Sampson_Well Abandonment_20241101

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- 1. 4.N.,9 WELL ABANDONMENT RECORD
a - - U te°' North Carolina Department of)nvironment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 6. WELL DETAILS:
LiOl((S `-( ,� if a.Total Depth: / ft. Diameter: c in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): cr ft.
\Zf=q 64e r^ L3 ci( Lb Measuring point is 3 ft.above land surface.
Well Contractor Company Name 1 r
STREET ADDRESS �A` `.3 lJ .,f l ieL1 6. CASING: Length Diameter
/*f1 e( 2 '3 "
�� � •'l/ �1 a.Casing Depth(if known): ft. in. .
City or Town - State Zip Code b.Casing Removed: - ft. in.
(.91O )- .27 -3/2C
Area code-Phone number 7. DISINFECTION: b. •
2.WELL'INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
-- SITI AVGLL ID#(if applicable) R" - - - S. SEALING-MATERIAL: - _
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement. lb. i' Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. ; Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite '
WELL USE(Check applicable use): IIE(Monitoring 0 Residential Bentonite ,a L) lb.
❑ Municipal/Public ❑ Industrial/Commercial 0 Agricultural Type:❑Slurry [}Pellets �.>
Water /tb gal. !l � .r a
❑ Recovery ❑ Injection ElIrrigation T
Other • NQ'V'i 1 2024
❑Other(list use) -
Type material , . .IG:Q. ,:i:!7:: r'-r TI•-
3.WELL LOCATION: Amount
. COUNTY CSQUADRANGLE NAME
NEAREST TOWN: "`(�C i^ 2 9. EXPLAIN M THOD OF EMPLACEMENT OF MATERIAL:
3t lJl ptillr3C,i'1ec 3!lS f..l,,Z'',4 �/Ve-J/
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) J •
TOPOGRAPHIC/LAND SETTING:
['Slope ❑Valley @-REF ❑Ridge❑Other '
(Check appropriate setting) j
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
— ---- /�-F ---May-bein degrees,---- - ---=--form showin total de0%depth-mid-diameterl of scieens if-an remainm T LATITUDE -3� �P IO Ift]]� minutes,seconds,or in a g p y} l g
LONGITUDE -')Al, �3 g3?' decimal format in the well,gravel interval,intervals of casing perforations,and depths and
types of fill materials used.
Latitude/longitude source: Ken S 0 Topographic map
(Location of well must be shown on a USGS topo Wrap and 11. DATE WELL ABANDONED 4)-- .r- •1 f
attached to this form if not using GPS.J
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH I5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) j n
NAME OF FACILITY i =r(e, I\e 'Il�rolltd-i:er. 1 / '`t K„---�� f -.2f�-may
SIGNATURE C IF D WELL'CONTRACTOR .. DATE
STREETq ADDRESS 7 - A9Gascl pi-)
LL.5641 ..0 A ', it • , .
City or Town • State • , Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accord ccc with 15. NCAC 2 .0113)
. NAME -3 e..,,eCa (/ / ��""LCf >
STREET ADDRESS �r$',�'i_. pc T7rj l r,/ PRINTED ME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. f Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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EXPANSION PLUG. •.•
* BOREHOLE OIL e A . .
GEOLOGIST
* MATERIAL O.D.. --2-' ' ! STATIC WATER LEVEL 6.115 . •
MATERIAL TYPE fV 6 6g .. DATE MEASURED I li5/0(6
* SCREEN SLOT SIZE 0'DI6
* Dimensions in.
• Inches . . PROTECTIVE OUTER COVER
I "---1
2 't 7...' Comcfaerg__rzzedy,
"r4rdri der .tillil/ZAtif/dr "41/ !
• ..2A .4 0/. 1 .
I' . 7 .
-NATIVE' iNT,
. .
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, . .
GROUT . .. ,_ .. .
. ,.
. /
4 . DEPTH TO .TOP OF i
- BENTONITE °45
BENTONITE ' ' - •
DEPTH TO TOP OF
• -
. . . SAND 45i
1 • • - • -•-- - .
- -
- •
, .
. . DEPTH TO TOP OF , Log
• 1 -.- SCREEN -
SAND PACK 1 - - - 2 Ii•-• -
- 1. • . z- •
•
• i' -- . • . ,
-.:
. . ...
NOTES:
.▪. - •
- .
•
NOT TO SCALE . -• ' -ALL DEPTHS REFERENCED -.- - ---- -- -▪- • 1203 DEPTH TO BOTTOM OF •
FROM FINISH GRADE IN FEET :-: In :•: . .
. . . . . . . .SCEEN
. . . . . . , . TOTAL DEPTH 12,0/
-mum
MONITOR WELL . CW-4 R-4 I. -,,
•' LA 441. cAtquit-tb .
tohl 0 . • 1 - igaracaaiti
; DATE DRILLED 1 o , Zieldn0012'2. . tow() smiRsoN,, 0141T‘1) JC
DRILLING METHOD Ii. A •-; , . FROI. # 08-5D
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Y "s' WELL ABANDONMENT RECORD
:' North Carolina Department of Environment and Natural Resources-Division of Water Quality
• - WELL CONTRACTOR CERTIFICATION# .
1.WELL CONTRACTOR: 5. WELL DETAILS:
LIDk./8 ' \cs4— -3 a.Total Depth: f LZ ft. Diameter: in.
Well Contrdctor(Individual)Name
b.Water Level(Below Measuring Point): A et, ft.
e`s;`j1e� �1. ! O Measuring point is a ft.above land surface.
We 1 Cont actor CompanyName STREET ADDRESS C),2.1 t-43 C iN.C.. 1 tra y 1 ._CI 6. CASING: Length Diameter
S� Cll.'it• /v + ` 1.- �C+ a.Casing Depth(if known): ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
(-(7/)D)- ""_- /'7S'
Area code-Phone number 7. DISINFECTION: 6 c`-
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) R--,.5-4- 8. SEALING MATERIAL:
- --STATEWEL-L-.PERMIT.#-(ifapplicabley -- `— - --Neat ement----- - an+1T'---Srmeiit "` ` _- - ---
-- Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite '
WELL USE(Check applicable use): ®monitoring . ❑Residential Bentonite 3 lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry BPellets
Water J'5 gal.
❑ Recovery 0 Injection ❑ Irrigation
Other
❑Other(list use) ..:NOV 0 T 202•t
�
Type material ,
Ill. '..i...1 .l.r�R^.^!
