.:Outcr casing len rf IsnnnvJ: unknown (ft) loc.EI \Voter.S,fnnts'&.in(cctinii t'elk: In addition ad.sendigg the fonn to
F �( the address(es) Aove,also submit brie copy of 11iis forks)vi[bicr 30 days of
co took.ion of Avdl ahandamnent totIhe coiuuy Itaatth depuanterd of the county .
6C Inner eniinWtubinyt tenjah Of tarou.n):unknown (ft) tc'hcrc abandoned.. ! ,
6g.Screen lenfith(If knotttt):,unknown 00 i
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Fain►GtV-30 NunllCamBroDepogmemofEu iroontcntalndNammiResottices-Dh•islanofWaterRcs!wl s R"ised AM"2013

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WELL ABAND®NNIEN.T RECORD ror MCI"Us;ONLY;, P
ThiTchacanlie used forsitiggleornndjiipkw: ells
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1,Well contractor information: WFLL ARANDONNIENT DETAIL R 1
Scott Hunt, Jr ?a NuntberriC�rills6cingnlrandancilL Il
11'c1CCauleagorrepisforterllo+ansipcisansllyrti5mtnniri;acllont�flkrVrepcny}- For ernquPle 11Jrctiwr by. rmra-ilvlfea• !sup'py welds- ONLY.'wilb 11k. sane
c_�,rurrrrcfiar%azbarrdrNrmaif;�vn cur+.nab,�irlt wrcj6nn,
4561-A
hie{Vcn CbrtteadvrCcrtilicalioii Kari>Scr 71r.Approi inate rnluute of orate ttrintiining in-11A s)� (gad,)
SAEDACCO FOR NIATER.$QIPPLY WELLS ONLY:
Ganyatiy Kamc 7e:,Type of dislull etant tired:
2:Nell Construction Permit&, ,
LfueJlaat>l:ivble,uxlJ}artrrilr_(ia.Curarrty,Srntn.Yarlarree,trJerLarr,.ett:►lfAtwwrt 7d.iWountofdislnWatitustd'
3.Well use(;6k c*l•eu use):
Water Sppply NVOL 7e Scaling rut itcrials:nscd(cliect.all Chat appl�j:
pAgri ulttntai. ' phftlnicipallPttlilic. M Ncai Ccnicni.Grui►t j 17 gcnto6itc Chips orPcllcts-
❑0cothertnil(H¢atingJt golia�Supply} . blIcsidetrtial%Voter SuPpb.(single) ❑Sand Centcgt Gtont ❑Dry Ctay
❑Induslriallcoitmtc!cial O[tcsideruihl�VntcrSupply';(stihred ❑'Cgitcte(r Grout O I)dllCitlliti„s
❑Tuts %ion 17 Specs lty Grout -,C7 Gravel
Non-%Voter Suppia•�Vctt:' -T - — Ct Hetnotute Sittay 0 Other(esplainunder 7g)
QOMaidladng... 13Recover
fajection NYctlp 7f.For each taatedil selceted'aboge;preside antotintoftitaterials used:
❑AquiferRccirarge I7Groundn�lerRein,iNlioil Neat Cem.:941b. ,Wtr:5 gallongalSand Cem::lb ,Wtr:gal:
O lqulfer Storitge aid.Recovety pSalbdlt Battier
OAiiniferTest DSlorunva[etDtabiage Bentonite.:5%lb ,Wtr:gal. portland Amount:7 gallons
17E.xpetinterilalTechnotoev >jSidrsideltce•Coitltul-
7d,Provide a hrlcf docription of the abandonment rrlrccllure:
UGeothemtat(Cfesed Poop) ClTracer-
Tremie.grouted from bottom to top
®Geothenna[(Eieitetin&'Coolie Retum} �i7tfterl2 lain udder 7A} .
d.Da(enell(s).abandeiircd:3-15-24
Sa Wemocat(on:
APR 1 UPI
Lewis.Service Station
.$.�C19lilCatioil: l;
racitity hvncrNam racilirti•IN(`appl;wblo) trtTo;Y.*4,.n .:F.;Wait
I G1fJQl��JG?
4733 Fallston Rd.'Lawndale, NC 28090 -, 3/16/2024 "
Pligskal-Addres.City.and Zip Yxt Re 01' 11; d Well Commaor or Well OivriLr .Dauo .
Cleveland py signing.1N.N fo)m,I hemby certify Aunt the irell(.sl iras(ieer+e)ahatdoneil he
corsair i-arsel fd:olil'r�itbli Me.(PlNj 'aaardance 0th 15:1:�CAC-02C.�lkh r KAZOO Well CUaas•Jivdion SAntclririls
oast/JJrnJ g mppbjilris record has bee);prrn idcr!la;tlte troll ot+nen
Sb.l at1Wdeand lungitudc in d�gr��slinieiuterlsceandsurdccitrue0 d¢�ccsi
(irlvell('a.ut,arc titilong is sii83Ckli) -9.Site diagram or additional Fell detalts:
You eta} use tlts•bacl:pf iltis.pdge to`'pioi•ide-additioltal%wil site ddails:or well
N IV Ai audou fern&Wts..You tuap Aso Anne udtiuioual poems if necessary..
