Davidson_Well Abandonment_20240429

l WELL ABANDONMENT'RECORD G() FerbdernaiUseONLY; • • i
• This form can be used for single or multiple wells -
t
i,Weil Ccintractar information: . WELL ABANDONMENT DETAILS
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Stefan Smith - . . . . . la.Number of wigs being abandoned: -
. . 1YeltCotlruclorNante(orntirll onr:�pJsonally:thin,ioniti;nail on t+is7lteipioticnyl ' . For uxidnple tale.tat:• or,rxaaruuter ari ipiy 'wells- ONLY teal) ll e..slew -
carutrecfirad,ibwrtnnmart,ivn can sntw it•eni fiirin,
3576A , . - •
. '71r.Approximate rirInnte of vrater:+crining in rt'eil(u*2 (pal.)
. NeWell CQnlractorCertifiudion Nniiber .
SAEDACCO
FOR WATERSUPPLYWELLSONLY• •
Congran)Name 7c.Type of.disinfeetaufused: " . .' . .
•
2.Welt Construction Pernttt#:t ,
1.140diepplliubleruietllarrniir fit.Cairrr!,Surlo,J'uriurre.fi sri1etr„rtc:.1(f nMty ' ' 7d:Atliatt-t of dWnfectstnt useth •
• 3.WO use(check well.,use): • . •
Water Supply Well: ,7e Scaling matcrdals used(cheekall that apply): : •
' ElArgricniturat: "pMtinicipalIPubltc• ' ❑Nat CcnientGtwut ' .' 51•fentoriitc Chips or Pellets. '
OCteodicrmat(Heating/Cooling Supply)' i7R.csideutiat Water-Syrpply(single) ElSand Cement Groot i ❑_Dry Clay
❑huttistrial/Comnicrcial 17Rcsideuial-Water Supply:(shared). CI:Concrete Grout El Doll CpitingS .
❑kdgntion . . . . 17 Specialty Grout • _ '❑Grayel
Non-Water Supply Well: . " Cl;Bentonite Sluay Cl Other(explain under 7g)
NMatritoting.,. . :.❑lies:orery. . . • . "
. Injection Welk7f,For caeh ttiatcrial selected ahoye,provide nutount.of.in materials used:
❑Aquifer Recharge ❑Gtiiundnaler.Remediattou
• . DAquiferSteny a an.i Recovery • 13Salinily llama:
•
. Bentonite.:111b ,Wte:gal, ', .
AguiferTest ❑SlonnwutecDntitiage .❑ -
' ❑Egteriniental Technotogv - .DSubsideuce Coniml 7g.Proude a brief description Of the abandonment procedure
IJGeoihennal(Closed Loop) - ' ClTracer j
Pour - .
rm❑Geotheal(Heating/Coaling Return) . ClOthcr(e plain under 7R) . --
. 4.Date,wcll(s).abandoncd: 4-5-2024 . I •
. AFR 2 S Z•DZ4 .
• 5a.Well location: . . • . ,
R_.. ...; , 7- cry
L&S Manufacturing . ICnv.1nrii z e•i ; -c:Z4"' 3'`j.,,
;$:Certification: `-f' OG•
Facility/Owner FaaililyIDS(ifapplicable) 13i" .
22650 NC Hwy 109; Denton, NC tQ 4/16/2024
Plo steal Address,City.and Zip• f Ante,.Cerlifuvl WenCorun:tot erWell Q•irn:r Dare
Davidson . ' - By soguing this farm; 1 hereby certify that the ii elifs)erase(were)ahatidencrl irr
Consiy - ' ' . " Parcel Idetuirraitlnit No.([r11). - ' accordance with l:;f VCAC 02C,0100.or2C.0200 Well Conslrucfion Starudorcls . .
• imd that a copy ofllris record hasbeenpravidcd to rtheuelt tether.• • .
5h.1(atitude and longttudein degreesrntinutcs(seconds or decimal degrees: • ' •
• (Ifnell veto,one lathoitgIssumeieri) •9.Sitediagramoradditionalwelldetails:
35.566502 80..097827 . 'You may use the back of this page to provide additional.uel site details-or well .-
N W .abatidoiunetu details..You tnuy also:Mach additiolrsl pages if it .e5saty..
