Northampton_Well Abandonment_20240624

WELL ABANDONMENT RECORD c6C\ For!Mental Use ONLY: . . .
This foitn cant be used for single or nlitlti{ile Wells •
1,Well Contractor inf2rmation: 0 k?\1 .WELL ABANDONMENT DETAILS •
\ .
Stefan Smith • 7a.Number of wells being abanda led: 1 • .
•
1WeltCoutractorNa,itc crudlouter ,tall'ohsnda goell.onlustyr crt For mulnplc nteellon or vonyiiater supply wells 'OVLY with i!e cane
( P S > waa, 9) consoiretta,:abm�rlru:ment,yo+cam nitm,ur age farm
3576A "
NC�VcI1 ConlraaorCcnificalionNanUies 71►•Apprnxtmate s'lume of~rate•retraining in u•cll(0 (all)
SAEDACCO FOR WATER.SUPPLY WELLS ONLY:
Cottpany Name" 7e.Type of disinfectant used:
. .2.Well Construction Permit 0:, ,-
List ell nppitrvblc urll parnatr(i a.Curlrrp;Stets l'unavice,In erhok.etc)r/,t',wwra 7d.:ltrionnt of dLilnfectlnt used: •
•
3.Well use(eiteckn"efl use): .
Water Supply Well: - . 7c.Scaling materials used(Check all ilIat a)iplr):. "
" ' OAgricnitnrd• ❑Mimicipal/Public CD_Ne at Cement Groitt -El Bcnuonite Chips or hfi)icIs -
I:Geo' thermal(HeatingiCooling Supply) 17Rcsirlential Water Supply(single) ❑.Sand Centeni Grout. • ❑Dry Clay'
Dhoti iallComtncrcial. _ . ' ❑Residential Water Supply(shared) , Cl Conctntc Grout Ef Dull
❑irrigation Cl Specinity Grout I • ' 0 Gravel. "
• Non Water Supply Well:' CI Bentonite Slurry- Cl Other(cxplainunder 7g)
.1gMonitotiug • . ❑Rectnwiy .
injection Well: " ' . - . 7f.For each material selected ab'o'c,provide amountof.materials Used: .
OAquiferRecharge' I]GmundnalerRemedinlion Neat Cem.:1881b ,Wtr:l5gal. Sand Cem.:lb ,Wtr:gal.
-❑Aquifer Stomiie atrJ Recovery ❑Salinity Battler .
°Ai)uife:Test • bStotnnrater Drsinaee ''
❑Experiretent tl Toclmologv •OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) CiTracer .
Tremie.grout from the bottom.up•
OGeothenual(Heating/CoolingReturn) ❑Otlter(explain under 7g) �, ',1-...-. .:,�.... ;,
4, G�
Date I iN 2 1. 2e24
. . .
is Welllucation: .
Info..:. ,7 i 7:7*:-..ra:.:c.,_;unit.. . .
Gaston Refuse Disposal - .
'9`(.or
•
.F.cility/O,r•rurNattc• , FaciliiyIDOrfappli:able) •
. S.Certifications DGrer •. 250 Porch Dr.. Gaston, NC 27832 ' 5/28/2024
.•
. Physical Address,Cit and Zip ;S• Irue:--Celt tried Well Co orglgor 6t Well asrtr ' ' Dole
Northampton 11y suing flail form,.I herby certify►hat the irellfs)iras•terere)abandoned in-
' Cont.*- Parsel l,L^iufiendo'n No.(PIN) accordance With I5.4 NCAC 02C1.01 t?a.or 2C-0200 Weil.Cons ruction Staudari4-
• and that a copy ofdris record lads been provided"lo lire h ell oiler..
b.Latitude and longitude in degtccs/nilatutcslsceonds or decimal degrees: 1 1
- (trivet'tUilon tahlnn issniriticrl) 9.Site diagramor.additional well details:
36.526815 77.653562 TunW aTunmay'me the back Of this page to provide adtlitienal mull site,details or.well.
• 1\ andonment details.'You may also attach additional pages if necessary.-
CONSTRitCI'ION DETAILS OF WELLS)BEING ABANDONED SUBMiTTAT.INSTRUCTIONS
' . tllaci'i,tell corslrncliun nkrrd(sa'ij•ove,l ub14-'For,r.ulliplie infection or two-if sir snppip - i •
'
wells O,VLY uitli Ai-sale evnsLrxfemwii)miialiuri niL_ind ear:submit one tbnrc • IO.t Fur All Welts: Submit this form within 30 data of completion of well
6g Weil IDg.TMW_1 abandonment to the follos�ing: '
Diyisinn of Water Resource,Information Prue sin,;Unit;
20 1617 Mail Service,Center,Raleigh,1 C 27699-1617
6h.Total well depth: (fit,)-
. 10b.For Iniectirrn.Wells: In addition to sending the fonit to-the address in tca
6c.Borehole diameter:2. (in.) •
*Ow:also submit one zopy of this form uithin'30 days of-completion.'af well
abandonment to the following:
• Division of Water Resources,Undeiground Injection Control Program.