3.WELL LOCATION: V Gl�-;: ; '`"::
Amount ;r +.:;;�
COUNTY..Sejui.r.3011QUADRANGLE NAME
/
NEAREST TOWN: 1::,T- r.V 9, EXPLAIN ETHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope ❑Valley al-Flat ❑Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
Mayin degrees,
LATITUDE /• 7 2 J be form showing total depth,depth and diameter of screens(if any)remaining
minutes,seconds,or in a
decline/fonmiat in-the-well,-gravel interval,-intervals'of-casing-perforations,.and-depths-and-
--- -LONGITUDE -7 5//2G}�7:57;7� types of fill materials used.
Latitude/longitude source: GPS 0 Topographic map
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED /40`--2 k.---2 t-1
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable)
NAME OF FACILITY f A sr j No Pod tire. i't ��� / L� cs''2 y
STREET ADDRESS 7(Er� Y'94D S TUR OF•CE IFIE WELL CONTRACTOR DATE
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15A CAC 2C.0113.)
PE
NAME �]C.s eI� ' )C )/ _ / kyd. A `Ctir?�
STREET ADDRESS -25s/d o�q+50 ( / J PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and time original to the Division of Water Quality within 30 days. 1 . Form OW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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EXPANSION PLUG . , .. . . .
Iti• . • , ' . , .
P 1/,
* BOREHOLE 0-.D - : 1/4,,.,- -• • \
•-•/
GEOLOGIST
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* MATERIAL O. J. Z. 6 , STATIC WATER LEVEL 1,0
MATERIAL TYPE . I'J f -97 DATE MEASURED • lill /7-009
* SCREEN SLOT SIZE 0'0)0 ' •
* Dimensions in . I . .. '
- -- Inches ,
-•;,-- - - : , -_ _ PROTECTIVE OUTER. COVER
..• I — ' / FINISH GRADE
2'i(22 (00cREr _....:/ .
- ,/?,/ . , - . 1 , •• /,\/ A./ -
• ?A /./. '
NATIVE SOIL .
'N+, ' .-- - • - -. .. .. ,.
'. ',. ' . ' ' , . • , .. , .
. - I , ' ., •
' .
. ' . GROUT /
7 .. . - •-- 1
, • I . -
•• I 'I ' , . . .
,
. . .
1
<
I DEPTH TO TOP OF i ok
I
.. . BENTONITE ' •
BENTONITE
'. . \ DEPTH TO TOP OF 1 of. .
. . . ......_ . -, - ' - - - •
- •, ---. • -... _ • .- - .. -.- .•. SAD
- , •.• - '
.•.-
...
DEPTH TO TOP OF Li 1
.,. -•-- - - SCREEN -1 i°
. •. .
SAND PAC,K
• - =_.-- .3 •. .
-.--.•6----U..•-.
.
- - NOTES:
NOT TO. SCALE . . .
' . ALL ,DEPTHS REFERENCED . -'-'. - ':-..- DEPTH TO BOTTOM 'OF 1
. SCREEN ILI'D
FROM FINISH GRADE IN FEET . - '''••- c' • • •
TOTAL DEPTH 15..cf
MONITOR WELL K- s'a '14'
. Al-a"a cArtki 1 1-1(7 •
PRatocat. SAMPLING SERVICE. INC,
DATE DRILLED 11130/409 0 " •
- , • .18 • P.O. Box 31133 .. Tugte.ayi ..A(,•ips 0 14 (c 04-Ne1 LIC..
Raleigh, NC 27622
DRILLING METHOD 1-IcA : 0• • • . , PROJ_ # 08-50.
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1-1: .--= s WELL ABANDONMENT RECORD
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i l! ; North Carolina Department of Environment and Natural Resources-Division of Water Quality
" 1 WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5, WELL DETAILS: •
L)0 ,1 �j •L a.Total Depth: ft..Diameter: .j( in.
Well Contr ctor(Individual)Name b.Water Level(Below Measuring Point): ft.
Ze-41 ;,-{'e•t-1,�)ell �.0 Measuring point-is 3 ft.above land surface.
Well Contractor Company Name
STREET ADDRESSSt 1 l"/� UYIt' / �t^C. 6. CASING: Length ,Diameter
+\�' r-I )'. ). ,L ((-LS^Q a.Casing Depth(if known): ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
(9/D)- ` 3i '� /
Area code-Phone number 7. DISINFECTION: 6 D
2.WELL:_INFORMATION:- ___ -- : _ __ _ _ _�Amountof65%75%calcium_h ypochloriteused)_ _ __�
SITE WELL ID#(if applicable) AZ--'3 `~ L.
SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. • Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable)lie) Bentonite t
WELL USE(Check applicable use): L-14-titoring 0 Residential Bentonite Wit, l lb.
❑ Municipal/Public ' i?w' ry-^;�--\�•�'` -
p , 0 Industrial/Commercial ❑ Agricultural Type:❑Slur Er 4 ,�,.C,,;,�_ ' ?_� J',`1 N
Water I,.5 gal. ..
❑ Recovery 0 Injection.• 0 Irrigation . NOV j 1 202,q
Other `F
❑Other(list use)
Type material •• r ma's:'
3.WELL LOCATION: Amount
COUNTY_5'4.'o4p:SutIQUADRANGiy..NAME !
NEAREST TOWN: /Li t(`I(,L` 9. - EXPLA,�METHOp OF /MPLACEMENT OF MATERIAL:
.3=2 6 1 e_OLi Con '1 (-) ,,29ctvred.,___ 6 c,...7 .
(Street/Road Name,Ntunber,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope ❑Valley lot ['Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
04 f / /_ May-beindegrees, —- - --1-'
LATITUDE 1 CL tP! form showing total deptVdepth and diameter of screens(if any)remaining
minites,seconds,or in a
LONGITUDE--It��3 decimal format in the well,gravel interval,intervals of casing perforations,and depths and
types of fill materials used.
Latitude/longitude source: S 0 Topographic map �t� -: C
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED
attached to this form tf not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH I5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(Ifa residential well,skip 4a;complete 4b,well owner information only.) .THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) - 7, s,-at�
NAME OF FACILITY - SIGNATUR C�D WELL CONTRACTOR DATE
STREET ADDRESS 756— 1V,t�.�`/�-C �: JJ�'
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
- (The private,well ownier must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: ' • _ • in accordance with 1'SA NCAC 2C. 113)'
� tv-
NAME C '.•P3 ty/ C ) r'( ' CCre
STREET ADDRESS "7 r /�,6 l- t -e#.1 PRINTCNA OF PERSON ABANDONING THE WELL
1 ,
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. 1 Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06
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MONITOR WELL SCHEMATIC•
i.