•
CONSTRIIC ION DETAfIS OFWELL(31 BE INC ABANDONED . SUBMrrrAL INSTRUCTIONS.
:Ifloth lipid cvrsua lien rncvrdtsl If ovaileNe. liar nrulhple d jectian'or riun•uutir sLppdy
nrdlrONLYwith:assmanecwcunicUOname*iwacru.!artrnuautfririarejyno. • bqa;For All Welts:' Submit-tins fain:Within 30 days_of completion.off well
• . 6a.Wclt t1) MW-3S • "abandonment to the following:
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Divisitin of WaterRespurem,information Processing Unit, -
1617 Mail Service•Cen.*cr;Raleigh,NC 27659-1617
Gh.Tatahfelldepth: 25 (ft.) ,.
lOb.ror.Tn!cram Wells:•In addition to.sending the form to the addn.ss In:[Oa
above.also submit one copy of this folio within 30 day§of completion of well - -
6e,,Borettolc diameter:2- MOablimiet itient to the following: • It,
Di isionof Water Resoure Utidergniund injection Control Fttigraul,
6d,Water levelbctow ground surface:,6 (ft.) 1636 Mail Service Cenier,ltalcigh,NC 27cP 9-1636 • ,
•
Gc Outer casing Ica th(if lvpRn)t • (ft.) IOc.For Water Sunnh•Ar infection%S lls: in addition-to sending the form to
the addresses) above. also submit.one.copy of this form ssitlliti 30 dabs of .
. completion-of well abandonment to the county health depatintent of the county
6f.Inner lasing/tubing Length(if lntmvn): (ft.) • where a ndancd•,
6q'..Scn�n length(if known): . (ft.) -
. . Fono GW-3n. Nonli Carolltn petnumen!of En Holum cru ant Niutuul Resources-Dividend'tiWaterResoi ices . . •Revised August.2013
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WELL ABANDONMENT RECORD . .
' For liitcnul Usd ONLY: . .
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- Tills form can be used for single or multiple Wells. • • i
•
I,Wcil ContracturInformation:. • . •WELL ABANDONMENT DE.CADS
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Stefan Smith . . ' . 7i.iiumber Of veils heinialtando fled:-1 . - •
wore:04,619i tank,or‘,.;11,;„„L,i„..,,,-„;tb,'7,b2iidonlii2,4„ifiut.hicAlerpiell,y) • . Far (nipple infirmr. or non,%iyeer simicily. waits. O\LY 'IsIth the •some
cottgrairenanlaboadonmenoion am.sulmor-onafinn;
3576A • . • • - - .. 1 — • ..
. r. '111.APpniiimate solarise of watOrenoitting in Well(s):1'2 • - " OOP - •
• .
NCI.VCII Costirittar ton i lioatioti Mutter ' • - - •r : •
• • .
• • • WATFA SUPPLY WELLS,ONEY: • • ..• .
' .SAEDACCO . . ' FOR .
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Company Name ' • ' " IF.Type ofdisinfeetant Used: , '
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2.Well Construction Permit#:, , - • " .
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. pm' pisfiroMe trOperiref4'p.it.Cirattl>.,•46y. iiiriance.,hrjecnon„eia..t If known . . . - Id;Athoutit(kills. ittrettAiii.used: I. '
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• - I.Wt41 uSe(ehech well use): . ' • . . . • • - •
. • •
. • . .. .•.. . . . , . . .
. • Water.Snpply Well:. . . • .70.Sealing matenalsmsed(checkallthat apply):
. .. .
. , bAgticultural • 13hltinieipal/Publie. - El Neat Cement Grout . • • D Bentonite•ChipsOr relicts • - •
•
. EIGeothennal(ticating/Cooling Supply): :•1:1Resicktuint Water Supply(single). '1=1. flgiicate.IIIGt011t . CI,Dry Clay , •
Ellndtistrfal/Cotnntercial ' • • Oftcsidemial Water Supply:fshared). .13 C°DercleGroul- • • n Prillq111illEs ' •
,.. . .. . . . . . . - . .