• fill Water!ever bclort tprountl surface: 2 (It.) 1636 Mail ScnicelCcntcr;Raleigh,NC 27699-1636
tic Outer casing length(dimo`i a): (NJ- We,Fnr•Water Sunnly&Injection Wells: In addition tosending the form to .
the address(es) abote: also submit one copy of this form within 30•dads of
completion of Well abandonment to the county health deparunent-of the county
• where abandloned.
61.Inner casingftub to rn;Length(if lawn): (ft.) :
• 6g.Screen length(If known): (It.)
.
Farm GIW--30 NonliCarnllm Derdrui cnm ofEnvironnient and Natural Resoo yes—Envision of W3icr,R4onio s Revised August 2013

.
WELL ABANDONMENT RECORD For!menial Use ONLY:
' This'foitiranlie used for Single orMuhipliWeis'
I.Well Contractor information: WELL ABANDONMENT DETAILS
' Stefan Smith 7a.Number of hilts being ahando led: 1
. Vell'Coutmelortlamc(or vellon piactely.abauituinoueflon his";her propnry) For nrulnple alec:ear o 'roiluater -supply kreis ONLY with .the some
eonsrnienrKr nbakiontnL'nt;iur,acne srlalut iviefirirn,
3576A
NC WcI1 ContraaorCcitlftatlion Number74.Approilnlate Tali int:of watea retiuining in well(s)?? (;uL)
sAEDACCo • FOR WATER SUPPL.Y WELLS ONLY:
. Company Dirac 7e.Type of disinfectant used: ' . .
• •2.Well Construction Permit fix, ,' i'
. List di alrpLriible well permits(i e_.Cuui t};.."tote;l uririnrx.h*atla14.etci jkimwu 7 d.amour t of dlsinfectsint used:
3.Well use(check:well use):.
Water Supply Well;' . 7c.Sealing matcririls used(check all tiiat apple):_ .
' DAgricuinirat ❑Mimicip liPtibhic. Neat Cement.Gtaat l7 Rcntonitc Chips or Pcllcts,
❑G odtcrmal alcatinziCooling Supply) . EIRcsidential Water Supply(single) ❑.Sand Cement Gtnnt • 0 Dry Clay
Olndnsirial/Comntcieial. 0Residentiw.Water Supply(shad) .0 Concrete Grout ❑DullCutting •• . ,
• ❑hriFittion - . . ❑Specialty'Grout . ❑.Grout! . .
. Non-Water Supply Well: 0 Bentonite Shiny El tither(explain under 7g)
NMonitotvrg ❑Recovery • '
tnjcction-Wcil: e-
• 7f.For each material selected ab ,plrnide aurount of materials used: ' .
OAgidferltediarge . ❑Gniundst.rterRentediation Neat Cem.:1881b ,Wtr:15gal. Sand Cent.:lb ,Wtr:gal.
OAqui&r Storage aril Reeoven• °Salinity Barrier .
•
❑Aynifetr Teti OSlormwater Dntinage
OE.xperintental Technotoev • ❑Subsidetxe Control 7g.Pturide a hricf,description o•
if the ahandanment pnicc)lure:
.OGeothertml(Closed.Loop) OTracer
Tremie grout from the bottom up .
U rn Geothett(Heating/Cooling Return) COther(explain under 7a)
.t.riatciccu(s)abandoned:.5/22/24
JL'N 2. 202
Sa Well[oration:
Gaston Refuse Disposal Ifi1`$fInrr:it'err aittiny lilti,7
Facilil)•/ihrncrN.amc - Fa.liiy Ito(fappliabte) 8.Certification: D'h'(K!'1+C
250 Porch'Dr._ Gaston, NC 27832 • • • 5/28/2024•
Physica!Address.•City.and Zip •5. lure_.Ceollied Well Cotnrw;.ior or Well Owmr. Date
Northampton By signing this Arm, 1-hereby certify that the.it-eli(s)was-(were)abandoned in -
'Couuiy Pareel Idciuifiictidu No:(PCN1) iicenr lace With'1$4.:V CACO26'i'.O1Q0 or 2C.()200 i ell Co tstratetion Standards: .
and An a copy oftltis record has';been provided to tire-Weil ornier..
Sh.Latitude Ibngitutle In dcgrectilminrtteslsccondsbrdecinlal degrees:
• . - (ifhi'e1i C Id,due liailon issailUicll) 9.Site diagram or additional well details:
36.526815 77.653562 You may use the back of this page to pioside additional well site details driven.
1\ �4 abandonment details:.You may also•attachadditional:pu esifuecessaty.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SURM1TFAL INSTRUCTIONS • -
.tttad,11e11 cornirodian rrcord(sr'if ovultobte.'Air nnrttiplc infection or non•tnrtcr snpplp
veils ONLI'with dye svrimewtstniction%ruaiuloyofe rt_ivu trim zabmit litre oarc Ina...Far All Wells: .Submit tins fano within 30 dais of completion of well
abandiiutucol to the fa11o}virig •
6a.Well IDl:TMW-2 I .
Division of Water Rrsourccs;Informntian-Processing Unit,
1617• ?.Lail Sc lie Center Raleigh I\C 27099-1617
• 6b.Total well depth: 25.5 - (ft.) ' �.: .
• 10h.For TOleellon Wells: In addition to sending the fault to to axidtess In[Oa .