EXPANSION PLUG, .
tf
* BOREHOLE O.D. _ _ 2 1GEOLOGIST
* MATERIAL O.D. • I + STATIC WATER LEVEL 8'11C+
MATERIAL TYPE NC + 6i\___DATE MEASURED 11J5J0?
. * SCREEN SLOT SIZE 0,1716;
LOCK
* Dimensions in ' •
Inches - PROTECTIVE OUTER COVER
J MISR GRADE
2',t2.' topE— /
xArtvE 80u, ...II
_ ,
i �/
i , _. ,
(• GROUT 1 4
1
V . .
, .
4 7
..
i DEPTH TO .TOP OF I
BENTONITE '''
BENTONITE ' ks.
j ,:,.\ DEPTH TO TOP OF i
SAND A
DEPTH TO TOP OF
SAND PACK j _ .-
• SCREEN S.°
•
{ . • .
NOTES: .
NOT TO SCALE -- - — _
•ALL DEPTHS REFERENCED ' = - DEPTH TO TOM OF IS-'
- - 1 0,
_ BOTTOM
FROM FINISH GRADE IN FEET, 15,o
• , - TOTAL DEPTH
..
MONITOR WELL (V1�-,5 R-3 —..
_.... .. ._. . ALLe� CANtiil��
{ bJ3����_ J PRGjC1C{SV SAHPLiNfi SERVICE' �iyf
DATE DRILLED a P.a Eox 3U33• U 1 EY s PJO 1 (00. i uC
DRILLING METHOD H SA s4terst�, rcc 27622 i
'1 • PROJ. # 0$-50
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I FL5 s WELL ABANDONMENT RECORD .
�� �i r�9:' North Carolina Department of Environment and Natural Resources-Division of Water Quality
�. ; •
'''--r. WELL CONTRACTOR CERTIFICATION# 1 ,
1. ft
WELL CONTRACTOR: 5. WELL DETAILS: 1
"�I`OL C'1 lit ACV" .-- a.Total Depth: /cS . Diameter: a in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 6 ft.
g Conti
j i 5.-le r U e e,t) Measuring point is 3 ft.above land surface.
Well Conuiactor Company Name �
STREET ADDRESS • iV, e f*i . C( 6. CASING: Length Diameter
4-- -(''._ ' ) ' ` , a.Casing Depth(if known): ft. - in.
• City or Town State Zip Code b.Casing Removed: ft. in.
(It/D )- A�5 '-3F-2,-S
Area code-Phone number 7. DISINFECTION: 16 0 e
2.WELL INFORMATION: /� (Amount of 65%-75%calcium hypochlorite used) _ _
SITE WELL ID#(if applicable) R-a, f7 -g- SEALING MATERIALc _ l`
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): O.-Monitoring ❑ Residential Bentonite .. 4 lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry [E1'bllets
Water //.S gal. Y ,. ,.,:A.=., q,, P,
❑ Recovery 0 Injection 0 Irrigation
❑Other(list use) Other NO V 1 2024
Type material In,-,'.,,...i..^: a-r _
�i' "�- �
. 3.WELL LOCATION: ~
Amount
COUNTY S 3O r^QUADRANGLE NAME
NEAREST TOWN:1 1�t,,4..,C key
9. EXPLAIN ETHOD QF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge❑Other
(Check appropriate setting)
p 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
1.-C LATITUDE , 2OV(rr May be in degrees,
minutes,seconds,or in a form showing total depth,depth and diameter of screens(if any)remaining
—LONGITUDE "2 8 A` D'--decimai_format __ in the well,-gravel interval,interyals_oLcasing perforations,-and depths and-
_ _ 33 types of fill materials used.
Latitude/longitude source: m-GPS 0 Topographic map ,,� �/
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED' /() ;:2 --,...2L/
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) tt �i { �
NAME OF FACILITY SF.-tl13-N3'ste.1L) RO LI.C.7i'I}r-t Ci---•-' /0 -2 Y.
•
� rr�� NATUR F CE FIED WELL CONTRACTOR DATE
STREET ADDRESS '7,5j'.S� ,D V e ,A —60 CW L
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER:..-. 0 in actor ann e with 1 A NCAC .0113.)
NAME ,5 et))( - • 6-k yd e,
STREET ADDRESS ) JO e.j a tA 0 f L�J� PRINTED AME OF PERSON ABANIDONING THE WELL
I ,
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

1
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,
MONITOR WELL SCHEMATIC '.:•i
'I
EXPANSION PLUG. .
1�fJ •
BOREHOLE O.D. %2 GEOLOGIST.
* MATERIAL O.D. 2'• STATIC WATER LEVEL b,501
MATERIAL TYPE PJ4 f— ^/ j
�( 89
* SCREEN SLOT SIZE 0. 06' i DATE MEASURED �h' �
I
LOCK
* Dimensions in
Inches GRAZEPROTECTIVI'; OUTER COVER -
/,'I f�� g jf
E'CoGRET — �//
';',/\// \/,,, I nwe4r413,4111)/r44 iro,",,,,,,o- ./y/ ",/,,
NATIVE,SOIL
I j� '
j '
GROUT 0
0
1
roj
1
..
IDEPTH TO TOP OF I
BENTONITE (5
BENTONITE
•
l.
DEPTH TO TOP OF 1
• SAND 11 S
DEPTH TO TOP OF 2 0
SAND PACT = SCREEN
NOTES:
NOT TO SCALE -
ALL DEPTHS REFERENCED — DEPTH TO .BOTTOM OF I
FROM FINISH GRADE IN FEET o SCREEN
�2
' I - - •- TOTAL DEPTH 13.0'
MONITOR WELL �,.28 ' • Ai-LE1, CA'N.uIIJ(7
} �3Q�.?�o9 pRorac'OL„SAMPLING SERVICE. INCH
DATE DRILLED _ 1 ei • P.O. Box 31133' Tuw ey s psoN cov m' uG
DRILLING METHOD H SA 1 •• • 1
Rn[elgh, NC 27622 .
PROJ # O8-5g
,
.
1

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f ii.1 „s WELL ABANDONMENT RECORD
„.-LL�„ ° sr) North Carolina Department of Environment and Natural Resources-Division of Water Quality
--`J WELL CONTRACTOR CERTIFICATION#
1.WELLt CONTRACTOR: 5. WELL DETAILS:
1 C' idJ cL;'��j a.Total Depth: -S� ft.'Diameter: in.
Well Contrdetor(Individual)Name b.Water Level(Below Measuring Point): ,2(..-( ft.