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. Elittiptian. . . , CI St:Fr:jab!.•Grout • ' . U Gravel _.
Nuo-Water Supply WeIS:• . " •. ',CI Dentonite Slimy . . ' CI Other(expiak under 7g)
Zlihniitorine _ • . CIRecovely. : •. -• - . . •• •
• Injection Weil: • . • •. . . 7E forCath Material selettetrabott,proside antotnitat materials used:
ElAquifer Recharge, . - '• CIGniunduater Remediatiott .. • . • .
•. . .
. ClAnuifer Storage and Reccri'ety • 13Salinity Harrier - . .
' ' - I • • •
' •
Bentonite.:511b ,Wtt':gal. .i • - • .
. . CIAnnifeir Test' . ' •. . ' . EiskitimotterOntiiinee •
• , .
. .0P..lietintental Technciloev . . PO'idenc4 Control ' . 7g.Providea hriefidese' riptIon cif the aliaininnntent procedure: - •. . . .
• 11Genthetmal(Closed Loop) . . LITracer.. ' • . .
Poor :. . . . .
. •
L1Geothemtal(Heating/tooling Return) . ClOther(explain under 7u) „• •
• . . . •
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,. • • -• . • r.-7.--eii"---. hi'•-•r-A .
• V . . • . . . . . - e lk 4..,...N,t,...e i.....-•i V' 1... Ll. •
. 4.Datewel(s).abandoncd: 4-5-2024 .
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• 5a,-Well location: • . .
• . • AR 2 N11 ZUZ4 • .
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L&S Manufacturing . •. • InfsDr.;,•,;',$k,r1 Pcr.....-:.3C-z;Fit3 UP,X • " ' •
Cert il katioil: , • • .
. . FacilkiDwror Name . • Facility IDN(iFirpplicablc) „ft; • C/Vi OiTiOG •
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. . 22 650.NC Hwy_109, Denton, NC• .. „ , • - -4/1 6/2024
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' " . _ hut..,-.Catilial Well Contractor Or Well°won. . . Date • •
..- • Physical:Address,City..atid Zip ' , . § .
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Davidson . • • ' qy signing Os firni,:1 heteby certifrithat the weilts)ii.its Overe)abandoned ill . . r•
. ' County : , • .: ' Parcel litanlifbaallint No.(PIN) pacottlance With 1.5.,1•xcid62e.oloo:or 2C:0200 Well.Con-sthectioti Stainkiri 4
rand!hal a nopy of this record has been provided t'o the n'ell owner; - - - -
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Sli.Latinidelnd longitude in t!egree(utirgneif.sceonds or dteitualitegrets:' •i
or Wen field,one taliiMig w suffleiela)- 9..Site diagram or additional well details: .
• _•- . •.
. You tnaY use the. bai.k of this page tO,prOyide additional well Site' •
details Well •
• • . .• .35.566502 . ' N . _. • ' •80-097827 W .abautfointteta-details.:You may also attaelt ilditiotralpages if necesSat±i. I ."'
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CONSTRIleflON DETAILS OF%VELL(S)BEING ABANDONED• ,NIIRMITTAT.INSTRUCTIONS
.math tie!!.cannraeyaa receordW A)availalite:•Par mukipte injectimiar ridnoratO•sisMi.' ' !• • •
• wita 041 itn1)t iv sam,....comern,ctioniab throroykieqt.Plo can submil Pte.16 nil, ' - . Wel Per All'AV011s:' Submit-this tntt within 30 days-of'completion of well ' - - •
• - 6a.Well.f1040:11'.4-3D .• 'abandonnicnt to the folloWing: ,• • .• • - •
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. . - . - ' • • hiyisitin Of Water ResOuVet ,Information•Processingruit,
' 6hTotal well depth: 45 • •- • (ft) • .• .- 1617 Mail Seitice Center;Raleigh,NC 2769971017 . .
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• . . • '. 10h.Fa r•in leetion'Wells:I In addition to sending the foon to the address in Wa " •
. - • •
• above."also submit one copy of this form Within 30 days of completion of well
6c.floreltole diameter 2. (In.) ' , • .