•Ge.Borehole dlantctcr 2 Ru:} above;also,submit one Copy of ibis•fornr}sithiii'30 days of coniptelioir.'of well.
ab ndotin ent tattle following: i -
{ •
fd.Waterfowl ct below ground surfacer 7. O.) Division of Water Resources,Underground Injection Control Program, -
1636 Mail SeniceCcnter,Raleigh,NC 27699-1636
l'
•6c.nutcr:casin lengthIOe Fn r Water Sourly&Insertion Wells: In addition to sending the form to
g (if known):): (ft.) the address(es) above. also submit one-copy of this form within-30'days of
completion of well-abandormient tq the county health department of•the county
GEInn!r-casing/tnhing length(if[mown): (ft.)
whew;abandoned.
•
6g.Screen length(if[mown): (114
I
Fonts GW-1O North Carolina Dcpoitnicm dfEnvirounicm and Natural Resources-Division of Waic4Re,mmees Revised August 2013

r d
AVELL ABANDONMENT RECORD For lmemal Ilse ONLY: .
• This form can be used for single or nntltipte hells "
I.Well Contractor I<nfon iiuiun: WELL ABANDONMENT DETAILS
•
Stefan Smith 7a.Nw g;nher of wells beinabando ed: 1 '
•
Weleear rorNante(orwellmompesonallyalunloninguellanliktlterpreperly) Far multiple. t?Jertiar or nonldnter •supply uelk ONLY with the sane
construed ivt.aivoisloirrne }brt am mihnit was fiunr.
3576A
NC Well ConlmporCenlTtdBoaN�mber 7b.Atiproiiniate taluine of slat q•remaining in well(s)?? .(Oil)
SAEDACCO FOR WATER.SUPPLYWELLS ONLY:
Con anyName 7c.• Type of disinfectant used:. a
1 •
- - " .2.Well Construction Penult#:,
Ltd v11 npphratt1e well peranitr tics.Cunirlit Sw e t arlitmee ItrJentinr;•elat ij ;con Id Amount of dlslnfect int used:
3.Well use(cbcekwell use): - • .
Water Supply well: ' ' . '7e.Sealing n►aterials used(circa,:all that apply):. '
OArgrieulturil CiMuniciptUPtililic DI,Neat Cement Grout " El Rcntonitc•Chips or fellers,
❑Geothennal(Heating/Cooling Supply) ••❑[residential Water Stipph•(single) ❑:Saud Contend Grout ❑Dry Clay "
❑Industrial/Commercial- ' . ❑Residential WitterSuppiyl(shaicd) • 9,Concre(CGrout i '❑Drill Cuttings
❑Lriginion . ❑Specially Grout ❑Gravel
Non-Water Supply Well: .❑.Bentonite Shiny• ❑Other(explain!ruder 7g)
CBMunitorine, . . - ❑Recovety . . I •
Injection Weil: . .. "7f.For each material selected above,peoside amohot of,materials used:
OAgrtiferRecharge ❑G,riiundnnlerRemedi:dion Neat Cam.:1881b ,Wtr:15 gal. Sand Cele.:lb ,Wtr:gal.
oAquifer Stontge•and Recioven� • . ❑Salinity Barrier - I
j,
.UAgniferTest UStormnsnterDrnin:ige
❑E.pperitrteittal Technoloev 17Subsidence Control 7g,Provide:a brief description of the abandonment procedure:
1Geotheunal(Closed Loop) CUTracer
Tremie grout.from.the bottom up
13Geothefnlal(Heating/Cooling Return) Cattier I'm-plain under 7g)
.(), 5/22/24 L•;
d.Datcncll s ab;rndoncd• ti.` "
Si.Well location: .. JUN ? [. 20?4
- Gaston Refuse Disposal • . -
raeilitglUnet>4rNmnc ra ility Il)e(ttfapplkablc) 8.Certification. - ifir5rAlle.5T:'i:A'rcit5 0•.y u: s.
d.
250 Porch Dr.. Gaston, NC• '27832 5/28/2024
' Pl sical Andres.Cit•audZi • . -5r._Aare% Codified!Well Com:mot or Well Onar Dale
S. P
Northampton . . • By signing-tk(s form, 1 hereby cerl'ilmr tle.trell(s)has(were)abandoned in '
County Pared Id:miitt¢itlon No.(PIN) a corrlancc with'1 i4\CAC(12C',,0100.or 2C_4200Well Cu»s7nlaion Standards-
and
thatacopyoftlris.recordhas$etrtprovider!tote ellonner..
5h.latitudeand longitude in degnruslminuteslsceonds'ordecimal degrees: ,
.(ifsi•ell i l4 ow-Woos nng is stilicient) 9.Site diigr•am or add _itional well details:
• 3 6.526815 T You May use the bacl:of this page to provide additional well site details or well
• 1\ 77.653562 W abandomiteru detanis. You may also!attach additional'pages if necessary.-
.