"Re!,i51j-e f Z-k( 0 Measuring point is ...-- , ft.above land surface.
Well Contactor Company Name f
STREET ADDRESS 2 I 4) ei Lf tr i �QC/ 6. CASING: Length Diameter
IPGSC f\j I I ) )t 6• c -8.- a.Casing Depth(if known): ,2O ft. ,2 in. •
City or Town State Zip Code b.Casing Removed: ft. in.
(°A ) )- S1-3i-2S
Area code-Phone number 7. DISINFECTION: �, O C.
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
--SITE-WELL-ID#-(if-applicable)- --, Q--7_'____ _. __ _ ' -8.-_SEALING-MAT-ERIAL:---; ;
STATE WELL PERMIT#(if applicable) _ Neat Cement I Sand Cement
Cement lb. Cement lb. •
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
•
WELL USE(Check applicable use): [Q'koiritoring ❑ Residential Bentonite �� lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry a ets _
Water i gal. = ;' ;-
❑ Recovery ❑ Injection ❑ Irrigation �x. � i, r
A �,.•,
Other
❑Other(list use) lJ0`/ 1 L�2�
Type material `t
3.WELL LOCATION: If,fv M�.i r
Amotmt L `
COUNTY 5'..y�pSot‘ QUADRANGLE NAME _:�
I NEAREST TOWN: _---. 'C
9. EXPLAIN MET OD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope ❑Valley Erfc ❑Ridge❑Other
(Check appropriate setting)
ey /�/ 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE ' , , 9s `7dG 1 Maybe in degrees, form showing total depth,depth and diameter of screens(if any)remaining
_ __ _ nunutes,seconds,or in a_ _-_ _ —_—
/ decimal format in the well,gravelaifterval,intervals of casing perforations,and depths and
LONGITUDE ���J �3 types of fill materials used.
Latitude/longitude source: 0 GPS 0 Topographic map 1 •
(Location of well must be shown on a USGS topo snap and 11. DATE WELL ABANDONED /D` �� 4
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner infonnation'only.) THIS RECORD HAS BEEN P OVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable)
-E /°f, /o-2saLI
NAME OF FACILITY ._ -0.1.1')-Vn V-rE• ):id7 ,,,;?t-tout civ.; i
,1 ht AT RE CER ,IED WELL CONTRACTOR DATE
STREET ADDRESS ' N I.e a�`1— _0 t'[-63 9� uc �cit iJ.� a 5
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WEL
/L
OWNER: in accordance1 with 15A NCAC 2C.0113.)
NAME �Csl,vt.•�� G( DX , Ot.C1 .M rk,r e-
STREET ADDRESS 7 it - ,V^.6 �2 iNks �i�(l PRINTED N ME OF PERSON-ABANDONINGTHE WELL
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Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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, WELL CONTRACTOR CERTIFICATION# 1
1.WELL CONTRACTOR: 5. WELL DETAILS: i -
L\o r eu c3 a.Total Depth: \7 i ft Diameter: in.
Well Contctor(Individual)Name /� _ b.Water Level(Below Measuring Point): ,_) ft.
e�is4 Cf"W Z 11 ( Measuring point is ft.above land surface.
\\ell Contractor Company Name
STRREETT `ADDRESS �6�i L) ell ( 6. CASING: Length Diameter
' ten "`t l i ,n ;. fU (-I1'l 58 a.Casing Depth(if known): 7,-51t. a- in.
City or Town State- Zip Code b.Casing Removed: ft. _ in.
(40 )- o2 `
-3 s iv �z
Area code-Phone number 7. DISINFECTION:
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
p �
SITE WELL ID#(if applicable) / \ 8. SEALING MATERIAL:
I
STATE WELL PERMIT#(if applicable) _ ._ Neat Cement j�l4Sand Cem ent -
-- — -- -- — Cement Ib. 1 Cement lb.
•
COUNTY WELL PERMIT#(if applicable) Water gal.: Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
n
WELL USE(Check applicable use): t onitoring ❑ Residential Bentonite ,Lj lb.
❑Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry ellets T
Water /� gal. T� z-..t• k_'' ,Fr'' T'
❑ Recovery 0 Injection 0 Irrigation , A R 3v P
Other NOV ti 1 20
24
❑Other(list use)
Type material
• : - G". :. k ' ,
, Rr
3.WELL LOCATION
-++ • Amount ,a ya
COUNTYai,i t1 QUADRANGLE NAME .
NEAREST TOWN: •
S`�S T �(r� � �g� 9. EXPLAIN MET OD�OEMPLACEMENT OF MATERIAL:
PI 'Po 6 \10 t-,) lv
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope 0 Valley EMI" 0 Ridge❑Other
(Check appropriate setting)
_ 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
Maybe in degrees,
LATITUDE 3_9 .9 ?, 9S form showing total depth,depth and diameter of screens(if any)remaining
minutes,seconds,or in a in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE'• ?�,- p' ..a p © decimal fonnat gp
�� — types-of fill materials useds �.-=-
Latitude/longitude source: 0 GPS 0 Topographic map 9
(Location of well must be shown on a USGS lopo map and 11. DATE WELL ABANDONED / �� (--(
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS,ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH I5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable)+► y� t ` le) OZ�
NAME OF FACILITY Stvl l t'li�•Ctl J Imo e `thciGt 1`an GNATU ,O ERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS ?as &- 2 q 9-6 /4,3y
City or Town State Zip Code - SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15A NCAc 2C.0113;)
NAME ' tt".S ` .el. f✓,/o (( AA&refg
PRINTED&AME OF PERSON ABANDONING THE WELL
STREET ADDRESS 7�Sik.. . Ltcl--CD )1,-)y p
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Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS: i
�I / � � r
`�' 1'�'l Ectr t� • a.Total Depth: /-� 'ft. Diameter: in.
Well Conti-actor(Individual)Name b.Water Level(Below Measuring Point): 7 ft.
i. m)e.�' 0 di _O. Measuring point is . ft.above land surface.
Well Cofitractor Company Name �"
STREET ADDRESS ��1 t) n 9\ek,r�k .�c I 6. CASING: Length Diameter
eetse-kdt .e a �s� a.Casing Depth(if known): ; ft. in. .
City or Town State Zip Code b.Casing Removed: ft. in.
(gib )- .2 5-,-3%`7S'
Area code-Phone number 7. DISINFECTION: 6, p
2.WELL INFORMATION: (Amount of 65%75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 1 -
8. SEALING MATERIAL: • ,
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water • gal. ' Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): E 1IInitoring 0 Residential Bentonite ag of lb.