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CONCTRII('WIN:DE TAi::_ti ON WELL(Rl nFiNC ARAIVDONED SUnbit7TAL INSTRUCTION,
ltlradr�r ell.eo@struetran ncrardfs)V'.AW1dj1e. r&uu lapk byecrion'w•min-rulir.supply
nells00iiO'd cnnsirbm,fl,wrej'onR Ma:'For ell .Subinit,diis famt ititWn 30 day of completion ori%tlI
Gs Wd1 ID � -1 abandounecnt to the following';
Divislanof WaterRe opr'cm,Infotmation•Proce-Ang Unit,
[6I711Liil Sciyice Center;Rulcly(li,ll'C.27fr`71-1617
Gb:Tatal ivOl dell1h: 45 ) I
bOb.T, r Tnleetlt+n Wilik.'in addition to setting the fount o the oddrasi lu_IOa
Ge.Borehole diiutctcr:2 liu.) above;&io.subunit sue copy of ibis,f°ml ivithin 30'doys of complelion of a+ell
abutidonntcia to the fallowing.
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4d.Water l ;el.bcloiv and surface 35 (fa) lfivislon:of Witter Resoutiesi Underground Injection Conitbi-Mgram,
1636!!fail Service Ccrf6er,Ralcigoi NC 27699-1636
Ge.Outer eosin Ice of Imnvrn): unknown (fi.) loc.i'ne Water srennh•.cr Lnicetinri Mlle: In addition'to.sending the form to
g ',( the 5ddress(es)aboye, also stibtuit'one copy of-this form vvithitr 30 days.of
completion of well'36daimrent-to the count)'health dep4anicid of the county
vvlicrc al>teFdoncd•. i
Gf..Inner casinWitnbin(;lailith(if ilricovvn):unknown (ft)
k
Gg.Screen length(if ktiott'n):unknown - A)
i
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Fenn G1Y-30 Nnuti Carotlm Dcina mm dffrtvlroanknt and Nararal Resources-Div iosrof Water Res uaccs Rci used Auden 2013
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WELL ABANDONMENT RECORD Fvr Imsm it Use ONLY: I '
Thii form can be used for single or multiple ivells
1.Wetl Contractor information: WELL A1iANnONNIENT DETAIf_, !
Scott Hunt, Jr 7a.Number 6fnells being abandanell: 1
lVeltConunctofNnnie(or%ikllo%vmNisax7ll)"alas>Dtofnnoucll.on"hivkr prop-cny) Fco' unrltrple 11fecNaf or fora-irafei ''sup'pdj' wells- ONLY wah 11m .sufle
LYXr>fl%fCflCel eil�OltclpllAh711,lYlu er17 slibil!t fM16f(1PJ11.
4561 '
Nc:;'tYc11 ContradarCcnificatioti Ntnibcr 711.Anproximete%olunte of crater ttrriaining in m-CII(s)0
sAEDAcco FOR W ��ATER.SUPPLY FLLS ONLY:
ConyanyName 7e,Type ofdtasnfettant used:
2.Well Caustmction Permit a:. .
113f rdl ultl>thvLle urUper(ritr ti.L: 11Urtrfine.Ilrfeccdawetct J,tttowo 7d.Autoune of disinfectant used:
3.Welt uyc(check n el1 u,c):
`Vater Supply°Well: 7e.Sealing n%aterialsuscd(cbcck a11;i11ar apply):
dAgriculturat Obhtnicipal/public 9 Ncat Ccntcut"Grout Q Rctttonitc Chips or Pellcts
13(3colliermal(Hcating'Coolino Supply) pRcsideurial 14;•ltrr St,tpl}•(single) 13 Sand Centeut Gmut ❑Dry clay
❑Industrial/Comnicrcial DResidentLat%Vatcr Supply(sh.•ited) O.CoucrnteGrout ❑Drill Cultings
Odni tion O Spo syGrant ❑Gravel
lien-Water SupplyNVetl: ❑BentouiceSlurry d 0ther(esplainunder7g)
19Mntiitaring aRecotien'
Injection NVctl: 7f,Foreach roaredal selected'above,provide amonritof.tuaterialsascd:
OAgrrifc,rRcchar&6 OGroundiva(erReniediation Neat Cem.:941b. ,Wtr:5 gallongalSand Cem.:lb ,Wtr:gal.