CONSTRnICTION DETAILS ON WELL(SI BEiNG ABANDONED SITBMiTTAL TNSTRUCTIONt
•Attach urtl constrzi rian nkvilitrojf eiva)larite_-.For sEmltfplc ngectieri or ran-nnta•supply
irons OA+LI'a nit the'swise cwutruefmmir5mrdowneat hint can a sbrat Sure fhmr_
Itja:-Fur All WelLc: Submit this'Font within 30 days of completion of well
6a.`Yet!ID :TMW-3 abau lotiti ent to the following: -
I
Dii•ision of Wutcr Re auras,Information-Polarising Unit,-
'
25 1617.-MailScavice Ccntcr,Raleigh,NC 27699-1617
6b.Total well depth: • (It:) +
10h.For,Inlection.Wclls:' In addition to sending the for*to The address in 10a
6c.Borehole diameter:2 above,-also submit.one.t of this forth.within"30 days of-completion.Of►null
fin') -abandonment to.the.following: 1: ,
rid.�Patcrtevcl below ground Surface:.5. (ft.) Division of Water Resources,'Underground Inject[on Couttiil"Pregram,
1636 Mail Service;Center,Raleigh.NC 27699-1636
• I •
• Gc=Outer casing length(if known): (ft) 10c For Water Sunnis'&Tuiectinn Welts: In addition to"sending the form lo'
the address(es) above.-also subinii One copy of this form within 30 days of
completion of well ahandanmen i tci the county health depanntent of the county
•6f.Innercasingltubing length(if Innnwn): (ft-)
where abandoned•
6g.Screen length(If known): '(ft)
Form GW-30 Noah Carolina Department uifEnvironmcsrt and Natural Rcsou:cce—Division of WaizeRcottm:s Revised August 2013 •
I '

. . .
1 . . .
. .
. . WELL ABANDONMENT RECORD Per Itaernal Use ONLY: - ' • ' . . .
ThiS forriteatibe.uSed for Singleor multiple Wells
• .
1.,Well Contractor Information; -WELL ABANDONMENT DETAILS
._
I I i . . • ' .. • .
Stefan Smith . . . 7u.Number of vie%being abandoned:,
WrEeetaractarName,Mr kis.lii CitiVD.:7 teaelaY alb.jarjllifig tidi,ap IiiSiterpreproy) iiu. antrapie. tebreition,•at' nonloitirer -•suppfr wells %ONLY with 0i, sane•
conmswenffliaboirdalimairoinvecuy xabmit linefiem.
' . 3576A , - I I, ,• ,,
lb.Ap'proiimate'velitine ef:Out&reinainin g in weli(sr.4.
NC.Well Centmet or Ceit ilon N1111bC/ , • • 1; :- - ' -
. '" • . - . . . . —
. . .... : • .
-SAEDACCO FOR WNfFR.SpPFLY WELLS ONLY: -
. .
Company 14mac . 7e,Type of disinfectant used • - . ' .
' . . . .
. . . . . . . , •
- .• .. 2,Well Construction f*atit ii:, , . . •
• . List ori.apphcithilr wei/piymii..'s p.e..C4gasy,qtEM.Iliriarke.beertivit,.e10?flitwowa
7d.AMOutit eldiiittlechint used:, ''. ' ' • ' . , •
. .
' . 3,Well use c.hech.vvell.use)::
. .
Water Supply Well • . . 7e.Scaling matetial.iuged(Check all that apply):
' ClAgriculorrid . • . EltdimicipaliPtiblic-,' fill,Neat;Cement Grent: - - ;; • - CI tilerdoniteEhipS orBellets
. „
.
-tle*.oillicirmal(Heating/CoOliog`Supply) EiResidenrial Waier Supply(single) 0•Sand Cement Gn34 i 11 .. •p Dry Ciay• . . .
1:11oduitrialitommereial. ' bit:side/4M'Water Suppliailitedi PI';cat'6tt# F6P-!: ' ' ;. ' CI Drill Cuitirrp.
.. . . . .
ClIrrigation- • . •- - - . . ElSpec:hike'Grout • . CI.Cravel .. . . . • .
' _ . - . - •
i
Non-Water Supply Well; CI Bentonite Slurry Cl Oilier(explain under 7g)
• .
iKIMenitorine •. .• . . . . ORecavery . . . .
Injection,Well: • '' -. - . . . . .. . - 7E For each Material selected abuse,piesideamorint Of matedals used - • •- ,.
I .
' E3Aanifet Itethorge.. EiCreiuruhraterRemediation Neat Cem.:1881b ;Wtr:lgal. Sand Cent lb ;Wtr:gal. - . .
. , ClAguifer Storage and;Reciwery • CiSolinity Barrier .
. .
.13Arprifet Test . - - bStOater Diairsiee
pkwerimeatal Techooloev' ' •.CISubSidence,Contoil ,
7g.Proiide a brief dt*iption of the alimidonment pneOutrri,
CiPeolhennal(cit4ed Loop) . E1Trarer
Trerai.e grout from the hottom.up . .- . • .
' • ClGeetheniod(Heating/Cooling Return) ClOther(explain under 7g) ,
' " I F27.--1- 7i—il'i•-•-•;--..
- • • . i; . 1.-...__c......c•. •v 4.., _,; ..,. ': . • - ,, . •. ,....L„,-
4,Date ive.11(s)Aban 5/22/24donedt
. . ,
. .
. . .
. .