❑ Municipal/Public ❑ Industrial/Commercial 0 Agricultural Type:0 Slurry)Pellets s 4.ha-. :'f1',
Water ) gal. NOV❑ Recovery ❑Injection El Irrigation ry V �1 2024
Other
❑'paler(list use) •�;
Type material { .,, vy
d'u
3.WELL LOCATION: . Amount • • •
COUNTY .`e, e(i_QUADRANGLEf NAME
NEAREST TOWN: r/c Ps./ 9. EXPLAIN METHOD OF MPLACEMENT OF MATERIAL:
3-)-()I Caw 6 to go po t,,.f`GC ,'Ski d bi y
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
0 Slope 0 Valley 11-Rat" 0 Ridge❑Other
(Check appropriate setting) •
10. WELL DIAGRAM:Draw a;detailed sketch of the well on the back of this
LATITUDE May be in degrees, _ form showing total depth,depth and diameter of screens(if any)remaining
/� �l minutes,seconds,or in a in-the-well, -interval,intervals-of-casin erforations,.and.dethe and .
LONGITUDE " Sit v`-7�� decimal format — g 1 g p P
—— types of fill materials used.
Latitude/longitude source: LaJ••GPS 0 Topographic map
(Location of well must be shotrn on a USGS topo map and 11. DATE WELL ABANDONED t� ^r '4 `I
attached to this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
• FACILITY ID#(if applicable) ,` 'r
NAME OF FACILITY e) 3t`.eeI llaaj ` c�1.tC+il7t-1. � � FfE L /� �'�y
�> ,/ / r7 r / A A U OF C I DWELL CONTRACTOR DATE
-`" STREET ADDRESS ?J5 it ie... v2�I¢" "� go •
`� 1 -
• e,i SCt t int A). ` s-.3 t'
City or Town State - , - Zip Code ' - SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
• • (The,private well owner must be an individual who personally abandons his/her residential well
• 4b.CONTACT PERSON/WELL OWNER: - in accordance with 155A NCAC .0113.)
NAME 3,. v-�.(-.3 en/ ^�y Lk(',( CQ6 4
STREET ADDRESS ?)5 ./V�0 S (1 LJ I`` � PRINTED NAME OF PERSON ABANDONING-THE WELL
{ •
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. ! Form GW-30
Attn:Information Management, Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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MONITOR WELL SCHEMATIC
EXPANSION PLUG.
�11
* BOREHOLE O.D. OI2 GEOLOGIST
* MATERIAL O.D. STATIC WATEER LEVEL 10—_
MATERIAL TYPE PSG I `� I DATE MEASURED 1115/0 el •
* SCREEN SLOT SIZE D,A10 1)
* LOCK
Dimensions in 1
_.._�_ _. �- _ _ Inches I PROTECTIVE OUTER COVER
2`(2J• /...,. (°NGR�TE_i :". •
O , •
�:rnsx GRADE
--„,„„r,i4r,- /
- ,, 0
NATIVE ion I �j,!r/,�
4
GROUT
I
DEPTH TO •TOP OF 1
{ BENTONTTE v+5
BENTONITE
DEPTH TO TOP OF
SAND•
1,Sr
_- DEPTH TO TOP OF 2 ,
•
SAND PACK - — _ .
SCREEN 'O
—_ •
1 ^+ ---
NOTES: j _ e . .
NOT TO SCALE _ •
ALL DEPTHS REFERENCED - - DEPTH TO BOTTOM OF
FROM FINISH GRADE IN FEET ;I - - - - ...TO AL �ZCIiEEN f1'o'
R-1 T DEPTH .._
MONITOR WELL C1f V- '� f , , •
�•m••r
PRLITDCOL SMtPL1HG SERVICE INC; AL-LEi CANJ.11t.&
(•. DATE DRILLED b r'31 lO. „ PS Box 3tt39 U ' �AMPJD H C ocJfp i' l.1G
DRILLING METHOD J4 Rnielgh NC 27622• ) 1
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b 1 'elBELOSZ£B I B i Kdd 1O3O10Nd WUEE:0 I 8002 Sa now

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". WELL CONTRACTOR CERTIFICATION# -
1. ,{
WELL CONTRACTOR: 5, WELL DETAILS:
�
�'/v y(� u ,fi)rC'S a.Total Depth: D ft J Diameter: -2 in.
•
Well j wti"C6ntractor P �. (Individuaal)fNamee •
b.Water Level(Below Measuring Point): fi ft.
j Aref- 1 I CD, Measuring point is f ft.above lane{surface.
Well Contractor Company Name
STREET� ADDRESS of I 1/I Ciicar`:1), Rd 6. CASING: Length Diameter .
C _5e 1:'f .44 C. V y El a.Casing Depth(if known): ' I g ft. in.
City or Town State Zip Code
b.Casing Removed: ft. in.
• ( l!0 )- PqA9`7 `3i`>5 6 'a.
Area code-Phone number 7. DISINFECTION:
2.WELL INFORMATION: , (Amount of 65%-75%calcium hypochlorite used)
i.
- SIT.E_WELL-Illigi£applicable)_ _t5
--8. SEALING-MATERIAL: —
-
I;
STATE WELL PERMIT#(if applicable) Neat("ement �' Sand Cement
Cement lb. . Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
•
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): VerVIonitoring 0 Residential Bentonite 6 lb.
❑ Municipal/Public Type •: ll._=' , fi ' •
p ❑ Industrial/Commercial ❑ Agricultural YP ❑Sttlun� ellets ��-F;,_,.i,,,,,.'" . i. :�•.. .
❑ Recovery ❑ InjectionWater /'', 3 gal. "
0 Irrigation NOV ti 1
Other - 2024
❑Other(list use)
• Type material .`y;,<.--
3.WELL LOCATION: Amount
•
COUNTY $ i'1?JQ(1 QUADRANGLE NAME •
NEARESTTOWN:I T^Irttr
��p� ��^ n�1 rl 3� C
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
3__y r 9 5 May be in degrees,
_LA1'!T_I7DE �_- 7_ r form showing total depth,depth and diameter of screens(if any)remaining
-—nunutes;seconds,-orin-o—-•—--�-- - --
LONGITUDE 7 S r . 1 tit 53 decimal format in the well,gravel interval,intervals of casing perforations,and depths and
— — types of fill materials used.
Latitude/longitude source: 12r6cS 0 Topographic map '„ L.