17Aquifer Storage and Recoven2 OS;dinity Harrier
❑AyuiferTesi OStonm%alerDrahiael Bentonite.:5%lb ,Wtr:gal, portland Amount:5 gallons
❑Eyrerintental Techuolo��e• DSubsidetxti CotNm1 7g,Pru%idc a brief description of the abandonment prrtmoure:
OGeoll!emtal(Closed Loop) riTracer
Tremie grouted from bottom to top
Meothennal(HeaGnWCooling Return) 0O(herLc lain under 7R)
d.Datcri•ctt(s).abaudoncd: 3-15-24 L.5a.WeH flicallon: R 9 2024
Lewis Service Station ITHt�c �r 1
PaeilitylCltsner Naitee Taeility IN(ipapplkablc) .
8.CerrlIIcaciaii:
GiPJC,tr`�'J�
4733.Fallston Rd. Lawndale, NC 28090 �r/ 3/16/2024
P14siod Address.City,and Zip y!!l J'imfi!"'rn.rNId WoO1 Cnnerraor or W e I I On•n.r Data
Cleveland ley vigniq this forma 1 fie-by certify-trust tree irellpd rras(here)ahmtdoned in
County pastel Id.tulticitllln No.(Pi©), accunlance with 114 XCAC 03C,0100.or 21--.0300 Mull Consltucuun Starnklrxls
and drat a copjrofilds record has been provided to dre well owner.
Sit.I ltitude and longitude in degrceslniiuutes/seconds or dcciatal degm a:
(ift}slt f-Rld,one L-100111,icpttite;aty) 9,Site diagram or additional well der als:
You«ray use the bad:of this page to provide additional well site details or%sell
N W abauilauuteiu details..You tuay aLso aitach additiowtl pages if necemn'_-
CONSTRUCTION DETAILS OH WELL(S)BEING ABANDONED SURNI'Mr'Al.INSTRUCTIONS
tlltxh 11_Ctl Ctl2rIrLL'11L7!riLLrGllSf If Ol'Ylilf2Jl1.. Par firutnple f(rjectiruf ctr Mri•u-iII&stlpptj- "
urns U,,VLI'n'trh rlx svnr�tafsrtrxtdofe"o5a rlfuuxvLtiu.juo corn svt mil wre fang 14a. For All Wells- Submit this faint%tithin 30 days of completion of%%ell
Ga Welt 1D#•MW-1 abandonment to the t'allotring:
M0.4ion of Water Resource,Information PraeLwing Unit,
Gb.Total well depth: 28 ((r,) 1617 btiril Sciviee Center,Italekli,KC 27699-1617
10b.for inleclion WLgls: In additioi to sending the fomt to tpe address in l0a
Gc.Borehole di tutctea 2 pit,} above.aLsa submit one copy of this form days of 30 d of completion of%%•ell
abindounicat to the following:
i
Gd.NVatcr level l,clom ground�Wrfacei 25 (ft.) DiAslott of Water Risouries;Underground bijection Control Frograrg,
1636 Mail Scnicc Center,ItAld-�h,NC_ 69l 1636
6c.Outer casing length(if it ionn): unknown (ft) 10c.rnr\V tier Sannlr S, Ltiection Wells: In addition to sending the form to
tile,address(es) above, also submit one copy of-this fora tvilhin 30 days of
completion of well abandamnent to the county licalth department of the coney
unknown win-rc abandoned,
Gf.dnncrcasinlftubin}!Icn}Kb(ifloia%%•n): (ft.)
Gg.Screen length(if Im0%%n);unknown
Fofni GRi-30 Nonli Carutim lkpannxin of Pmlronnient nut Natural Resawres-Division of V49tcr Rao Iurn:s Revised August 1011
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WELL ABANDONMENT RECORD For Iracmd Usr ONLY;.
This•faim can be used.for single or multiple It etls
1,Wett Contracwr inrorniation- )YELL ABANDONMENT DETAILS
Scott aunt, ar 7a.Nutnher6ftsillsUcindapandane�:�1
11cICCounadorNoaiolorarl!o�rn�p�ronally ilfs�InningaclloahishcrNroperlyT MU-rie pn • ONLY WNh t1 . suaFa reiufep r I'
c»nstrrrartvn/obmrrirriaw��i1}rrncmr,wluiU►wrajoruL
4561-A
CbnttarxorCcnificaUori'Nnnbcr
76.Approximate 11d'"Me of water rtyualnin>;in itYll(x)9
NC''}Vd7
SAEDACCO FOR 1VA'rFR.SUPPLYIVFLt;S_ONLV.-
Caazflany ltattic' le.Typc of dish.ilketani ti.4cd:
2.Wdt Constructfon Permit 4:
L[stulinpirlGwbleueNfarmiir(La.Crnan¢,Srn1e,I'arinrre Infrciiarrelc}tJ un 7d AnlatmtOfdlilnfecfsiat'ttSCd:
3.Well user(checicr eff nse)-
1VnterSupply Welb 7c.Scaling tnutcr7Alsuscd(cbixlcall l»tt ttpply):
t7Agrfcutntrat pMttnkipaUPltbl[e M Nrti.Ccmcnt Grout. ❑9clltotiitc ChipsorE'dlcts
17090tliettn11(Hcatign,JCoolitio:Supply) pLtcsidetm ii Water Supply(single) . 131Sar4Centei t Gmut ❑Day Ctk .
