Alamance_Well Abandonment_20240814

WELL ABANDONMENT RECORD 6st/ L aknaluaeONLYThis formcan be used for single at multiple wells
I.Well Contractor Information: WELL ABANDONMENT DETAILS
ROBERT MILLER la.Number of wells being abandoned: 1
W cii C'ateractor Nang tot Nell too prruuuIh abandon's well on hnrlrr propem r Far wi Jnph , +rchrur, or wm-wale•; swpplr ;ruts ONLY rlrb Nn mole
r.difruc nwi nAemh VIM,of n ,mr ttiiww v. barn,
2675A
71i.Apposeimate toluinc of water remaining in wrilia): (gall
NC Well Coturugor CenI1kai nit Nemec;
SAEDACCO FOR N'ATE R SI PP1.1'WELLS ONLY:
Convent Name 7c.1)pc of disinfectant used:
2.Well Construction Permit a:, ,
!�<i:dln,ri..:ri, u, i.� iwnfi.,`'rNr.Iununr+r.IMrdu�u,etcirlkJ'nrn
7d.Amount of disinfectant used:
3.Well use(thesis wall use):
Water Supph Well: 7e.Scaling materiak used(check all that apply):
❑Agricultural ❑Municipal.Public Cl Neat Cement Gmm CI Bentonte Chips or Pellets
❑(irnthcnnal iHeanni'C'ooling Supply l ❑Residctatal Water Supph';singlet El Sand(etnenl Grout ❑ Dry Clay
❑lydusnwalrt-omntcrcial ❑Residential Water Suppis';shared) El COncrete Grout ❑ DullCttings
❑Intention ❑Specialty.Grout ❑Gras el
Non-Water Supply Well: ❑Bedorute Sinn O Other texplain under'c)
BMonuonug ❑Recover
Injection Well: 7f.Per each material selected aho",e,provide amount of materials used:
0 Aquifer Recharge ❑Gmuidwater Reutedta.on
El Aquifer Storage and Recovers ❑Salunls Darner
❑Aquifer Test ❑Stonmsaler Drainage
Bentonite.:SOlb ,Wtr:gal.
❑Expenmenwl Tedinologi ❑Sdtstdeirr Control 7g.Pr'otidea brief description of the abandonment procedure:
LlGeothermal 4Closed Loop) LiTracer
After water sample collected, removed DPT tooling and
LiGeothennallHeating?Caoling Return) LlOtherlcxplain under'g1 -- — — '
backfilled boring w/ hydrated bentonite chips.
4.Date wcs)abandoned: 07/22/2024 I '
wows)
5a.Well Mention: AIIf, G 2074
US Car and Tool , ,
Faclns Owner Nam Facility.Mani'applicahki IL Certification;
214 W. Hanover Rd. Graham, NC 27253 7/22/2024
Pta mu!Address.Cie,.and Zip Darn
ALAMANCE B.signing this firm, I hereby corn that the wilts)was(were,abandoned ut
0,11a. P.,t,.t ld;min:::iir,i Nu ;PI\ aironlanc'e with ISA.AC-IC 02C'.0100or2C.0200 Well Construction Standards
and that a copy of this record has been Provider)to the well owner.
5b,Latitude and Iongitwde in degr estminutes+seconds or decimal degrees:
!il itch fold one Lai kni ik sufficient) 9.Site diagram or additional well details:
You nest one the back of this page to pros de additional well site details or well
N N' abandonment details. You may also attach addiewmal pages if necessary
('ONSTRI:CTIUN DETAILS OF N ELIAS)BEING ABANDONED SU'BMITTAI.INSTRUCTIONS
.math writ cOrxrlriidrvut n•n,r.L s+a a 'ask. he mainplr oyrcnuv cv non-wafer sipt.•h
w r1Lr O.h'LY with the mime ewe o»n5ut ills nhr.0 nest)ee run SWUM/role krrm. 10a. For All Well* Submit this fart within 30 d:n s of completion of well
ilia 'wdl IDt;:B-1
ahandonmcm to the following
Disision of Water Resources,Information Processing Unit,
1617 flail Sevier Cetera Raleigh.N('27699-1617
Oh,Total well depth: 25 tft,l
lOb.For Ielectlor to sending the fotta to the address in Ina
225" above-also submit one cop", of dos tonal"what 30 da}s of completion at well
he.Rnrrholc diameter: .25" tin.1 abandonment to the following
Disislon of Water Resources,I ndergrnund Injection Control Program.