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED /L/,_ i('
attached to this fora:if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF '
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable)
Cz�---- �!/-vim a
NAME OF FACILITYS6V7r�A :Ei(� 1�J pl 7 (gC`�.�� _(,,,� -�� �=,'' /
e� f SIGNATURE PIED WELL CONTRACTOR DATE
STREET ADDRESS / SS ,�C t2lf 5) /TLii f
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual,who personally abandons his/her residential well
4b.CONTACT P�E-RSON/WELL OWNER: in accordance! f(e with 15AA.NCAC2C.0113.)�
NAME l C1'')N Co); '-` (//J .-- 4,..—eSj
STREET ADDRESS /A7S V a', (4450' /J ry PRINTED E OF PERSON ABANDONING TILE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. I I Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] est 568. Rev.5/06
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-- WELL CONTRACTOR CERTIFICATION#
I.WELL CONTRACTOR: 5. WELL DETAILS: i
lie( 1 -k r a.Total Depth: /th ,ft.'Diameter: in.
Well ContYactor(Individual)Name b.Water Level(Below Measuring Point): ft.
le€ 4c r ,ell e_o Measuring point is ft.above land surface.
Well Co tractor Company Name f
STREET ADDRESS '2)./ L.A..) ff 1'1L%1'14-`/ �l:C/ 6. CASING: Length Diameter
OS 'r 4/ /(),L enr' r" a.Casing Depth(if known): ft. in. .
l City or Town State Zip Code b.Casing Removed: ft. in.
(q/O )- ;--2.-S'/ 7
Area code-Phone number 7. DISINFECTION: .
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
_____ _SITE lVELL ID#-(if applicable) 4- 9 - _ 8. SEALING MATERIAL: .
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
COUNTY WELL PERMIT II(if applicable) Water
Cement gal.lb. WaterCeme I gal.
Water_ gal.
DWQ or OTHER PERMIT#(if applicable), Bentonite
WELL USE(Check applicable use): [i1Monitoring 0 Residential Bentonite -2 H lb. .
0 Municipal/Public 0 Industrial/Commercial El Agricultural Type:0 Slurry [[�.Peflets < '(, ,Q;.C._.. _' s•• i
Water ), gal. i,.,,1..2
0 Recovery ' 0 Injection ❑ Irrigation NOV , 1 2024
Other
0 Other(list use) -
Type material `" e ,'�L ..�.u'�_ s'J
3.WELL LOCATION: Amount
COUNTY ,,.,, ' QUADRANGLE NAME
NEAREST TOWN: l 1s_Y e lit
` , 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
3D-if, I ? ;'Qt4f,,n ' cI -3-2 VCkx,r- QI ,S'!e,it)k/
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope 0 Valley at 0 Ridge❑Other
(Check appropriate setting)
- --- 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
?? jj t - May be in degrees, form showingtotal depth,de'th and diameter of screens(if any)remaining
JY��� IP� � minutes,seconds,or in a p p
- -decimal-format -__-- •in the_well,_gravel_intecval,-intetvals.o£casing.perforations,.and�lepths,and- �-_�
..LONGITUDE--:'MRS ^5"7.3 types of fill materials used.
Latitude/longitude source: Ll'GPS 0 Topographic map '
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED �C/v2c 1
attached to this form if not using GPS.) f
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) 1 I �I 1 1
NAME OF FACILITY�r`+1 t�2qq ![T.. I7 j�S(yy.`ll'Ls''Cnit'jpa� � CE IP[E13\V CONTRACTOR / DA ti
TE
STREET ADDRESS 'DS--- .,�45L-- 0 4{4—�� �T1� 1
Ceres61.3.-
. A),Q "Z ,13--
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with.15A NCAC 2C.0113I)
�� ,>! . L40�JCI PA^ems
NAME J�ti. ej 5 Ito ee-� y_ — rl
STREET ADDRESS 7& N C. . C` y�� PRINTED AME OF PERSON ABANDONING THE WELL
i
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. ' Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699,1617, Phone No.[phone]:ext 568. Rev.5/06

MONITOR. WELL SCHEMATIC
. EXPANSION PLUG.
g 1z GEOLOGIST
* BOREHOLE O.D. I
* MATERIAL O.D. Z STATIC WATER LEVEL 8,�
MATERIAL TYPE P,/G; Y- DATE MEASURED 1 I 2-009
* SCREEN SLOT SIZE o. Din L\ LOCK
* Dimensions in PROTECTIVE 'OUTER COVER
Inches
FINISH crone
2' 2' Co1.IGRE-TE_..._�
n>,� SOIL f
. , . X
,�
GROUT
— / �
DEPTH
C TO TOP OF• BENTONITE 2'o
BENTONITE
N . DEPTH TO TOP OF I
SAND 3,b
•.-
DEPTH TO TOP OF 0 1
x ".-- SCREEN Ir°
SAND PACK -
.•: fir:•:
NOTES: i • = :.
NOT TO SCALE = DEPTH TO BOTTOM OF
ALL DEPTHS REFERENCED 1 I:_ SCREEN ��'a
FROM FINISH GRADE IN FEET _ : • _°. _ - . TOTAL DEPTH 15.fl'
MONITOR WELL 1;k` 9 AL.L tL CAN.kJIll&
11 . pRo-roCQL sAHPLING SERVICE. INC,
DATE DRILLED 11 f 30h -009
Tu I, APSo-1 (UUNO, UG
s RPLe 322
DRILLING METHOD NSA _
PROJ. # 0$-5Q.

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� WELL CONTRACTOR CERTIFICATION# '
1.WELL CONTRACTOR: 5. WELL DETAILS:
L\10\1(, ACtr'5 a.Total Depth: f 5/ ft. Diameter: in.
Well Contractor(Individual)Name( • • b.Water Level(Below Measuring Point): 7 ft.
'ec.45 7-`-r 1.34 --0 Measuring point is _ft.above land surface.
Well Contractor Company Name �+ /
STREET ADDRESS � �`-� t `rt cn y ��1 6. CASING: Length Diameter
`20.Se i,dI /0l lQ- c3, 5-11 a.Casing Depth(if known): ft. in. .
City or Town State Zip Code b.Casing Removed: ft. in.
(q)0 )- oZ31- 2il3
Area code-Phone number 7. DISINFECTION: OF
2.WELL INFORMATION: y � (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) � �'^ `� 8. SEALING MATERIAL:_ _ __ - __ __-----
-
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) ' Bentonite
. WELL USE(Check applicable use): [ icIonitoring 0 Residential -Bentonite .2.S lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:❑Slurrx- ellets --: -'' . ; , 9
Water ,� gal. ` t:...0 it =, , 't L
❑ Recovery 0 Injection 0 Irrigation
❑Other(list use) • Other NOV ti j 2024
- -
i.:
Type material “-,-.-,i , ...`r i:
.. ; :.