❑liulustriallCOntmdreial ❑Rcsident$it Water Supply.(ounod) ❑Cij6cietrr Grout ❑Drill CittUut s
❑Ina lion. []Specsalty Grout I. .. 17 Grai'el
Ran Watcr Supply Wclt:'• ❑Benloldte Sluny, I' ❑.(7ther(explain under 7g)
Q9Maititoring. ❑Rccoven�. '
fajcctiatt lYcltp 7 f.,lror cacb)natcrir(I selected abocc;pi otide antot)tit df inatesials lased:
❑ Hafer Rcc[4ir�e ❑Gtouiidt�ater Reitted[iuiou
! 1 L Neat Cem.:941b. ,Wtr:S gallongalSand Cem.:lb ,Wtr:gal.
EjAqui6v Storage and-lteop en, liSalinity Barrier
❑Aijuif&Test ❑StoiimtaterDrai.iage Bentonite.:5%lb ,Wtr:gal. portland Amount:5 gallons
OEgt:iftttettlal Technotogy $ubsittetuti Cotnml 7>; Provide a brief,ticscriptian.of thi Abandonment pra ut't::
❑Gaothennat(Closed Lodp} ❑Tracer,
Tremie grouted from bottom to top
®Geathertietl(HeatinalCoalinRReturn) BOttter(� Iaitiunder7R)
4.Daic,0t 3).abandoncd: 3-15-24
5a.WeHlocoNon:
Lewis Service Station i1►r`tji'ir:8«£1 Pr^^ryr,.4N-g UK
8:CcniRratiau:
Facilit}a'Qn•t-crNaarrc Fac[lii«•ID>a(it'appliwlils) i, LYifrQi30C
4733.rallston Ra. Lawndale, NC 28090; / 3/16/2024
Physical Addre ss,Citg;sridZip' all at!tren!'yo.-AWellCoxancwrOrwell01VM:r Dog
Cleveland lJjr sigttir{g Saes fnrrn; 1 Gemby certify,.rlutr the xell(s)trcrs(ireraf ahatjd ed ire
Cqutity Ikurcl ld-Wit'rCltinn No.(PIN) zaaurcicriice will;lSat:C11C.02C,O100.dr 1C.0?O(J il'e11 Go»sliatctiun'SfnrritrrrtI
arillkat a copy oftbis recard hm beeia pr m4d,6 l to.dre well on'ner.-
$6,,1xitudeand Vingitudc In EtcSnsesriutttuteslsccontls ordceiut;nY dcgrcc3: .
(If«cu rn4td,oise Lithl ngis snt(mrct>i)_ 9.Site diagram or additional well deta[Is:.
You.ivay use cli - ai,.0 tl►is.page to provide additional ttvll s[te c[ztails.oi tall
abalidoimtent details..You may also attach additional pages if nexessan'_
C.ONSTRltl I'ION.DETAII q,OF 1VELL(S)BEING ABANDONED SURM11TAi,INSTR[TCTIONS:
tfrvdr MC/+Cn21')flfClfAn K'LL![lI3)�'dVtlll�la! !ur mu(fipfr hfecfion'.ru'rz�n-nurrr stryply ' - - - ', ,
xelltONCririthilu svurrrrunnrrr(Jare'ahairrtorri:r�rrr,iuucnnsrrfimilcurefumr. Ift For All,%V&% $ubtnit Ihiq farrit«ithiu 30 da)S of egmplctian of hell
6g Well II)�t• -5 abauddtnacnt to the fdllgtving;
Division of Water Resources,turormation Processing Unit,
6b.Total well depth: 28. (<Y:) 167 AL•tifSciyice Ccuccri Ralei;li,KC 27699-1617
Ub.Fnr.inimllon Wells: in addifi to sending the fotni_to ilia address Ili i0a
Gc.Borehole diametew,2 �u,)' above:,Aso subntil one top),of this form itilhin 30 days of comptetion of welt
abundanuteid tothe fallan11'9
fad.lVatcr tevclbelaiv utitl surface.-,.25 (fg) Di%istou of Winer Resources,Underground Yti eL a Conitvl'Prdbnam.
1636 t)lail Senicc Center,Ralcigli;NC 27699.1636
unknown 10c Fnr Water Snnnh•'&Ldccttgn 1VellA; in addifion'to sendingtale fowl to
Ge.Outa r c tying lcu ih(if lvpstn): 00 the,,address(es)above, also submi Fotie'copy of tlils:feral within 30 days of
completiati-of a-dl abandauamnt ro Ihr cotuuy health department of the coutgy
unknown where aMindoticd,
6f.inner easinl:/tabinl;PxnlKb(if Gva4ti'n): - (ft.)
