Mecklenburg_Well Abandonment_20240814 (5)

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
NN'ELL CONTRACTOR CERTIFICATION# 4169-B
1.WELL CONTRACTOR: 5. WELL DETAILS:
Roy Charles Killian a.Total Depth 100 ft. Diameter:6 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 43 ft.
UES Professional Solutions 29,INC Measuring point is 0 _ft.above land surface.
Well Contractor Company Name
10121 Pineville Distribution St 6. CASING: Length Diameter
Street Address
Pineville NC 28134 a.Casing Depth(if known): ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
(980 ) 581-7105 7. DISINFECTION: 3 oz
Area code Phone number
2.WELL INFORMATION: (Amount of 65%75%calcium hypochlorite used)
8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable)
Cement 240 Ib. Cement lb.
COUNTY WELL PERMIT #(if applicable) Water 150 gal Water aal.
�. •'�• �';.�-'����-,
DWQ or OTHER PERMIT #(if applicable) Bentonite
Bentonite lb. A rr
WELL USE (Check applicable use): Monitoring ✓ Residential Type: _ Slurry Pellets AUU 2U24
M unicipal/Public Industrial/Commercial Agricultural Water gal. n,._�y�.;:'.it
Recovery Injection Irrigation p Other (,�f:•'J _-7
Other(list use) Type material
Amount
3.WELL LOCATION:
COUNTY Mecklenburg QUADRANGLE NAME
NEAREST TOWN: 11601 Trails End Lane Huntersville,NC 28078 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Neat Cement 9rnut was nlarari intn the well frnm the surfarp via 2"
treemie pipe.The well was completely filled with approximately
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel.Zip Code) 150 gals.A 6"concrete plug was placed over the abandoned well.
TOPOGRAPHC/LAND SETTING:
Slope Valley ,/Flat Ridge Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 35 ° 23 5.9700 DIMS OR 3X.XXXXXXXXmD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 80 °48 44.2600 "DMS OR 7X.XXXXXXXXVD types of fill materials,sed
Latitude/longitude source: i63PS Qropographic map 7/31/24
(location of well must be shown on a USGS topo map andattached to 11• DATE WELL ABANDONED
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well.skip 4a,complete 4b,well owner information only)
FACILITY ID# (if applicable) I � '14 - ate.: I 7/31/24
NAME OF FACILITY SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wbersonall�ebandons his/her residential well
in accordance with 15A NCAC 2C 0113)
4b.CONTACT PERSON/WELL OWNER: Roy C. Killian
NAME Shea Homes Carolina LLC PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 10130 Perimeter Pkwy STE 300 Charlotte NC 28216
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, Form GW-30
1617 Mail Service Center, Raleigh,NC 27699-1617,Phone : [phone] Rev.5/10

A.-
ti!
Capped with a 6" thick concrete plug
o
6'' Steel Casing,
With a total
depth of 100 ft
filled with neat
cement grout
approximately
150 gals.
Figure 1 11601 Trails End UESWell Ln Well
Abandonment
Abandonment
Diagram
10121 Pineville Distribution St
SCALE: NTS
UES Project No.: A23117.02498.000 Pineville,NC 28134

1W Li L.L AISA1N VU.NMLIN'1' KL+UO" For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
s�a C'a b L K, t" 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
q&) l ' wells abandoned:
NC Well Contractor Certification Number 7b.Approidmate volume of water remaining in well(s): (gal.)
c6 2 liX ni d 6 t U FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
Us(all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if knouht
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural OMunicipal/Public EVNeat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
Olndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Olrri ation ❑Specialty Grout ❑Gravel
No Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
Zonitoring ❑Recovery :
Injection Well: 7f.For each material selected above,provideamol., of xtsttu alb used:
OAquiferRecharge OGroundwaterRemediation
❑Aquifer Storage and Recovery OSaiinity Barrier
Mt
OAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7 .Provide a brief description of the aban tidient tm;,
OGeothermal(Closed Loop) OTracer
OGeothermal(Hearin Coolin Return) OOther(explain under 70 t X Pirl d— I n rX /f _
4.Date well(s)abandoned: 7 q
r
5a Well location: J��� G�
Facility/Owner Name Facility ID#(if applicable) S.Certin tion:
Physical Address,City,and Zip t i of Ce ified Well Co tmctor or Well Owner Date
pG/t— By sighing this form, I hereby cenify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Constnictioh 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:
(if well field,one la/long is sufficient) 9.Site diagram or additional well details:
` 7{� 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 SUgMWA,INSTRUCTIONS
Attechirellcmrstractiarrecord(s)ifat,ailable.For audliple injection or non•trruersuppb,wells
ONLY with the same cottsinrciiohJabmtdotunetit,you colt submit one forms.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: W v _ abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1-14 M.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Z (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface (@,) Division of Water Resources,Underground Injection Control Program,
r� 1636 Mail Service Center,Raleigh,NC 27699-1636
V
6e.Outer casing length(if known): -3 6 00 10c.For Water Sunnly&Iniection Wells: In addition to sending the form 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 where
6G Inner casing/tubing length(if known): 0 (ft.) abandoned.
111-1,4
6g.Screen length(if known): r ✓7 U (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