bd.eater les el helms nntnd surface: (ft.) 1636 Mail Sen ice('enter,Raleigh.NC 27699-1636
21 hoc.For Water Sunuls & Inkctinn Weth: In addition to sending the fonni to
be.Outer easing length id know n i. (ft.) the address(esl abuse. also subunit one copy of this form within 30 tuns of
completion of well abandonment to the comas health department of the counts
where abandoned
of.Inner casing/tubing length Isnossn;:
fig,Street.length(if know n1:4 Offal
Font.GW-to North Carotin)Department of Ent irnnnten aid Natural Resources-Disiena of Water Resoufees Rey iced Anglin P)l i

WELL ABANDONMENT RECORD Yar,,aer,la,C;yeONLY
This t r n can be used for singk or multiple wells
I.WIN Contractor Information: WELL ABANDONMENT DETAILS
ROBERT MILLER 7a.Number of wells being abandoned: 1
'r+clll l,lYlai fur matopk nrrrason 13, ClIC L�I trill„,.11,I 1L1IIt 1111.11Ak.11111 ac:I on haler platens)
rw raw-water supply wells ONLY ter,! Nn• ,war
r Ytflaryn(fuel l#pr,i)osiiwe r.1.,!!„11,,Nh,,llr r.Jl•'Awn,
2675A
NC Well Collor-tor Certification NNnticr
7b.Appnasimate wdnme of w ate(rrinaininE in w cilia): 410
SAEDACCo FOR WE AT R SUPPLY WELLS ONLY:
Corpse}three 7c.•l'pc of disinfectant used:
2.Well Construction Permit It:r ,
e,�t adr oppItcuhk well perm,u.e.['vaulty.Var.I drlaaKe lntnafirm,etc.,1t grow,!
74.,\mount of disinfectant used:
3.Well VW(cheek well oar):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agrwnhmal ❑MinicipahPublie ❑ Neat Cement Grout ®Bentonite Chips or Pellets
❑f;rnthennil tHcatina Cooling Supply} ❑Reside tial Water Supph !singlet ❑ Sand C'ennen Grout 0 On Clay
❑Itdustnal:('omnrcreial ❑Residettial Water Supply!slurred! 0 Concrete Graft 0 Drill Cuttings
❑lmgattom ❑ Specialty.Grout ❑Gras el
Non-Water Supply.Well: 0 Bertonite Shim 0 Other(explain under 7g)
ISMomlontig ❑Recovery
Injection Well: 7f:For each material sekrcted above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remedianon
❑Aquifer Storage and Recovers ❑Salmih Hamer
Bentonite.:501b ,Wtr:gal.
ID Aquifer Test ❑Stonmsater Drainage —.
❑Espenmental Technology. ❑Subsidentce Control 7g,Provide a brief description of the abandonment procedure:
f_1C,eottwnrztl(Closed Loop) Lllracer
After water sample collected, removed DPT tooling and
LIGeothemral(Heating/Cooling Return) [:)Other(explain under 7g)
backfilled boring w/ hydrated bentonite chips.
4.Date wee(%)ahandn nrd: 0 7/2 2/2 0 2 4
5a.Well location: AU G 1 ?UT
US Car and Tool
Fxili ,tiksncr Nan,c r a. r 1, n i'.,1r,1t1,,i.lrit, S.Certification: ICI'S:F.''` `'
219 W. Hanover Rd. Graham, NC 27253 .,k30767/22/2024
Ph,sical Address.('in.aid Zip aylap� S':tie;«Qc C•arCr Date
ALAMANCE 1!y signing this fern, 1 hereby certify that the wellfs) was(were,abandoned in
Comm Panel 11knunc.IIwi1 N,, :I't\1 accvrthalce with lS•i.k't'-ll'(1 .0100 or 2C.0200 Well Construction Standards
and the a copy of this rec a,;•!/has been provided to the well owner.