5a.Well Mullion: -, • - • ' .. , • • '.• • •
•
. . -
e-,AMF.,,-1 .rc.- gis.c. ,:,A2 Gaston Refute Disposal . Uni.•
' - . . . •
• . • , . 8.-Certillcathin: - ElViCi!IGG
• , .. . IracilityithmerNanc•- Fadlity ma diapplkablel • - - - • --• '• ", • . - • . .
. .. . . • - -
'
A ' 0,
'.
. . • • 250 Porch-Dr. Gaston; NC 27832 • ' - ' • , A '5/28/2924
$ . ' - ... . . . • . .
Physical AMMO.Cily.'arid Zip - • .S.`,4L-iIiire.,. al- 1%M Co.neracumor.Wc11 eater , , Mae
Northampton. . . . - • — ' • ' -. By siguMg.thislorm,.I fietyby serlik ilia the.treli(s)was.(were)abandoned in
CdsInly' . Paled Idzatiftlan.No:(PL/li accordance aqiit:15 1-NCAC 020110100 or 2C.0200 Writ Constinction Standards
. " and Ilnit it coil,of this Petord)las been Plinided to theItell Owner..
Si.taiiittile and hinginnle in ttegimeshntiorteatsectmds'iir d keinuill-degrees: . t i-
.(irivett Brill ene latilang is sailleica) - • •9.Site 4iagrain or additional well details; • . .*' . .
You May use the baek of this page to provide additional well site details or well
. 36.526815 • N : - . 77,6535.62 W ahatuletuttettidetaiis:You may age Mach additional'polies if necessare.
!! .
' cONsTittrertoINT DETAILS OF 1,VELitifSi BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Aitatie tir1Pcanstriicifinz realtdalif qviklidi fe..-Par)itulfiple.ittjectirm or mo.tatar sapply • • " . •• - -• .. ' •
. •
• ' .- oes-DitLI'witOtheyalviterturstruetiowaildaymentjtm coo sulktriit me/ono. . 10-al,For All Wells: Submit thg'for,m within 30 days of completion of well
obandonritcrit to the felleWing: I •
. • 6o.Weil 11)#:Tmiq-4 .
.
• Dgision of Water Reonras,InformationTrocessing Unit,-
.
61)...TUtal'veil depth:_2 0 ((1.), •1617 Mail Service Center,Raleigh,NC 2.7699-1017
10h.For.inkellon Welg:•In addition to Sending the feral.to the address in Ica .
' 001V;also;submit uric tOp y of this feria within 30 days of-completion of' well
6e.Borehole diameter:2. • On.) - •abaridountria to thefollowing: .
• 1
. i
DitiSiottof Water Roonties,Underground Need-on Coottiil-Prcigrmu,
Gd.Water!es-el-below ground Surface:.2 , - . • 1636 Mail&nice Center,Raleigh,NC 27699-1636 .
10c,For Water Sunalv.&buiesttan Wells: In addition'leRIl i diug(be form to"
6e..•Outer easiog leri.Will(if known): , '' (ft)
the address(es) oboye.-also submit one-copy of this loon within-30 days of
completion of well.ehatuletanene in the-county health department-of the County
where abandoned. 1
6f.Innereashig/tubing hOrgth(it known): (ft.) I, ;
I .
6g.Screen length or tarowo (ft.)
Form GW-30 North-Carolina Dcpartmem OfEnvimonamt mxt Natural Resources-Division of Water Moores Reviscd'Augun 2013 •
. • •

i
1.
WELL ABANDONMENT RECORD innui Use ONLY;
This form can be used for Ode ormultlp ife1l
I..Well Contractor Jiifortnation: 1VFLL ABANDONMENT DETAILS
S •
tefan Smith 7n,Number of Hells being abandoned: 1
Vi iiICoirrrctortlame or UCH Mina pcisonally xhamiordiy rsclt on Itis8kr property) For multiple tiyertiar, or rwrt.i.t ter -super wells 'ONLY 'biuh the some
cothfruenrxuibandonrncrit xuu ernesark vtie fiirm
3576A 1,
NC Well Canlr�aorCsnific anion Minter . 7b.Apiimziniate,°Hine of Wain-remaining in well(s)?2 (Iti)l.)• .
SAEDACCO •
FOR WATER.SUFFIX WELLS ONLY:
Compaq Namc Te.Type of disinfectant used: ' •-
2.Well-Construction Permit#:, , •
Lioolluppkethle•u-edparmiis tie L.Coonte,Startrurirrrrce.Lyertiuu.e1CiIIfkrmirn Td:Amount ofdisi fectantused:
3.:Well use(cheekit ell use):
' - -Water Supply Well: . 7c.Sealing materials used(check'all that apply);
❑Agii nitutid • cMimicipaliPublic• @t.Neat Cement.Gtout ['Beotonztc Chips or Pellets,
O ieothcrmnl(HcatinriCoolingSuyply] i]R -idential Water Supply(single) ['_Sand Cement Gmut 17 Dry Clays
•
❑hiduoirial/Commcrciol. . , . cltesidrntiat Water Supply(shared) , CI Concrete'Gmut ❑Drill pith*
11
['Irtigation• . Cl Specialty Giout I - ❑Gravel.- •
Non-Water Su pplyWell: CI Bentonite Shiny ®Other(esplaintinder7g)
ligManitorina ['Recoven
Injection Welt: - • 7G For each material selected aliose,provide autonotof materials used: •
['Aquiferltecharge cGroundnmterRemediation Neat Cem.:18811i ,Wtr:15ga1. Sand Cern.:lb ,Wtr:gal.