• i
6g Screen let h(Ir Imottn):unknown (�) }
Form 011-30 l%6th CamUw aad Natural Resotuces—61%-islon of W.gtorRcsouta s Raiied Aar 20 t3
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WELL ABANDONMENT RECORD". For Irttorualii5ONLY;
This1onncanbeusedl6rsineleorundliple)iAs
I.,Wen Contractor tarormation: WRLL ARANnONMN.NT DETAIL,,;
Scott Hunt, Jr 7u Numbcrofily lsbeingab.)ndaneldi�l
Welt Cortlr�tlorNamef,Ofltr(ln{{c�p.Isasully al�udaniuoseunoul�lL�rprdperty) For. R+i apk. f1Jec11ae br mri kiwfer I supply welts-. ONLY "with the .-mvne
coorrtrCrlGVliabpjYh;Y141er1r,IYIN CAR sahkk Wtdf nx
4561-A'
71).AppniYltnatc♦olteittt of tratir mine lining in u•ell(a�
NC WellCamlrsporG:rilfi�tloti Pfoai�bcr. -
srEDACCo FOR WAT RSUPPLYWFLfSUNI.Y:
Canvany Name 7e.Type oCdisigfi'ctant tised:
2;Well Construction Permit M:. i
Lat to l all lmle urU pu utter(i.a'.Cuunfy'.4r6yv.i'driorre."flo ier,.¢1c t if ra 'j " •
7d.Alnount of disinfi�efaurumyl:
3.We11 use twell use);
Water Supply Wee 7e.Scaling materiats:uscd(cbedkali d14 appty):
-17Agtccultural CIINrtnicipallPubGc M Ncai Ccmtcnt Groot -C3 Hera ite Chips orPOIcts-
17Grnttumtal(Hcatinr-)Cooling Supply} q[tcsidcttrial WatccSoppty(sin�rlc) �Sa>d Cement Gmut 1 Dv Cory
❑btdostrial/COtnntc)cial, ORcsident$d%Vatcr Supply:(sWrrd). ❑.Concm[e Grout E3 brill Cutting s
Olrti limn O Specialty Grout �• E3 Gmel
Non-%Vater Supply.Weil; -- -- — — O Iientouite Slum 8.Other(explain under 7g)
I9Manilorirrg... Oltecovem
fajcction'Wcll; 7f.For each utaterltll selected above;peovide nmount.af.ntdterials cased:
AgtdferRcch_bM O OGtouwlraler-Rcmedujioq Neat Cem::941b. ,Wti::5 gallongalSand Cem.tlb ,Wtr:gal.
DAquifer.StontgdandPt cwery OSaliikBarrier
❑AgrdfeTe5i OSlomnt uer.Drtiirage Bentonite.:5%lb ,Wtr:gal. portland Amount:5 gallons'
pE.eperinterital Techuotog-v pSubsiderre'Cotmrul, gg Peovidt tt Irricf'd eriptlondf tl c abandpnmcnt pnlcr+laer:
❑Geothermal(Closed Loop) bTracer
I.[7Geothential(HeatinirlCoalinRReturn) ClOther(ea laitiuttder-711) Tremie.groute.d from bottom to top
d.gate well fs)abandoned: 3=15-24
5a.Well tneatiou:
Lewis Service Station ?r:7,:�*axd r g(;n
Par:ilit yiOwncrNttinc tail 1D1d(if plicablc $•Ccrelficaligil: ; '
l av ) / GifGCu:.JC
4733 Fallston Rd. Lawndale, NC 28090 ( 3/16/2024
1 1•Y'�
Plr}'sical'Addmz.Cii)•,:wW Zip hiro U[ 'crtJs J�VC1l Glntcrctor ur W¢tl Dirt r. t]att
Cleveland diy.signing III&faint 1 bereby certify durf the trell(s)wim(were)abandoned he
Couuiy P=cl Wsal'tntlanNo.(Pl.1Nj '(rccvidance wiNr 15A XC.4C 01C.0100.or'1C.0 00 Well Curislntcliun Cwa*rds
mid f rii a cop),ofllds.recurd lr{rs&6;provided to7lre well oisirer.
Sb.I�rtittrde and lon�ihic�e In dctymceslminutcslsecr�ntle"or ilccitu;n9 dcfircesi
(Ir'611 C4'kl,one Iarll na Is mi07 k* 9.Site diagram or additlonat Reii deltas:
You.164 use the bat:);of this page to.provide'addilional hell site details.or well
N W -abaridaimtent aletttils=You rut}also attach ad+liGotxtCpages if r►ccessary_
C.t1N TRtrc'f ON-nE.TA1L.14 OF WELL(q)REM.ABANDONED SURMMAL INSTRUCTIONS:
.-tlfudr n:ell cvrrslruiYinrr n'�ordfs)J,f avd7rarili f ru`irrulriplr ixjrcri�ri ar ra7n•riur�•auppl}' '
xr11.4 ONLY rrltb rare avmetauorarfrordrr9oirtlorrrreru.yzucan srrbarlr core jyrnz 10a:'Nor•All-We 6 Submit thi-i form ttiihin 30 days of cgrriiiletion of uell
Est Well 16#:MW-6 ab'andonmcnt to'thrfollowir►g:
- Dhision of WuterResquicu,Information Pryc�.�sag Unit,.