Sh.Latitude and longitude in de Imineteg econds or decimal degrees:
Of well fr,d.ow larlong i.sulrierw*} 9.Site diagram or additional well details:
You mat me the bacl,of this page to pros de additional well site details or well
N W abandonment details. Von may also attach additional pciges if nccessan_
(ONSTRL(TION DETAILS OF%ELLIS!BEING ABANDONED SUBMITTAL.INSTRII(TIONS
Attach wet/com+'trlrctr+w trturd;s,,lit lnmlatk. Poe mlinpir oyethart ru rkn•siaer sun*
wefts ONLY with die Wear cvmtrewar m abandonment 1.'M can.Vlbmat are ham' Ina. For All Wells: Submit the farm within 30 days of completion of well
abandonment to the following
6a.Welt IDs:B-2
Division of Water Resources,Information Processing(Init.
1617 Mail St-nice('caner,Raleigh.l's('27699-1617
soh.Total well depth: 25 (f1.►
It}b.For[election Web: In addition to sending the tom to the address in ttla
2.25" alxnc_also submit one cops of this form within 30 days of completion of well
tic.Borehole diameter: (in,) abarrdonnrem to the followm g
Disislon of Water Resources,C'ndergruued Injection Control Program.
bd.Water level hrtim geimmi surface: (ft.) 1636 Mail Service Center,Raleigh,N('27699-1636
21 Inc. For Water Sunnis.& lnicctiuti Wells: In addition to sending the form to
GcOut rcasinglengHm(Hknownt: (�) the addresstcs) at>tlte. also submit one cop} of this fomt within 30 days of
completion or well ab:udomnent to the county health department of the county
where abandoned
of.Inner c asing.tithing length tit*known): (ft.)
6g.Screen length of loon ol:4 Uf.l
tale•t;U-;n NorthCamlm Dgmin'em of Ern non111rn:min(N:Iil1131 RCS011r12CS -finis isw,n On Water Resources Rcti reed Auguu?n13

WELL ABANDONMENT RECORD For haerrrl the ONLY.
This form can be used for singk or multiple wells
I.Well('ontractnr Information: WELL.ABANDONMENT DETAIL 4
ROBERT MILLER 7a.Number of wells being(abandoned: 1
11'.11( /;IL aol'..mr to ,.all , lb../persmulh abandoning aril on Les.he r ptop.m, F„r mtrlOpk• uVeatins, ,Ar rY.n-w21fa'Y serppA rah•: tl\!1 .th rife
.',Nl'rrl,t 0.41 a1l41.1rAMIA„',lf.,.•N,,!' ,ntv,ur Moe A'nw
2675A
NC Well Contractor CCrI lfiCatnnn Nonfat 7b.Appnas imate%Manse of w as r remaining in otitis,: 1 gal.)
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Comm)Nam 7e.'fh pc of disinfectant tined:
2.Well Construction Penrit M:, ,
!AV,dl rptp/k at,i, will ln'rwit., r • ienr,, \'bra'.)Jelin a Lair.hart r!c.,,IAmwr,
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(cheek all that apply):
❑Agricultural ❑Municipalli'tnbltc ❑ Neat Cement(;not LE Bentonite Chips or Pellets
❑(i oihcnnal(Heannr''C'ooling Supplvl ❑Residential Water Supph)single) ❑ Sand(enteni(,runt ❑ Dn Clay
❑Irtdustnal'('ommcrcial ❑Residentuil Water Supph(shared) ❑ C'ancrete Gmw ❑ Drill Cuttings
❑Imgatton 0 Specialty Grout 0 Grad
Non-Water Supply Well: U Bentrnute Slum U Other(explain under 7g)
ISMorntonua ❑kecosets
Iujectinn Weil: Tf.For each material selected chose,pima ide anraout of materials aced;
❑Aquifer Recharge ❑Gmundwater Remediatio n
❑.Aquifer Storage and Reim cn ❑Salinity Hamer
Bentonite.:501b ,Wtr:gal.
