Union_Well Abandonment_20240507

WELL ABANDONMENT RECORD Far Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: " WELL ABANDONMENT DETAILS '
John W. HUneyCUtt. 7a.Number of wells being abandon Jd:I 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection--or non-realer "supply 'wells ONLY 'ivilh the same
construction/abandonment,you can submit one form.
2465-A ;
7b.Approximate volume of water remaining in well(s): 634.8 (gal)
NC Well Contractor Certification Number
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type ofdisinfectant used: Granular
2.Well Construction Permit#: 23-283
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)iflmmvn• 7d.Amount of disinfectant used' 1/2 lb.
3.Well use(check well use):
Water Supply Well: 7e:Seating materialc.used-(checkall that apply)--)
tt��� r.0
❑Agricultural ❑mwucipal/Public ❑Neat Cement Grout" je;i,.�.;.t +!'[I1 Bentonite Chips,or Pellets
❑Geothermal eatin Coolin Supply). Residential Water Su 1 (single) ❑Sand Cement Grout Dry Clay
g PP Y). PP Y tsin e . r ^ �'
❑lndustriaVCommercial ❑Residential Water Supply.(shared).,
❑Concrete Grout' MAY V ��t74Mill Cuttings
❑Irri ation Q Specialty Grout
Non-Water Supply Well: ❑Bentonite Slun4r"oi T--A r r o • N'' ❑Other lain under 7
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 6 yds-Red Clay i 1.5 yds-Concrete
❑Aquifer Storage and Recovery ❑Salinity Barrier 3 yds-washed stone I
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) gTracer Top 3'of well was excavated out 1'all around.Well was gravity filled with washed
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
stone from bottom up,to 29 below surface.From 3'to 20'below surface
4.Date well(s)abandoned: 10/23/23 was gravity filled with red clay.A 1.5',concrete cap was gravity poured from 3'up to
Sa.Well location: 1 H below surface.Remaining 1.5 was gravity filled with red Gay&excavated materials.
SM Smith&Sons Inc.
Facility/Owner Name Facility ID#(ifappGcable) 8,Certiflcation:
3124 Waxhaw Indian Trail Rd., Indian Trail 28079 . & (.l), ' 12/31/23
Physical Address,City,and Zip Sign a of Certified Well Contractor or' ell Owner Date
Union 07-138-007 By signing this form,I hereby cerrify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200'Well Consttvrction Standards'
and that a copy of this record has been,provided to the ivell rnvner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well'details:
You may use,the back of this page,to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED - SUBMITTAL INSTRUCTIONS
Attach ivell construction record(s)if available. For multiple injection or non-water supply -
wells ONLY with the same construction/abandonment,you can submit one form
- .. 10a: For.All Wells:..Submit this form within 30 days of completion of well
'abandonment;to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
161.7 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 32 (R-)
40b.Toriniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 36 (in, ab&i ,,also,submit one copy of thus form within 30 days of completion of well
) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 20 (fL) 166 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Satoh&Injection Wells: In addition to sending the form to
6e.Outer casing length(iflmown): (it) the address(es) above, also submit one copy of this form within 30 days of
completion.•of,weli.abai donment to the county health department of the county
where abandoned:
6f.Inner casinghubing length(if known): (ft)
I
6g.Screen length(ifknown): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I

# 9—Well Diagram 36" Well Diameter No casing was.removed
from well site.
Top To well was excavated
out 1' all around.
0' to 1.5' Filled —=►
with Dirt and
Excavated 1.5' to 3' Filled
Materials 4 with Concrete Plug
3' to 20' Filled with
Red Clay
♦+♦++++♦No+N+++ 20' to 32' Filled
+,++N++++s♦♦+++++♦ with Washed
+++++N♦♦♦♦+++++♦S+ Stone
++♦NN+♦N++♦++N
32 —Total Well Depth
++++++++♦+ +++♦♦♦

I ,,
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
John W. Huneycutt 7a.Number ofwells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water �supply wells ONLY-with the sane'
construction/abandonment,you can submit one farm
2465 A
NC Well Contractor Certificaiiion Number 7b.Approximate volume of water remaining in well(s): 12 (gal.)
Denys Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Typeofdisinfectantused: Granular
2.Well Construction Permit 4: 23-302
List all applicable ivell permits(i.e.County,Slate,Variance,Injection,etc.)ifknoivn 7d.Amon ntof disinfectant used 112 Ib.
3.Well use(check well use): `
Water Supply Well: 7C Sealing materials used(check all'that.apply):.
❑Agricultural OMunicipal/Public ❑Neat Cement Grout " ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ..❑Concrete Grout ❑Drill Cuttings
❑hri ation ❑_Specialty Grotit ❑Gravel
Non-Water Supply Well: O Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
i
❑Aquifer Recharge ❑GroundwaterRemediation 150 lbs -.Bentonite Slurry
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
i
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment'procedare:
❑Geothermal(Closed Loop) []Tracer Well was pumped with bentonite slurry,through.-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
a 1"tremie pipe extending down~mto will.fr6.r�t;battom
O 10/24/23 t _ .. ..�
4.Date wells abandoned: to the top.
Sa.Well location:
Pulte Home Company, LLCUPA
Facility/Owner Name Facility ID#(ifapplicable) 8.Ccrtification:;
3756 Perette Rd., Monroe GfJ 11/10/23
Physical Address,City,and Zip Signa of Certified Well Contractor or Owner Date
Union 08-300-054A By sighing this form,I hereby certify that the ivell(s)was 6vere)abandoned in
County Parcel Identification No.(PIN) accordance with'1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has be n provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construclionlabandonmenh you can submit one forme 10a For All Wells Submit this fform within 30 days of completion of well
abandonment to the following:
6a.Well IDM•
Division of Water Resources,Information Processing Unit,
36 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
4above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
I
18 Division of Water Resources,,Underground Injection Control Program,
6d.Water level below ground surface: (it) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection'Wells: In addition to sending the form to
6e.Outer casing length(if known): (B•) 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
where abandoned.
6f.Inner easing/tubing length(if known): (fL)
6g.Screen length(if known): at.) I
Form GW-30 North Carolina Department of Environment and Natural_Resources—Division of Water Resources Revised August 2013

# 9 —Well Diagram 4" Well Diameter
�1 No Steel Casing
Removed
....................
...................
...................
.....................
Casing Depth
Unknown
0'-to-36 Pumped
with Bentonite
::.
36' —Total Well Depth IX