167 A iil Service Center,Raid h ABC 27699-I617
6b.Tota1well depth: 30 (ft.) ,
tob.Tor TnMon W-01s a additioii to se-uding the form to the address iti-LOa
6c.Borehole dtamtetcr:2 (in.) aboty;Also subudt one topr;of ibis!fonii�Ftittr{ir 30 days of completion'of hell
abiindomttent to the follROug: I'
Di�•islott of Witter Resources;Undet ground tel jedlou Couttbl Pi dgram,
6d.Water lerdbclow ground surface:.26 (FtJ 1636 llfail-Scr%icc Ccudcr,Raleigh,XC 27699-1636
6c.:0utcr eosin 1 h if l+volrtt)�, unknown, ( .) loc.rnr WaterSurinls•&Tniectin 1• Yells; In iddilion to sending the form to
?; .( the addres(es)above. also submit bile cop}• of this font %vilhin 30 days of
eattiptetiati"af tirell abarulanmcm to ttic court), health department of the county
unknown wlurc abr ndoncd,.
6E Inner c:tsin;/tnhiog 1C r1 Wh(if Lm.w.). (tY)
6g.Secret,length(if Itnotvn):unknown 00
Penn GW-30. North Caroula Depo"Mcni dEnvirouutcnt a.1 Naruml Rcsou:ccs-Ulvlsbn of W'aEukeso I Revised Aar MB
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WELL ABANDONMENT RECORD ror Imemal Usd ONLY:
This faun can be used for single or multipte,wells
1.Well Contractor information. WELL ABANDONMENT DCTAt6g
Scott Hunt, Jr 7a NtiutUerrif,rcllsbeittl;uUandoncd: 1
%Vc9l'Corlracro%Name{orl+ettnsrerttxansralty ilu i�ilne„coon"hisrherproperty) Icv nrulnple !r}crNar ru mrr-irtuer sirIV), wells 'TNILY alrh 11w sruiie
c�xutrrrefitaa:a'arrLanrrn�rrl,iv,e ctur s7rhritrt arejornt.
4561-A
NCMilConlraclor( nIAmflonNnribcr
71r.Appr+)kimatc vulutne of%vattr ruetttsining in wcll(n)Q
SAEDACCO FOR WATF,R.SUPPLY WELLS ONLY:
Can�an+Name 7C Type nf+lisinfictant used;
2.�FcIF Cousttvctioit Pct'rtdt M:, ,
L[if Uhl trplr!'tv61a trrlllx7•irrirr g e.Ckat lv,Stare,I'arlarrce•by'ectiotr,.elc}ttfkWwrr 7d.Amtiune of dLi[nfectsint used.-
3.Well use(chedcnell use):
Water:Supply Well: 7e.Seating materials used(chcck all th;%t apply): "
❑Agdcuttunl t7hlnnicipaUP%tblid M Neat Cement Grout ❑8monitc Chips orYcllcts
00 milicimat(HcatinglCooling Supply) r3kcsidertinl Watcr Supply(singtc) ❑Sandfientelia Grout ❑My CIj3,
❑lalustrialfCornntctcial ❑Rasidenliitl Water Supply"(shatcd) ❑concrete Grout ❑DtillCultillp
❑itri •tian ❑spegalty Grou l ❑Gri el
Non-Water Suppty Wctth - - IJ Benlonite Slug d Other(explain under 7g)
R9Mmiftoritte ❑Recovery
injection Well: 7f.For cacti tnawdid selected abo}fie,pro,ide amount of.titaterials viscd:
❑Agnifcrltechurge ❑Gruundnuler.Idemetlialion Neat Cem.•941b ,Wtr:5 gallongalSand Cem.•lb ,Wtr:gal.
DAquifer Storage and Recovery I7Salini(v Barrier
❑A[iuifetTest ❑Stoma%aterDruhuge Bentonite.:5%lb ,Wtr:gal. portland Amount:5 gallons
❑t%prrintental Tot huoloev ❑Subsidence,bmdrol 7g,Pardile a l riif description of the abandonment ptvtcCdn=
Meothennal(Closed Loop) ❑Tracet
0Geo(hennal(IieatinwCoolinAReturn) ❑OUterlex lainunder7t) Tremie grouted from bottom to top
`-- i
a.Date tsell(s).abandonctl: 3-15-24 r X �!E�-i ' t—
5a.Welt location: APR F"
Lewis Service Station
8:Cetlilleaciaic 1n,.3r•Fr",.ns,•z"O: ,.,�),�_:� l��s:
ractlitlf(hvo:tMum ra;,ilhy IDS(ifuppliwblc)4733 Fallston Rd. Lawndale, NC 28090 :F,.i -..