CiAgttifer Stooge and Recoven� •.°Salinity Battier I ,
,DAipriferTest • OSlonm%.ucrDrainage '' '
• ['Experimental Teclniotog_v ['Subsidence Connra! 7g.Provide a brims'description of the abandonment:procedure.:
ClGeolhermal(Closed Loop) ['Tracer ^
Tremie grout.from the bottom up
®Geothernial(Heady/CoalingReturn) ['Odier(explainunder7g) a,' r�. i'�,.f'_ ,c ', ti
4.Date iell(s).abandoncd: 5/22/24 JUN � E. 2024
5a.Well lueation: Irr`9f ci 741.+°r•~'1..6ioge.i
•Gaston Refuse Disposal seam 8s�tia
•
Ftsilitpli7n ricrN irrc' Facility IDt3(ifapplicablc) s.Cer•tllleatioir:
250 Porch Dr. Gaston, NC 27832 5/28/2024
P1 sital'Address. ;City and Zip • -St...., Inre:.Cenilicd Well Con n:m er Well Oister n ue
Northampton. - By signing ties Ann; I hereby citrtifv that the irell(s}was(were)abandoned,at
• Cou ty Rated ld_mitie itibu No.(PiNj dean-dance with'I I\C-IC 02CI.af 00 ark Well Conshatclion Sfttnthirds
and that a copy of this record liar'be n provider!da the*ell owner:.
Sb,Latitude and longitude hi des nccs(n:hiuteslscconds or deci nal degrees: E ,
(hest!t SW,one lofting is sniticxw) 9.Site dltlgrain or additional well detaiis: . .
36.526815 . 77.653562 Yon ntaa•use the back of this page to-provide additional well site_details or Well.
N - W abaudolmteia details You may,also attach additional pages if necessary_
CONSTRIICI'ION DETAILS OFWELL(S),BEINGAI3ANDONED $LIBM17TAf.iNSTRUCTiONS
Attack treli coirxtriactiou recvrd(sl 4!arviluble."For nndople mkctiw?or rmn•uiuter supply l;
iieits'ONIY with t a swift!etitstrcrtrmra!uirdoitric'ru_iaoninaibmitweejorni 10a::lttrr All Wells: Submit this,Fonn within 30 days of completion of well
6a Well ID#:TMW'S abandonment to the following:
i
Division of Water Resuurces,Infarmation-Pructssing Un1t,
6b.Total well depth: 20 {ft.}
I617-Mail Scniec;Centcr,Raleigh,NC 27699-1617
10b.Fo r.In leetIon.Wells: In addition to sending the fount to The address in l4a
fie.Borehole diameter.2. (hi.) above.also;submit one tope of ibis Conn within'30•days af-coniplelioy'of well
abandonment to tite(ollawing: I'
Ertl Water.level below ground surface: 8 (ft) Dh1slon of Water Resouri C;:Underground Itijectdou Control Program,
1636 Mail ScrviceiCcntcr,Raleigh,NC.27699-1636
ti
Gc.Outcrcasin Icn (iflmawu): (ft) IRc:For Water Slowly&fuieetiOn Wells: In addition to sending the form to
g � the address(es) above. also siabinit one•eopv of this form within 30 days of
completion of well abandonment to the county health department of the County
6E.Inner easing/tubing length(if!mown): (ft) where abandoned. 6
•
6g..Screen length(if ineow n): (ft.)
Fenn GUI-30 NonhCarolina Depart erd ofEnvirooaicnt and Natural Resources—Dhistan of Water Rcaowns Revised Augug 20l3
1

•
WELL ABANDONMENT RECORD For Internal Use ONLY: .
This form Can be used foi slue or multiple wells
l...Welt Contractor^Information: WELL ABANDONMENT DETAILS .
Stefan.Smith ., 7a.Nuntberof wells being abandoned: 1
WYellCorlraclnrName.(orndlunorpelsonallyabandoningwellanitaatllerpropcfy) For mlopie Weaker -or nonluaiter •somas. wells •ONLI' with Ike sarie-
C/,nI7rfetiont7boticlonm rif,1t0NCO!anlanirurrefonn
3576A
I
•71).Approximate volume of*attn.renuining in well(s) 1.)?? . {
NC tYellContradorCcrtifrcotionilmtficr i,' •
SAEDACCO . FOR WATER.SUPPLY WELLS ONLY: •
.
• Cancan).Name 7e.Type of disinfectant lewd:
•
• 2.WeU-Constnrction Permit Or f ,
LW 01 rtppLii hle well permits li:r..Cwoff,Pak;Fork:Nei.beertiui;.etr Orlaurwn 7d:Atliotslle of tllilnfectslilt 115141:
.
• 3.Well use(chedcwel use):
Water Supply Well:• 7e.Sealing muted ds.used(check all that apply):
t]AAriculturil ❑Mitnicipit/Ptibtic-' • ail Neat Ccment.Grout: El h3er4onite Chills or Pellets
E]Gcotitcrmal(Ilcating/Cooling'Supply) . "Q El
Residentint Water Supply(single) .Sand Cement Grout ❑Dry Clay
❑Endustrial/Coamicrcial, ORcsidenti:tllVatcr Supply:(shiaird) U: mro Cote Gut - ❑Drill:Cuttings . . .