-
':l. 'J.9
3.WELL LOCATION: Amount
COUNTY 5_v...4O1 S - UADRANGLE NAME
NEAREST TOWN:11 -VAX-V'Lyy
SAL
9. E IN METH D OF .MPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
1
❑Slope 0 Valley ❑Flat 0 Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
L.I,,?3 9 2 C' May be in degrees, form showingtotal depth,depth and diameter of screens(if any)remaining
LATITUDE _ ` P P g
_ _minutes,seconds_or in a___,-�_ --
—_�</---1/09—0- decimal format to the well;giavel interval,'inte'rvals of casing perforations,and depths and
LONGITUDE i
types of fill materials used.
Latitude/longitude source: GPS 0 Topographic map
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED ,7-- —2
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITII 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) '` I r
NAME OF FACILITY fi r.-t i ,�,-e(cI !I eTOCI LI i b), G /(�-2�- t�
A fU' RF Df CE 'IFIED WELL CONTRACTOR DATE
STREET ADDRESS 7S S (L `-2`� l) )- L q
l.t ,,t,to ,Q -2t,3 4c
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT�-PPEERSON/WELLQW�NER: ` in accordance with ISA NCAC C.0113.) i '
NAME - 1ca.Y',C�v v`W(� r/ �(� t/49l! r'f-LS ,
STREET ADDRESS '7OJ'/".�- ; V HL3 PRINTED NAME OF PERSON ABANDONING THE WELL
i
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. i Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

. ..
. , . .. , .
'
•
• . • .M 0 NI IT 0 R WELL SCHEMATIC
• , .
. .. .
. • 1 . .
' EXPANSION PLUG. . .
' .
* BOREHOLE O.D. ev2 . GEOLOGIST
D i c•1
* MATERIAL 0.D. •Z . .. STATIC WATER LEVEL v"•••
MATERIAL TYPE P46 • <,— ''' P'1 DATE MEASURED 11/5/0e.
* SCREEN SLOT SIZE . 0'1)10 •
LOCK . .* Dimensions in
. . .
Inches _ PROTECTIVE MITER COVER
1 / MISR CRADZ
. 2!'eV et4VAZETE—eldeff • ilr I, . .
.. "1
. /.•/ s',/ - "o'r4e, 4411e. . AY
• 44 A//. '/A . AZ.
NATIPZ iOIL
. 0.4°1 • ., . . .
•
' • , .. . 0 • ,
. • .:.
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, • .
. . .: .; .
. GROUT 4
. ,./ , • • . . • ..
. . 1 • .
.. .
i .
. .
. ;
k. N.0
DEPTH TO.TOP TOP OF
g,0 I
BENTONITE
BENTON/TE
. .... .,. . sk . .
DEPTH TO TOP OF 9 i
' . . . .
. . _ . _
. , . ... - --.•. DEPTH TO TOP OF
•
- SCREEN
..•. • •_-_
SAND PACK .-.
. , . .
..- 1W_•-7.,--.. . P •
_-: 4I _
.%
.. ' ::: :::
NOTES: -.- ,.• -.• . •
, .... .. . . ,, . • , . .
, - - BOTTOM OF
. .. _ r . •
-:ALL DEPTHS REFERENCED i
;
DEPTH TO
•
• Ill. • • i ' • SCREEN I5P
FROM FINISH GRADE IN FEET - '
;, • P • • • • If • • TOTAL DEPTH :
4
MONITOR WELL 64,.. fiR-8 • •.. '. • 11.1-, . :. ..., _........ .ALElsi. CANklirl7
-.1‘i''';''•-", DATE DRILLED 1°411°g- ,&72c. tn.psziA.mpi.90nouswEri.vicE. irtc,
URICEY p4piat covvY;LIC•
Raleigh, NC 27622 ),
DRILLING METHOD 1.16•A • • • PROJ. # Of3-50 -
AMMO......nallagm
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6 01 861.09286T6 XU1103010Nd WU2C:OT 6002 90 now •
- •

a,Y SrAreE,,^,.
s/// b �_ ` "s WELL ABANDONMENT RECORD '
\'j - s i North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:1 5. WELL DETAILS:,r
L6.tel �Y e._S a.Total Depth: / ft. Diameter: r2 in.
Well Contradtor(Individual Name b.Water Level(Below Measuring Point): '7 ft.
R f_c.j -3' U.)t_k( C'—') Measuring point is .3 ft.above land surface.
Well Cont actor Company Name \ }
STREET ADDRESS .7 1! ej,�� C,,r;itL/)2J •6. CASING: Length Diameter
12P?Se fl•-_J'' e2"1J/-s a.Casing Depth(if known): ft in.
City or Town State Zip Code b.Casing Removed: ft. in.
( e)1O)- 6 - 3()S
Area code-Phone number 7. DISINFECTION: (9 D
_2,MELLINEORMATION:_ _ Cf _ - _ (ALountof65%75%ocalciutnJtypocltlorite_tsed)___________
SITE WELL ID#(if applicable) t &'d /' y 8. SEALING MATERIAL: 1.
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
' Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. . Water gal.
DWQ or OTHER PERMIT#(if applicable)ic� Bentonite
II
WELL USE(Check applicable use): 'bl�onitoring 0 Residential Bentonite ( lb. ,
❑ Munici aUPublicType:
p. 0 Industrial/Commercial 0Agricultural yp El ellets
❑ Recovery El Injection El Irrigation Water ,�S gal. NOV d 1 2024
Other
El Other(lisfiise) .r '
Type material . r;•-„• i:.3
3.WELL LOCATION: . Amount
COUNTY _,...vp.SQ., QUADRANGLE NAME
NEAREST TOWN: a4-:e 9. EXPLAIN METHOD F EMPLgCEMENT OF MATERIAL:
fX
(Strcet/Road Name,Number,Community,Subdivision,LotNo.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope ❑Valley at ❑Ridge❑Other
(Check appropriate setting)
`, Q 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE---TN-
ATITUDE— `7 `/7 - seconds,
rees,__-,__- ---
�73—� --form-showing-total total depth,depth,and diamefe�oof screens(if any)`remammg
/ minutes,seconds,or in a in the well,gravel interval,intervals of perforations,and depths and
LONGITUDE �[ �i'ILI decimal format dasing P
types of fill materials used.