❑Aquder Test ❑Stonanaa►er Drainage --
❑E\penmetual l echnologs ❑Subsidence C'oatol provide a brief description
ption of tine abandaumcnt procedure:
11Geothemwl(Closed Loop) UTracer
After water sample collected, removed DPT tooling and
11Gcothemaal(Heating/Cooling Return) DOtherie plain Older 7g)
backfilled boring w/ hydrated bentonite chips.
1.Darr II VMS abandoned: 07/22/2024
5.4.Well location: {�
US Car and Tool A�,+ ` t;
Facklm Ooi r Na,,, R.Certification:
214 W. Hanover Rd. Graham, NC 27253 Ls it `��% 7/22/2024
PIP Steal Address.City.and Zip Salynle•:•"' 'r"" r:4 ace IY.a¢
ALAMANCE 13)'.Awutttg the.harm. 1 hereby cernfr than the wells)was(were,abandoned to
('a,mP Pata.I Id.nnIa,:akni No.(PINT aacconlance with 15.4.VC.-IC 02C.0100 or 2C.0200 Well CisostrucAun Standard',
and that a copy of this record has been provided to the well owner.
She Latitude and longitude in dl liuMtea/ucconde or decimal degrees:
if well fold.ant.L•atlung is s,drkur) 9.Site diagram or additional well details:
You mica me the back of this page be pros ide additiotral well sue details or well
lY W abandonment details. You toot also attach arid itknutl pages if Itecessan
CONSrRI'("I'ION DI.'C.AILS OF W ELI.tSI BEING ABAND()1ED SUBMITTAI.INSTRUCTIONS
.?(wcit situ rurr!rv.!,:ur near.'.+.{I at ju,goc- I-or m,r/npk•ulnanort or raw-wirer wlgdr
weN.ONLI stabrhr.amwcos.mk(kin,as.rnk,rrnnrtt low Carl'airmen wre,Amn. IOa. For All WeLL.: Submit this form within +() days of completion of well
6a Well ID+f:B-g abandonment In the following
Disiuian of Water Resources,Information Processing)'nit.
1617 NUB Service Center,RakiLh.N(•2'699-1617
6b.Taal well depth: 25 (ft.)
lOb.for Inertia.Web: hi addition to sending the form to the address to l0a
2.25" above.also submit one copy of dtts tone within30 days of completion of well
6e.Hiunlnila diameter: tin.) abandonment to the following
Division of Water Resources,Underground Injection Control Program.
bd.Water tent below ground surface: (h•) 1636 Mail Senior Center,Raleigh.Ni'27699-1636
21 loc.For Water Sunnis& Iniectlon Well : In addition to sending the fonn to
be Outer casing length lifknownI: (h•) the addressiesi abuse. also submit one copy of this tome within 70 days of
completion of INCH abandonment to the county health department of the zottnts
where abandoned
6f.Inner casing.+tuhin>;length(if luown): (ft.►
6g.Screen length iif known):4 (ft.)
Fenn GW-to North Carolina Dcpnnm:n of En,'moment aid Natural Resources DP tsn,a of W'atcf kcsuarecs Reseed Au,iu 2013

WELL ABANDONMENT RECORD Fot Internal Use°MX
This fomt can be used for single or multiple wells
1.Well('nntractnr Information: WELL ABANDONMENT DETAII.ti
ROBERT MILLER 7a.Number of Vella being abandoned: 1
Well t'ourracror Nane iur acll Lipner peronulh atutdonutg%el,n htiter propene i For mid ph nttet hull ar re,n-w afar supply writs ONLY with law a.ow,.
,.iiYrrio non.g' ,wA.U,,,l,',If 1,.t,,.iII',Amur Ilr NI,'fi.rmw
2675A
NC Well ConomctorCcnifiatlmn Nastier
711.Approximate stibnite of water remaining in wettish (Ral.I
FOR WATER SUPPLY WELLS ONLY:
SAEDACCO
Compton Name 7c Tmpc of disinfertant used:
2.Wdl Construction Penult 0:, ,
Ludloprla.d,i, w. r, , .' t4/111:l.State.1anamce lnlerimon.etc.+!!known.