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abandOnntem tit the following: I:I
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• - . . • Pirisiott of Water jtesou ries;UndFigtuund litijectioncoultUl PrOgratm, • .
.641.Water level.bctow ground surface:*23 ((t.) ' 1634 Mail Service Center,Raleigh;NC 27699-1636•
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• ' 10c.For water Sunnis.&iitfeetinu•Wells:•In addition'to sending the form to
• 6e...Outer easing lenoth(if Iniown): • - 00 the address(es) above, oho submit one copy of-this fault within 30 days of
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• • • •. • . completion of well libanclaitment to the county health department of the county
• where atrandoncd..
(If.Inner easing/tubing-length(if lotown): '. (ft.) .
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6g.Screen length(If known): • (ft.) V . I • • •
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• Fen •n GW-30. NanliCaratim bccontnera al Environment real Natural Resources-Division of Water ficsoiucles - Revisal Augur:120B
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WELL ABANDONMENT RECORD Far Internal UscONLY;
This form can be used for single or multiple wells 1 •
I.Well Contractor Information:. WELL ABANDONMENT DETAILS
Stefan Smith . . 7a.Number of wells being abandoucil:.1
WclreordraclorNatue(or rtilt Owns persanad}abundunito%tollon Esther property) FOP multiple. MJeniwr or m l-tinter I sirpili •wells ONLY with dk, .same
construchotti7handoilahmt,jYos tali.subliftt Otwwfurwr,
3576A
71r.Approximate volume of water remaining in w elI(s)?2 • (Rol.)
NC WO CantmctorCenifu�llion trainer
SAEDACCO
FOR WATER.SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfqtaut used:
•
2.Well Construction Permit tr:, ,
tad rtoppIk.$Ie urea/lwrieitx(i.e.Cuatily,Ste i.l irlars:•a.Lrfariion,nut:.!ifknawn 7d.Aiataunr of disinfeefaul'used:
3,Welt use(check well use): •
Water Supply Well: 7c.Scaling materials used(cheei;all that apply): •
❑.agrindturat , CIMttnicipah•Publie. Cl Neat Cement Grout tt Bcruonitc Chips or Pellets
Of otherrttal(Itcating?Caoling Supply) ❑Residential Water Supply(single) --❑Saudfieutept Grout ❑Dry Clay
❑IndustriaUConmtcrcial ❑Rcsidential\VaterSupplv-(sltatcd) ❑ConcreteGrtw.t ❑Drill Cuttings
Obligation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
®A9nuiladne • ❑Recovery
injection Well: . • 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge - ❑Grouiulwaler Rentedi:uion
•
DAquifer Storage and Rec wety °Salinity Barrier
❑AiptiferTest . ❑StomnvaterDrainage
Bentonite.:331b ,Wtr:gal. . -
❑Experimental Techuafoev ❑Subsidence Collin''. 7g.Provide a brief description of the_abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer - •
Pour
OGeothermal(Heating+Coaling Return) bather(explain under 7g) .
4. •
Datcwcll(s}.abandonctE:
4-5-2024 l ..'C_�.r. i.'
7,r��
$a Well location: I.�f'K� � ' 2024
L&S Manufacturing In o ;y^z.i,r,,il 2i ,r. .5r;,,'V- 'Jet
Facilityi0n•ncrName - FacilityID!)(Puppliwble) R•CclCilTctiOioil: �+ ;3 �`�
22650.•NC Hwy 109, Denton, NC ,. Yl 4/16/2024
Physical Address,City,and Zip SSl_-nure Certified Well Con ny:totor Well Un•rtrr Dim
Davidson !i),signing this faro!; I hereby ce,Yl v that the sre11(,)was.(were)abandoned in
County Parcel Iit.ritificatign No.(PINj accotrlance with ISA KCAC 02C,OIOO.ar•2C.0200 Well Comfruction Standards
and that a copy oflbis record has been provided to the reel!comer.
•Sb.lathudc and longitude in degreestminu(esfseconds ordceimafdcgrees:
Orwell ri:ld,oute htilong is ortriciett) 9.Site diagram or additional well details:
You may use the back of this page to-provide additional well site debits'or well
. 35.56.6304 N • 80.097905 W .abandonment details. You may also attaclr additional pages ifnecessary.