3/1�6/2 024
Physical-Address,City,aid Zip ,tJ t 'own,, Neil Utni aanr ur Wetl(hvWr .Dale
Cleveland By.signhtg This farm,I hei rby certify chat the trell(s)was(trere)abatrdoned he
Cnatsiy Lintel Idcnui!titian No.(PINj acwMance with I iA AV AC 02C.0100.ur 2C.0200 rf ell Cmisfiltcttun Stawkrrds
and!drat a CoPvgfthis record has been provided to the weft Oliver.
Sh,i ltitude and longitude in ctcgrisesln%inuteslseconds or dceirnai'degrees.
(tfviell raid,One I:ullnng tc sufrtcicty) -9.Site ditgran%or addit(ouat well details:
You Irmy use the ba&of this page to provide additional icell site details or%cell
N W abatidoimtent details. You may also attach:dditianal pages if necessam.
CONSTRfTMION.BFTAIII-S OF WELTa31 BRING ABANDONED SURRTT7TAT.TNSTRLTCTfONS
:lJfrxlr fre•N criru'lrac7Jua taivrdls)1J uertllrbtile. For rruJriplr rr�et:tiuri ur rxtn•irarrr srrpplj
u•e!&gNLY u•rtb rim svutc trt7rsar JtOrr 15ri rthrnrrcnL i+rr con hrbttti2 are jernrL 10a.For All Wells: Submit this farm%%ilhin 30 days of completion of uell
63.Well LD#:mw-7 abandonment to the Following:
Dlyisitin of Wuter ResourrLs,InfonttationTrocessing Unit,
30 [617 tlLril Scntiec Center,lfalci(;ti,NC 2769'J-1517
GU,TataCnell depth:
10h.For ittleclion Wells, In addition to sending the form to the address In 14a
6c,Borehole diatueter:2 (iu.} abo%+e•also subndt one copy of this'fonn willrin 30 days of completion of ivell
abntulomueut to the Fallowing:
6d.Water[c�cl below ground surface: 26 (ft.) Divistott of taster Resoucees;[lndergrouud injection Control Prdgralu,
1636 Mail Scr-Occ Center,Raleigh,NC 2769I 1636
i
6c.Outer casing length(tf Isio%,n); unknown (ft.) 10c.Rr Water StmU .f ly S tlisfign ti`etly; In addition'to.sen ding the form to
the address(es) abate. also submit one copy of this fors within.30 fts of
compictiomof%%•ell abandon n ant to the
county health department of"(tic county
unknown %%•here abandoned,
Gf.Inner wvin/tnbin(;lenj,Kh(if laru%vu)t (ft.)
6g.Screen length(if lcuo%%'n):unknown (ft.)
i
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Font MY10 Nonh Carolltn,iklntn>m orEnriroanncat at 1 N:ttut3l[tcsou:ees-Dlvisiosv oC VimcrResourccs Revised Aaguo 2013
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T,7
N' LL ABt ND-ON1!EE N.i RECORD Forlitteiiml Us;ONLY;
11tis;fann can W used for singly or.unihipieWells
I.We"'Contr'actor�Information; )YrL L AHANDt1NATNNT DC•CAIC_R IiI
Scott'Hunt, Jr '7a.Number dfmilsVeiny)abandon eof
welutocimaorNanie(of ucllhuWp:wmlly.rtsam[onitioeet Ran Msilwrpioperty) For fimItrple.. hyetwon or-. rota-ntirfir supplj" wells ONLP 411h Av. .dw:ie
c�.vtifrrrcflcka�o6oaedNrnat'taf,Iran ccw sraBuiUr v:ie.fo'rnr. -
4561-A'
NC Wcn.CbnlradarCojtffi ,tioti Nntrbcr 7II.Anpntzimlteriilnuet ufwat Mmuiuw8 in trell(2jp
sAEDAcco FOR WATF,R SUPPLY WELLS,ONLY:
GonQ3rty Natnc' 7c.T�Vpe'ofilbinfect rtit 6,w -
2.Welt Construction PermitN:.--'-----_-_
Ilttall.npJ:f.'tuhl�nellpirmiir(La Cccinh;Stare:Yuridrrce:lx}eitinn„elcllJdtmwvn •
?d:.ltnounl of disinfectant ttscvli
3.1vell usr(ghe Wcl1 usc):
Water Supply Well, ?e:Soarlin tnatcrials:uscd`(drect{all that apply):
17Asricnittiril IglNta icip dlPtltilic' CG tdcat Cemcnt.Gon a ®8ctttotiitc Chips orl'cllcls
00ccolknn:11.(H44611 f Cooling Supply) mcswmial Woter a`Wplp(singl,)- E3 Sand Qmem Gmut ! 13'Day Clay
❑hrdlistriaVCommcrcial 130c0cnthit%Yatcr Supply-(shared] [7 Ciincret Giout 13 brill 01itigp
❑Irti •lino- •
1 Speciallyy Grunt
Non-1Vatcr5ullptyNVcit [t BentoniteSluny I' 0 Oiber(explain under 7g,).