7d.Auuuut of disinfectant used:
3.Well use(cheek well use):
Water Suppt}Well: 7e.Sealing materials uscrl(cheek all that apply):
❑Agri:ultural ❑MunicipabPublic 0 Not Cement Grout E Be tonite Chips or Pellets
❑Geothermal tHeanni'C'ooling Supply) ❑Residential Water Supph tsingle) ❑ Sand(enrenl(imut ❑ Ors Clay
0 Industrial,Commercial ❑Restdenttal Water Supph 'shared) ❑Cottcehh Groin ❑Drill Cuttings
❑Imgauou 0 Spec:lath Grout ❑Gras el
Non-Water Supply Well: 0 Bentonite Slum 1 i Other(explain under 7g)
Nklututonne ❑Recosers
Injection Well: 7f.For each material selected aho'.e,provide amount of materials used:
❑Aquder Recharge ❑Groundwater Remediation
❑Aqudler Storage and Recovers ❑Saluut} Barnet
Bentonite.:501b ,Wtr:gal.
❑Aquifer Test ❑Stomnsater Drauuage --
❑Expenmemal Technobgv ❑Subsidette Control 7g.Pro%idea brief description of the abandonment procedure'.
UGeothennal(Closed Loop) 1_1Tracer
After water sample collected, removed DPT tooling and
UGeothennral 1Heating+Cooling Return) UOther(explain under 7g)
backfilled boring r/ hydrated bentonite chips.
1.Date wrllts'ahandnncd: 07/22/2024 rLL^-
{' '• •
54.Well lot Minn: Cf1!J2a
US Car and Tool
S.Certification:
I., rlin I iIs (h.nt Ni,,. FacD4Oni pltablc• ,.-.•.fyit.� jt"
214 W. Hanover Rd. Graham, NC 27253 _ 1::• '•..!t,-' 7/22/2024
Phs seal Address.Cm.and Zip StgmWh::•!" fate
ALAMANCE 13v wgturtq this pros. 1 hereby cerfi/y that the teeth's!was tweret abandoned at
count I Ana 1,kin,I,.iIK,n N„ :I'IN accontan a with 15A.'iCIC 02C,0100 or 2C.0200 I1'el1 Construction standard,
and that a copy of this record has been provided to the well owner
Sh,latitude and longitude in tlegreesiminetesiseconds or decimal de-gre s:
tit edt fwld.one Ian hmng is v tTkrenrt 9.Site diagram or additional well iktaBs
You ma% me the back of this page t 3 pros isle additional well sac details or sell
H W abandonment detaib. You man also snack additional pages It Is essan
('ONSTRt'CTION DETAILS OE IA El LLSI BEING ABANDONED SUBMITTAL.INSTRUCTIONS
.!float writ,roalrf,,Jern mcord.'., U at luid.k. h,u mtllnpir ofrcetm a'numndtrr sappt
is.!!,'ONLY with the maw,00stret ru,r.hhotwk.mnent.IOW Can&Obmit mute farm IOa. For All Wells: Submit this from within 30 lass of completion of well
abandonment to the folltnitne
6a. %ellIIN*:B-4
Division of Water Resrruret.M,Information Processing Init.
tab,Total well depth: 29 (ft.)
1617 Mail Service fatter,Raleigh.M'27t.99-1617
lOb.For telethon Wdj: In addition to sending the form to the:address in Ina
bc,BtIlelMlle diameter:2.25^ min.! abuse.also submit one cops of this form within 30 days of completion of well
abandonment to the following
Division of Water Resources,Underynnued Injection Control Program.
Lid,Water kid behiw giitund suurface: (ft.) 1636 Mail Service Center,Raleigh.NV 27699-1636
10c.For Water Sunni & (niceties Wells: lit addition to sending the form to
6e.Outer casing length lifImnwu): 25 (ft.) the address(esl abuse. also submit one cop) of this form ssithm to dams of
completion of well abandonment to the count} health department of the:ottnh
where aturrdoncd
M.Innereasing.tubing length of limitsni: efts)
6g,Screen length of Allow n m:4 (ft.)
h,.rantr11'(ii NonhC'arobroDepanneraofEmimmaentredNaturedResources DisIsomof Water R ources Rei tied Aligns'?u1t