Union_Well Abandonment_20240507 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells { r
1.Well Contractor Information: WELL ABANDONMENT DETAILS!
John W. Hune cuff _ - :-
y -, -.. , 7a.Number of wells 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 'same
cotutruelion/abandonntent,you can submit one farm
2465 A . . . -. .__ . ...
NC Well Contractor Certification Numtier 7b.Approximate volume of water remaining in well(s): 90 (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Nam Granular me
7c.Type of disinfectant used:
2.Well Construction Permit#: 23-282 •. ;
List all applicable well permits(.e.County,State,Variance,Injection,etc.)ijlmown 7d.Amountof disinfeetaIIt used: 1%2-Ib.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used'(check all that apply):
❑Agricultural ❑Municipal/Public =❑Neat Cement;Grout _ _ _-_ O.Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ?, ❑Sand Ceiitent'Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) . •❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑,Specialty.Grout ❑Gravel
Non-Water Supply Well: m Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For-each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 150 Ibs- Bentonite Slurry
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer Well-was pumped with behtonite slurry through
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4-1".trelriie pipe-extend''.down nto.,w,ell-#-o4n bottom
4.Date well 10/13/23s)abandoned: t0 the't0 ,r- 1„-,i a�p �T'
5a.Well location: MAY d i LUL4
Stacy Faile/SM Smith&Sons Inc. s t
8.Certification:
Facility/Owner Name Facility ID#(if applicable) }
3308 Waxhaw Indian Trail Rd, Indian Trail 28079 11/10/23
Physical Address,City,and Zip Si a of Certified Well Contractor ell Owner Date
Union 07-138-006 By signing 1his.,Jorn4 I hereby certify;that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constniction Standards
and that a copy of this record has been provided to the well owner_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j.
(ifwell field,one Wong 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 abandonment details. You may also attach additional pages if necessary.
I
CONSTRUCTION DETAILS OF WELLfSI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply
wells ONLY with the saute constructionlabandonmeni,you can submit one farm 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,
120 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
5 above;:also submit one copy of this!form within 30 days of completion of well
6c.Borehole diameter: (in.) ,abandonment to the following:
6d.Water level below ground surface: 30 (g,) Division of Water Resources,Underground Injection Control Program,
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): (fL) 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.
611 Inner casing/tubing length(if known): (ft.)
I
6g.Screen length(if known): (ft) �.
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
r

# 9—Well Diagram .6" Well Diameter
1 No Casing
Removed
Casing Depth
Unknown
0' to 120' Pumped
with Bentonite
120' —Total Well Depth

I �
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
John W. Huneycutt 7a.Number ofwells being abandon
ed: +1
Well Contractor Name(or well owner personally abandoning well on his/her property) For nmltiple injection or non-ovate'' 'supply 'wells ONLY with, the same'
consiructionlabandonment,you can subm ' one form.
2465-A =. .
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 255 (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c Type ofdisinfectant used: GraClular
2.Well Construction Permit M 23-284 List all applicable well permils(i.e.County,State,Variance,Injection,etc.)jlmown "'1/2"Ib. '
7d:Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):- -;
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidendal Water Supply(single) ❑ Sand Cement Grout { ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
DIrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 400 Ib.S-Bentonite Slurry
❑Aquifer Storage and Recovery ❑Salinity Barrier �.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control j 7g.Provide a brief description of the abandonment procedure:
❑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 into:weJI;fharn bottom
4.Date well(s)abandoned: 10/13/23 to the top. '.'=< --`•'�`"'` f ''�
52.Well location: MAY
Stacy Faile/SM Smith&Sons Inc.
Facility/Owner Name Facility IDH(ifopplicable) 8.Certiffcation
3312 Waxhaw Indian Trail Rd, Indian Trail 28079 11/10/23
Physical Address,City,and Zip Si a of Certified Well Contractor or ell Owner Date
Union 07-138-005 - By signing this farm,I hereby certify,that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC,1C 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been 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($)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with Ike same constructionlabandonmenl,you can submit one farm 10a. For All Wells: Submit this form within 30 days of completion of well
i• abandonment to the following:
6a.Well HW: I.
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 2O0 (ft)
'10b.For Iniection Wells: In addition to sending the form to the address in 10a
6 above,also submit one copy of this;form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
r
30 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (fL 1636 Marl Service Center,Raleigh,NC 27699-1636
106.For Water Supply&Iniection Fells: In addition to sending the form to
6e.Outer casing length(if known): M.) 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.
6E Inner easing/tubing length(if known):
i
6g.Screen length(if known):
Form GW-30 North Carolina Department of Enviromnent and Natural Resources—Division of Water Resources Revised August 2013
f �

# 9—Well Diagram 6 Well.Diameter
—� No Casing
Removed
Casing.Depth
Unknown
0' to 200' -Pumped
with Bentonite
200'—Total Well Depth

f
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
t .
1.Well Contractor Information: a WELL ABANDONMENT DETAILS''
John W. Huneycutt',., 7a.Number ofivells being abandoneri: i1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-haler supply wells ONLY with the same
;. ,..
construction/abandonment,you can submit one farm.
2465-A
NC Well Contractor Certification Number 7b.Approximate volume of water re i airing in well(s): 168 (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7e Typeofdisinfectautused: Granular
2.Well Construction Permit M 23-310
List all applicable well permits(.e.County,State,Variance,Injection,etc.)ijlmown 7d Amount of'aisinfectaut used: 1/2-lb.
3.Well.use(check well use):
Water Supply Well: 7e,Sealing materials used(check all thatapply):
❑Agricultural ❑Municipal/Public ❑Neat Cement;Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
131ndustriaVCommercial ❑Residential Water Supply(shared): ❑Concrete.Grout ! ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: 21 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,;provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 650 IbS-Bentonite Slurry
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage !
❑Experimental Technology ❑Subsidence Control .7g,Provide a brief description of the abandonment procedure:
❑G eothermal(Closed Loop) ❑Tracer Well was pumped with bentonite slurry through
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) '
a 1"tremie' pipe extending down into,Well from bottom:
10/31/23
4.Date well(s)abandoned: to the top.
5a.Well location:
MAY d i
Stacy Faile/SM Smith&Sons Inc.
Facility/Owner Name FacilityIDN(ifapplicable) 8.Certification:
iTrt�i• f ru r ip
3625 Phifer Rd., Wingate 28174 GfJ r`" �' `j' 11/15/23
Physical Address,City,and Zip Si a of Certified Well Contractor or ell Owner Date
Union 02242026 By signing this form,I hereby certify that the wvell(s)was(were)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 been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong 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 records)ifavailable. For multiple injection or non-waler supply
wells ONLY with the same construction/abandonmenl you can submit one jarm 108. For All-Wells: Submit this font within 30 days of completion of well
6a.Well Mabandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 130 (ft)
1617 Mail Service Center,Raleigh,NC 276994617
� '
10b.For Iniection Wells: In addition'to sending the form to the address in 10a
6c.Borehole diameter- 6 (in,) above,,also submit one copy of this ifomw within 30 days of completion of well
abandonment to the following:
• j ;
18 Division of Water Resources,Underground Injection Control Program,
6d Water level below ground surface O 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): (ft.) the address(es) above, also submit lone copy of this form within 30 days of
completion of well abandonment to ithe county health department of the county
611 Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (M)
Form GW-30 North Carolina Department of Enviromneut and Natural Resources-Division of Water Resources Revised August 2013
i
t ,

# 9 —Well Diagram 6" Well Diameter
No Steel Casing
Removed
Casing Depth
Unknown.
O' to'130' Pumped
with Bentonite ..
130'—Total Well Depth

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
i
John W. Huneycutt 7a.Number of wells 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 same
consiructionlabandonment,you can submit one form.
2465-A
7b.Approximate volume of water remaining in well(s): 238.5 (gal.)
NC Well Contractor Ceriiflcation Number 1'
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type ofdisinfectantused: Granular
2.Well Construction Permit#: 23-319 ;
List all applicable well permits(1.e.County,Stale,Variance,Injection,etc.)if known 7d.Amount of disinfectant-used: 1/,2 Ib.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑,Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single), ❑Sand Cement Grout �. ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 4 Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 300 Ibs-Bentonite Slurry
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ;
❑Experhnental Technology ❑Subsidence Control 7g.Provide a brief description of the,abandonment procedure:
❑Geothermai(Closed Loop) []TracerWell was pumped with bentonite slurry through
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) _
a 1"tremie pipe extending.down into,well.from bottom
4.Date well(s)abandoned: 11/3/23 to the top. 7-
5a.Well location: r
Stacy Faile/SM Smith&Sons Inc,
Facility/Owner Name Facility lD#(if applicable) !i.Certification: vs�a„5•,.�?,--.rv��.�.b vi:�
3121 Waxhaw Indian Trail Rd, Indian Trail 28079 G!J � 11/30/23
Physical Address,City,and Zip Signatur f Certified Well Contractor or W Owner Date
Union 07-138-007 By,signing this form,I hereby certify that the well(s)was(vere)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latnong 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 WELLISI BEING ABANDONED SUBMITTAL•INSTRUCTIONS
Attach well construction record(s)if available. Far multiple injection or non-water supply
wells ONLY with the same construcitoWabandonmen4 you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a,Well ID# abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 185 0L) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6 above,also submit one copy of this!fort within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 26 (B) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
• I'
10c.For Water Supply&Iniectiou Wells: In addition to sending the form to
tie 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
6f.Inner casing/tubing length(if known): (g) where abandoned.
f
6g.Screen length(if[mown): (fL)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

# 9—Well Diagram ..6" Well Diameter
No Casing
Removed
Casing Depth
Unknown
0' to 185' Pumped
With Bentonite
185'—Total Well Depth