Q9Matdtoriug. 1711ecovety
Injc�Kfon'Wcllp 7f,,For eadr uiltcti�tl sdected'aboFr,prosnde aotonnt 6f.ulitc�lals ttscd:
l]Aquiferltecbrrge_ �Giotuidttnerltentediiriian Neat Cem.:941b. ;Wtr:5 gallongalSand Cem.:lb ,Wtr:gal.
CAquifer Storage and tte ery 139aliiutV Barrier
Bentonite.:5slb ,Wtr:gAl.� portland Amount:5 gallons
OAgnifeiTest ❑Stoetnca[er.I7niinagd
OE epetiuteutaY Tt�buotoey pSubsidetice CorMiul' 7g,Pry;r{dc s hricfilescription of the ahuridnoment r �tiJuFe:
❑Geotlterutud(C[ose4 Loop) ®Ttacer"
Tremie grouted from bottom to top
CGeothermat(Heitinn/CootingRetum) ©Gther(ex lainunder7F) .
d,Date n'dl(s).abandoned: 3-15-24
mod:1. V
5a.WeB location:
Lewis.Service Station �, I o r.:
8:Cci'ellfiiatlait: )Ttrt� 7r7:x.F•Pl; ,';'ZO�.g UR;;
FaciligaGivnerNam Facility IDN(1fap-plkabk) ' [j!/;1�;" �DG
4733 Fallston Rd. Lawndale, NC 28690. r 3/16/2024
Pliysical;Address,Ci1},`atidZip V}!!{JJJ0KKKt///anU!' t.!:rllVgll nlrl:totortV�t1(}trr>Lr Doe
Cleveland ay cigrabig this forWr,I hve by certify Ilwr the well fsl wax(Isere)ulraarrdaraed iu
Coutuy Bail li,Wit'h6&6nNo•(PhMi acwnlance lath ISA AUAC 62C.0100-or 2C.6200 Wel[Cbtis'tiatcdon SAmckards
and llrnt aCopyrofilrisrerord lraasbec aPr uvided(o!Newell owne).
56,,1.;ltitudeand longittidc in ctcgrccelmlatiUcslssenndsbrdcciinal dcgrcPss..
(lrtt•rll Aa41,orw W414,is tallrcocii!) 9.Site diagram or additional well deritts:. -
You tut}•ttse tlie•ba&-,bf thii.p�ge to proc'ide'additiotW iseU site deWis.or ivdI
.abandomitem detallt-You«iay ulso:at(aehaciditiotialpgems if tiet'sary_.
CONSTRUCTION DB TAIE-S O MAS)BEING ABANDONED SUgNtn 17AT,MSTR[TMONS.
Am tic/l nurstnc9i+an rnivrdw 1f ovwAble. •ror nw1hple rwa-want sarpplp
urlls MA ulfli i?r ananrcwutrrncliordrabnirrkruneru.iv v cansarhrrilt wrefynrr_ (jai,Nor All Wells: 3 uelln or .
6a Nell ID¢•sstKW-2 abaddonmcnt to the following:
DiAilon of Water ltesonlrces-,Information Prowosing Unit,
1617 5Liil Scriicc Cenrcc,Ralcil,*li,NC.27649=1617
6b.Ttital:rvcIl depth: 28 ((fit j'
10h.Fnr.Tnlecli on Wells: -lit addition to sending die form'to ft address WIN
6c.Boreholo diatneter.2 On.) :wove:also sulmtit oud copy of this',form itidain 30 days of completion of .Yell
abiiridotunent to'the follo}Yang:
-Mis{ou of Water Rrsourees,Uuderground Injection Coutrvl Mgram;
fd,Water tevc(bcioR'ground surfirce.25 (ft•) 1636 STail Scrnicc Ccnter,Balc�ti,IBC 27619-1636
unknown IOc.Fnr W stet Strntth A,Tnicctiol Wells: In addidodto sending the fonn to
6a cas
ing sing length(if lanorrm): 00 . the address(esl above. also submit)one copy of this fomt within 30 days of
comptetioti,of%M abwdaiunent to'ttie county health depatiment of the county
unknown WlICTC RM,4iiotrcd,•
6f.Inncreasinwitibtug khti vah(if Imown). (ft)
i
6g.Screen length(if known)-unknown 00
Farni GLV.30 Nonh Carollm Dcynttru m at Pnvironnacnt and Nintaaol Resources-Dlvkion of WatcrResoar l s Rcvrsed Agwd 2013