CONSTRUCTION DETAEI S OF WELLS)BEING ABANDONED rSLiBM1TTAL INSTRUCTIONS '
Attach h:eli mash-adieu ttiurd(s)41 available. Par tuulnpie itrncrioa'or rxtn•uwtir rttpfdy ' -
orlit ONLY u•lti the sung tietsinettvtrabarrelo,roan.jar/Cum ntbmlt one Arm. 10a. For-All Wells: Submit this farm within 30 days of completion of well
Ga.Welt m tMW-1 abandonment to the following:
Division of Water Resource,information Processing Unit,
1 29 5 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Totaiw•eR depth: (ft.)
10b.For in lectiart Wells: do addition to sending the Coati to the address in lOa
6c.Borehole diameter:2 OHO above.also submit arc copy of this form within 30 days of completion of Well
abittidoonteut la the following:
Division of Water Resuurecs,TUtiderground Injection Couttol Pragrmu,
6d,Water level below ground surface: 2 (ft,) [636 Mail Service Ccntcr,Raleigh,NC 27699-1636
Gc Outer casing Icn lr(if'mown): (ft:} 10c.For-Water Sunnis& !nicotine.Wells: In addition to sending the fort to .
,the address(es)above. also submit One copy of this'form within 30 days of
completion-of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if lmawn): (ft.) vvhcro abandoned,
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6g.Satin length(If'mown): (ft.)
Fe nit GW-lo North Carotins Dcportuvon of entironrncat aid Natural Resources—Division of Water Resources Revised August 2013

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. WELL ABANDONMENT RECORD- .. - • Forlmcrrctl Usc ONLY: •
Deis form can be used forsingle or mtihipte wells - " - j,
I •
I.Well Contractor Information:- WELL ABANDONMENT DETAILS ;
Stefan Smith " . , .. . " - . .la.Nuniberoflvdls being abandoned: 1` '
worCou4mclorNatnc.(ortiiliawr!•rpetsdnallyn1alioahii;uaitanhiatbrpidpcny'), Foil drgluple- bfeettai. .6,. rn'.rm!virerf supply walls- ONLY_ wit sire .Awe
eavurmerltti 7bandrillne.gf,pncloy alwurimobrnt,
3576A - . . : • I- E .
' -71i.Ap iruM me.nutte volu ofviat*retmtiftingin vi'ell(.)?2. ' . . (gap
NGWdl Cbbiractor Ciliation riutitbcr 1 I -
Sr>;DACCo •
FOR WATER SUPPLY WELLS ONLY: •
Con>rait)Namc 7c Type of disinfectant used: '
• •
2.Wet Co»stniction Permit 4:, , •
LLtrnil applicable well larmits(i"e.C.an -Stela,•Parlmte,htlerriov,rtc)J,Gmisa • 7d-,,,„.-ottntofdlslnfecta i.uitsed:
3:'«`dt use(eheckwell nse);. . •
Water Supply Welld 7c.Sealing matettalsused(ehec► all tint apply);
•
• ElAgiicultivalt pMitnicipal/Pttbliia:• I]Neat Cement.Gtout • . " 60 Bentonite Chips orPeilets •
• IJGeotlicnna1(H67ting:Cooling Supply) . iJticsidential Water Simply(single) EI Sanrf,Ccntent Gttigt . ' El.Dry Clay . -
. , • ❑huinstrial/Comntcaeial• ' - Clltcsidentiul Winter Supply.(sliared) ❑COnge(e'Grout - : ' El brill CuItltigs
-17ircieation•: - - - . . . . . O Specially Grout" . . '• •'0 Gravel
•
ik in Water Supply SVeIi:. . 0.Bentottite-Slitny 0 Other(explain under 7g).
•
- ®Moititodna - .. - . ORecovety • . • l•
Injection Well: .. . . . . . . . . .. - 7f,For'eacb'niaterial selcetetabove,Provide amount af:ntatetiats used; ' ,
1:AquiferRedtar};e. - . DGniuiidnaler=Rentediation 1 • .