.
❑Tniattion ❑Specialty.Grout - : :❑Gravel
•
Non-Water Supply Well: Cl Bentonite Slimy + • Cl Other(explain under 7g) •
• Q9Monitoring . . ❑Recovety , •
Injection Well: ' 7f.For each material selected above,provide amonutof materials Used:
' U ruler Recharge. OGmiauisdwater Rentedia Lion
�1 5 Neat Cem.:1881b ,Wtr:15ga1. Sand Cem.:lb ,Wtr:gal.
. l7Agttiter Store,e:prl Recovery .❑Salinity Barrier
f]ApiiferTest []SionmsaterDrrinage .
❑Experimental Technoloev lSubsideitce Control 7g,Provide a brief description of the abandonment piricedure:
ElGeothemral(Closed Loop) ❑Tracer 1
Tremie grout.from the bottom.up .
CGeothermal(Heating/Cooling Return) • clOthcr(eplain under 7g)
S.Date ivell(s).abandoned: 5/22/24 �L`,p IL:.3 tlor'
is Well tacation: JUN ' [. 2024
Gaston Refuse Disposal 'T+
irikO gill;71.7Or,tM34.'77,w,UrA
• Facilitl/hcer Name'. Facility 8.CetllRcation:Dt i p (;1C c
250 Porch Dr. Gaston, NC 27832 5/28/2024
P1r swat Mthess Ca) and Zip 5 htn..Co;ltial Well C.oturt:tarorWcIIOwner Date •
Northampton fly'silpring•tkis form; 1 hereby cert/fy-that the,irell(.$)rras(here)abandoned in -
Ca,io[y Parcel Ideriit'ttltiuNo.(PIN) accordance tvi111'154 NCIC Ole i:01Ud.or 2C.O200 Well Canstrueiion Sftmdrrri#s
and drat a copirofllus record has'beu,pros ded to the u ell(iwner.. '
Sb.T.atitude and longitude in dega resfmihutca/seconds or decimal degrees: i I •
• driven Mild,otte L:ttltmy is sulti�cra) 9.Site di. ram or additional cell derails:
• 36.526915 77.653562 You iva} use the back of this Page',Mutaside additional well she details or.fell
• . N W ahattrlomitettsdetaiis:;You may also ttlach additional pages if neeessat .
•
CONSTRUCTION DETAILS OF WELI4SI BEING ABANDONED SUBMITTAL INSTRUCTiONS
:t(ludh tall cunsirectida ncvrd(sj'ij available.-;Fur irvleple injection or rsen•uiattr snpplp . . • . ' . . . 1
well ONLY midi the sinilecvirsrrtxtimeduilt fumirrwu._tad air,srrbmtt atejomi 10a.•Far All Welk: Submit this form within 30.days of completion of well
Ga.Well ID§:TN4'6 abandoinncnt to the following:
Diyu tn iun of Water Resources,Inferatton:Processing Unit,-
1617 Alai!Service canter,Raleigh,N•C 27699-1617
66.Tetal well depth: 15 (ft.) • r
•10b.For Inlecthon.Wells: In addition to sending the form Lobe address in EAa
Gc.Ba rtchole diatstetcr.2 (tit y aboi�e;also submit one Copy of kill's form within 30 days of completion.'Of Well
abandonment tet,thie following: I ' •
lid.Watcr.Ecvcl bc[nvv ground surface: 1; (ft.) Di islon of Water Resources,Tlnderground Injection Control Program.
1636 Mail Service Cwntcr,Raleigh,hC.27099-1636
i
t
Gc Outer using Ictt h(if Imon n): ( ) l0e For Water Sitnnic it;Tuici'ttan }'ells: In addition-to-sending the form to'
' the addresses) above:also submit one copy of this fonts within 30'days of.
completion of well abandotunent to the county health department of the county
GE Inner easing/tubing'length(if latown): (ft.)
where abandoned.
I
6g.Screen length(if known): • (ft.)
Fonts GWV 3o NonhCarolim Deparimem ofEn iromncot mil-Natural Resources-Division of Water Rciaiuees Ltevocd Augurs 2Ut3
.

•
•
WELL ABANDONMENT RECORD For[manta UseONl.Y: •
Titis:foim can be used for single or mnitiplk.wells .
•
I.Well Contractor Information: ♦YELL ABANDONMENT DETAILS
Stefan.Smith 7a.Number Ofgtclls being abandoned: 1 '
•
WellCorlmctor Name,(or uciton pMsoWilly ahMitioningai;Iloulristlairproperly) For multiple ayeetiat or rOOtrafer •.rgpI walis..ONLY rc:rb .ile stare
comoyermnihbo tang r'lit iim clime submit pvrefirtn.
' 3576A , ' r '
1 C We11 ronrraaorCsititr rvon Nnirbcr 71i.Ap11ruilmate volume of Wat i meaining in well(s)?2 (;id.)
SAEDACCO F OR WATER SUPPLY WEt,.LS ONLY:.