VV t'rLld HDAINVVINIVMIN I K.LU-URU For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
r loco b Z_ e 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
`/ 2 J^) 1 + wells abandoned:
NC Well Contraacctorr Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
C O Z 0- XO'0(-Q�K)rN FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well catstraction permits(i.e.UIC,County,State,Variance,etc.)Il'knorwt
7d.Amount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7e. ealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic C7 Neat Cement Grout ❑Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
Oindustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Collings
❑Irri ation ❑Specialty Grout O Gravel
Non;}Nater Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
@Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation -
OAquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control 7 .Provide a brief description of the aband6hiient' ;.gprocedured r'
❑Geothermal(Closed Loop) ❑Tracer ,�
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 ) /'►/rl l� �)�r //1 Q 0(.r /1'1 •
t-f-np C eln&l 1CO LAL d erns G
4.Date well(s)abandoned: 7`/S Z�
!Uu u C C
5a.Well location: T
Facility/Owner Name Facility IDN(if applicable) 8.CertifieatiOn:
1'0 r.L);C'J CJ
Physical Address,City,and Zip nature of Certified Well Contmclor or Well Owner Date
/ `" d c By signing this fotirt, 1 hereby certify that the well(s) was(urere)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constriction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and drat a copy of this record has been provided to the well owner.
(if well field,
one lat/Ilonng iis,sufficient) 9.Site diagram or additional well details:
N w D� 7 37 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anaclnrellcartstractiatrecord(s)ifavailable.Fornadliplelnjeaionornon-nYuersupplt urUs
ONLY with the sauce cominrcdionlabandonment,you can submit one fonu.
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: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Z 10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (R,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): / r (ft.) 10c.For Water Sunoly&Infection Wells: In addition to sending the form 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 where
6f.Inner casing/tubing length(If known): (R,) abandoned.
6g.Screen length(if known): / 6 Zv!) (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

a ailA-3L1\111J1\1ViL'1\1 AVU' For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
a(-Ct b 1-- )(, )�-C. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
W l A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s): (gal J
G 6 Z �x U��(Q��c FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable urll construction permits(i.e.UIG Comity,State,Variance,etc.)if lvrown
7d.Amount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7e.,Seaiing materials used(check all that apply):
❑Agricultural OMunicipal/Public D/Neat Cement Grout ❑Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout O Dry Clay
❑Industrial/Commercial DResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout O Gravel
N Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
znitoring (]Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery OSalinity Barrier '
OAquifer Test OStormwater Drainage —
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment pr�'cenitlte:'
❑Geothermal(Closed Loop) ❑Tracer / n
❑Geothermal (Heating/Cooling Return) ❑Other(explain under] )
C em cyNu 1-1 Al'4- p r-2111
.
4.Date well(s)abandoned:
So.Well location:
Facility/Owner Name 1 //Facility ID#(if applicable) S.CertiH tion:
Physical Addrc;s.City,and Zip tute of Certified ell Contractor r Well Owner Date
By signing this fonn, I hereby certify that the well(,) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constriction Standards
and that a copy of this record has been provided to the it-ell owner.
5b.Latitude and longitude in degrees/ininutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
f� N I �(� �3?s' W
7 You may use the buck of this page to provide additional well site details or well
7 J / abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMYPTAL INSTRUCTIONS
Aitac6 well construction records)ifarailable. Forntnitiple injection ornon-unier'sapply u-ells
ONLY with the saute carstrnctiot✓abandonmen u can t,yo submit one fomr.
109. 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: Z (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (;n,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (n,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c,For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (fL) 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
6f.Inner casingitubing length(if known): (ft) abandoned.
6g.Screen length(if known): d (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016