17Aguifer Storage and Recovety pS dinity Barrier
DAgniferTest . ' . ElSlomnvater.Dhiitiage .
Bentonite.:571b ;Wtr:gal, . i
lEytetiutetnal Technoloev .17Subsidence Control
• 7g,Provide a brief description of tbe.abandnnment pnmedure.:
❑Geothemtal(Closed Loop) t1Tracer I "
Pour
®Geothermal(Heafntv'CaolingReturn) ©Other(explain under 7g) .
•
4.Datewef(s)•abaudoncdt 4-5-2024 •
' 5a.Welt tocatien: ' •• •
OR 2 Z(�[4".
L&S Manufacturing • . . "' lr u�rib•,t'ni: P`ft'c.r -g U8A.. .
..Certification: ' I D'c
Facility/Owpa-Nutttc Facility IDN.Cfupplicabic)• • A. / �u'uLl�r •
! I
• 22650.NC-Hwy 109, Denton, NC t, 0 T • .1• 4/16/2024
Phy'sical'Address,City;and Zip . S 1nne (cruised Well. +ntri,tarmVicll Otvtur. Date
Davidson - By signing this f nin, f hereby certify that the tre110)wag(icere)abaridoaed 6t
• •Couuiy• . • • . : • . • Parcel Idemif iainiNo.(PIN) . • ricrair&nrcc lvilk lid.\CAC.02C,0100.oir 2C.0200 R'ell`,Colislructron Standards •
•• • - • and that a copy ofthis record lau•b€en pros ided to hre urn out'ncr.
Sb.•Latitudc'and longitude-in dcgiveslntinuteslsccondsordicint;thdegrecsi • • • l: '
Of well ram,one tmitnng if s tlrcuu i) 9..Site diagram or additional nelldetails:
' You nuyuse the,bach'of this.page to,pros ide additional Hell site`details-Of well
. . 35.566304 N - . 80.097905 - W. ' .a bandomitetttdetails..''ion may also atlaeh additioiul pages if ikCtssaty..
CONSTRItCf1(IN.nFTAILC O1r WELL'S)BEING:ABANDONED ' ,SUBlt1)TTAT.iNSTRUC rrONC , '
:Itruh tic!)cvrviraCtnl a rttivrdtsl if avai1ra!1e. .Air rruhiple iry&tian or bin•Ut14r supply " •
mils ONLY Wei the svut.!cvri+rrrxnmr ab:vrrhr:iacnar._rau am s rLnefr cure funrt., 10a.Pnr All Willa Submit tins fomt'vvittun 30 clay$of t atrip(ctian•of well
6a.�VeB'mt7:MW-2 • abandonment to the following;
Division of Water Resou rcis,InfonnationProcessing Unit,
. 1617 Mail Service Center;Ralekli,I C 27699-1617
6b.Total well depth: 50 • - (tt4 .,.
IlOh.);nr.Tnledinn Wells:'In addition to sending the form to the addntss in:IOU -. -
above.also.submit one cope of this Conn st'itldu 30'days of completion of Well
. 6c.Borehole diameter,2 (ln.) I,
•
. ,abisniionnicnt to the fallon•ing:
Divislortof Water Resourres;Underground itijeMlon Control Pnigratn
fed.Water Iescl.1 e1nw ground surface:.23 ' (ft•) • 1636 Mail Service Center,-Raleigh,NC 27699-1636
•
Ge•G)utcr.caning Ic (if (ft.) tOc.'For Water Slimily. infection Welts: In addition to.sending the form to
F nh( 'mown): - tire_address(es) above. also submit one'copy of this Rum Within 30-days of
: , - completion-of well abandonment Co the nni cotnuy health depaent of the county "
•6f.Inner casui/tnhuog•tength Of laiawn): (fr.)
where abandoned. •
I
6g.Screen length(if baotvn): - (ft.)
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FennGlV-o ' NanliCatutltnDcpJnutcwafPatrlroonucnlntudN:tturaIftesounes—Dhlstonof'VaterResowris' ltdEicdAuFitsl2Dl3
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