• Ca'nJran}Name 7e Type Of diainfiYtant used; `
• . . 2:Welt Construction FermIt#:, , -
Lival1 utiltllrableuell permits.ti:at.Cmioy,Saiie.Pa la:tee.Itr;eciiui;,etci Ifhtanra. 7d.Atttenut of dlilnfectant used:
3.Well use(cheel:•stell nie):
Water Supply Well 7c.Scaling m.teri:tls:used(check all tliit appl}-):'
OAgriculturtt- . ❑MitnicipaliPubbtic ID Ncat Cement Grout- El:Bcntonitc Chips or Pellet
OGentlermal(HcatinntCootm Supply) .Clitesidenttal Water Supply(single) ❑.Sarin C•enieu1 Grout ❑ ry D Clay•
.t]IndusitiallComntcn ial. OltcsidentialWatcrSupply(shared) . a Coiicrctr Groui . . ❑Drill-Cuttings
❑irrigation ❑Specialty Gout ;: ❑Gravel-
it�tn-WatcrSupplyWe1L; ❑Bentottite5lutay ❑OIlier(e�plainunder?g)
191Nonitorinu ❑Recover_ .
--Laj4°tion Weil 7f.For each material selected abo•Ve:,preside amount of.materials used:
°AquiferRecharge'. . OGimtndttatetr-Rentedlition . Neat Cem.:1881b ,Wtr:15gal. Sand Cem.:lb ;Wtr:gal.
OA.gtrifer Storage anti Recosety • .OSalinity Barrier
. . DAguifer Test. OStormwater Drainage . .
.❑E.�petimeivalTecliuolojv ❑SubsidenceContml iti•scri I'7x.Provide a hri�' ptiau of the ullrrndnnmcnt nerfrivlttrc:
" ❑Geotbermat(Closed Loop) CiTracer.
Tremie grout from.the bottom.up
®Geothermal(Heatine/Cooling Reim) 130ther(eaplain under 7At
�i�..`,pL..,rdel
.L Datcitel1(s)abimdonctl; 5/22/24 •1 i)
Sa.Well location: - . . . . ' . - JUN 9 !. 20?4 .
Gaston Refuse Disposal
8.Certillcatieu lr a;r,.t+rtE t" i;t.ry9a¢;?,fr 11
, .'Facrlityo hen rNarte' FaziliiyIDN(i(appl:mble) _
Dttirzr lit:;
250 Porch Dr.. Gaston, NC 27832 5/28/2024
Physical address.Ci1y,•and Zip , SI_ Ina Certified Well Grrtttactor or Well(Ircn:r • Date
Northampton - fly signing the farm, 1 herby.cerflfy lliat the wents)was.(were.)abandoned in '
' Conuty' Parcel hi_nrifielithin No:(PL\) iltcorrlaace with'I S_4?tCAC 02C'.0100 or 2C.0200 ifilf Conslratcfrun Strinrktrr is
and that acopyof this record h sbeetrpmvided-(alheudtearn . • •
-
Sb.Latitude and iongitsde its degreevlmiifutes/seconds or iiectum'degrees:
(iiti eu fwIti,One 4nJtOng.is Snitieier4) - 9.Site diagram or additiort:tivr'el details:
36.5268i5 77.6535.62 'You tuay use the back of this page to provide additional well site derails or well.
• fi' W .ab:aulotuiteni details.'You may ale attach additional pages if necessary.
CONSTRTIC'11D'I DETAILS OF WELLiS)BEING ABANDONED S[1RbTI7'1 Ai.INSTRUCTIONS
:tlfuc*marl currsrrleliera tealilia)'if avitilable_ .Pcir multiple ityectiuri 6r m n•aurtcr.wpply
udlrthVLI'trig'tiresomerVntrrttoniaLarihuevat iou eau�rbmrtirefomi_ lOa For Alf Wells: Submit this form within 30 days of completion of well'
•
Ga Well ID :TMW-7 abandonment to the following; II;
:f
- Division of Water Re nurcmi Information:Processng Unit,•
•
6b.Total well depth: 7 {ft.) I617 D4:ril Service Center,Raleigh,NC 37699-1617
14b.For.lnlectlon Wells: In addition to sending the forth to the address la i()a -
above;also:submit one topy-of this form wiiltui'30 days of eottipletion of well
6c Borehole diatueterr 2 (in.) ;tbnndorvnenttth tie following: '
(:
6d.Water'[ct'cl heron ground sttrfacc.�2 (ft.) Division ofti tter Resources,tiudergrouud Wee. iron Control Program.
'1636 Mail Scrvico Center,Raleigh,NC.2769 9-1 63 6
1,
Outer casinglength(if Insets ct): (ft.) tOe For Water-Sunnli SrTefectinn'Netts: In addition'to-serxling the fort to
6c.
the addresses) aboye.also suttritit one copy of this form within 30 days of
completion of well abandonment/to'the county health department-of the county
6E tunereasingjtubing to gria(if!mown): (fL) where dkianrfonctl.
6g.Screen length(if known): (ft.)
FOmi GW430 North-Carotins Dcpaioncra alEnvironriic:i oat-Natural Resources—I)Ivision of Water Inc oniz s Revived August 20Li
1 1
s