Latitude/longitude source: GPS ❑Topographic map
(Location of well unist be shown on a USGS topo map and 11. DATE WELL ABANDONED`-:_z Ci
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH l5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) II_, �t J
NAME OF FACILITY fTn5-t'eIi �-!U \`rye.Lee.t► (J✓I SIGNATURL+'OF C \ CONTRACTOR /O`--T2 i`
STREET ADDRESS 7 A G ,2 Lk D Rks '- .
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING TIIE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with I5A NCAHC.0113.)
NAME '-c `s C f3j( ( lfJt/d —A-4 Gerd---.' ,
STREET ADDRESS '7 )0 e, ,4 >T` o �W 1PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

n H i �
1
.
f . ..... a...
t
MONITOR WELL SCHEMATIC
' EXPANSION PLUG. -
I
* BOREHOLE O.D. e 12 GEOLOGIST
* MATERIAL 0.D. Z• v STATIC WATER LEVEL 6'
MATERIAL TYPE PJG 4- fitrI I 6,,,, DATE MEASURED 11/S1O$
* SCREEN SLOT SIZE 0'aka
* Dimensions in LACK
In ci t.es , PROTECTIVE OUTER COVER
Tnnsli CR.MIE
af le 2.1 Cootrarris'__40,40W/Fils; •
/ / .' *'4 V Zi e7/#4;4' ,j 0 f''. . 7/ V,
WIVE SUIT. I ,�r /� ��
•.1. /
1 1
•
GROUT •
4,14 DEPTH TO.TOP OF• •
BENTONITE d'S
BENTONITE
DEPTH TO TOP OF
i'S SAND
DEPTH TO TOP OF
SAND PACK 1 _ SCREEN �4°
F. ,
. s
NOTES: ' = .
NOT TO SCALE _
.BALL DEPTHS REFERENCED DEPTH TO" BOTTOM OF 12
FROM FINISH GRADE IN FEET - - .SCREEN
,. . . . . _ _ . TOTAL DEPTH lx.o
MONITOR WELL Cam- $ } �-�-EN, CAI�U llfi�f(�
t. DATE DRILLED Ohl 108 eROTOCOL S(INPLING s Ryllx'."INC,
• P.Q. Box 31i 3' U `( s PJON COU�T1' UG
DRILLING METHOD NSA ' . rIP Raleigh, NC a7622 1
,. T..d BEL09296 T 6 XFid 70001ONd WW72:0 T 8002 92 now

`ice
s<>F
s �.. WELL ABANDONMENT RECORD
- t-
„V.1 t .. North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS: �/
_ID,y(CI .' &CC(' j' a.Total Depth: /'d ft. Diameter: in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): / ft.
is-1-c \Ze(1 6Q Measuring point is ft.above land surface.
WeCont/actor Company Name
STREET ADDRESS 'T) ) W e__,ICe.ri)y �('- 6. CASING: Length Diameter
i 5('I-1(1/ 0 te a3 s a.Casing Depth(if known): ft. in. .
City or Town State Zip Code b.Casing Removed: ft. in.
( 1ID )- g9'7-3)'15 �
Area code-Phone number 7. DISINFECTION: e) Ot✓
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) li t,,,5' .-6 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): ❑ Monitoring ❑ Residential Bentonite 2s✓ lb. 1.4 c-
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry PEllets ['•
Water 4 gal. r�O V d 1 [G 24
[
❑ Recovery 0 Injection 0 Irrigation
Other
❑Other(list use) In`v .. :^ , ',
Type material f'' ;, ;3-3
3.WELL LOCATION: Amount
COUNTY.e,,,,., OfQUADRANGLE NAME 1
NEAREST TOWN: -RI keki
a ` �L�lt 9. EXPLAIN METHOD�OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope 0 Valley [=}'Flat 0 Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
• LATITUDE I.6
�� G�!-5JQ s May be in degrees,
minutes,seconds,or in a form showing total depth,depth and diameter of screens(if any)remaining
— decimal-format ---__ --tn the well,-gravelimerval,intervals_of casimperforations,_and depths_and__
LONGITUDE '7 7 OO —
types of fill materials used.
Latitude/longitude source: 1'S- ❑Topographic map
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED /69-0.�0 L/
attached to this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(FACILITY
applicable)S� .,,, I�1f, / f > /2) %Z y
NAME OF FACILITY �yt.t ji1+,�;PfC! ��rI[tC �Ota SIGNATUR ,IE WE L CONTRACTOR DATE
STREET ADDRESS .7S5• AZ .2 11 'ism ll-6)l"
1,062I5(4 A),e 393'
City or Town State • Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
- . (The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WE/JLL OWNER: - -in accordance with ISI NCAC C.0113.)
NAME ,,.., `�7�e r (q� ( ,,, .i�c
rlie
STREET ADDRESS 7.- / �.aLi ►.�U N"0 r) 1'RINTED,1lAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

(; -
' MONITOR WELL SCHEMATIC_ '.
,,
EXPANSION PLUG. -
Ift
* BOREHOLE O.D. ev2 GEOLOGIST
* MATERIAL O.D. 2 . STATIC WATER LEVEL S•65r
MATERIAL TYPE p46 o ~
- DATE MEASURED 1115 f U 1a
* SCREEN SLOT SIZE 0•DIb'
LOCK
* Dimensions in '
Incthes PROTECTIVE OUTER COVER
FINISH GRADE
2.1 4 7-.1 Comazerc_el, A . //7 .
. .47%,/ :<, -**711;47,0014111116p.'A r Z ,e''-' 7 N.‹,
/•NATIVE Son g / /•�
/ •
jr
0
- /' , /
GROUT -
•
DEPTH TO .TOP OF I
BENTONITE "•O
BENTONITE ;
I
DEPTH TO TOP OF i
- - SAND f 10
1
- - DEPTH TO TOP OF , --
•
SAND PACK , ' ' SCREEN 'fl
s
- a
j
. iiiNOTES;
F
NOT TO SCALE ...
LE - =
-ALL DEPTHS REFERENCED - - -"='-- '-' DEPTH TO BOTTOM OF ,SQ1
FROM FINISH GRADE IN•FEET - o o EEN
• • - - - - TOTAL DEPTH f .MONITOR WELL cw-r R-6 •, ABLE '
h�
.. DATE DRILLED ��� �f d8
1 ?Rowan_ SAMPLING s6ivi E. i �i�&
Rn a BoxC31 622 UQke`�j stopibN cowry/UG
DRILLING METHOD HS4 . PROD. # oe--50
111S-
0I •d $EL092CST6 XHd 100010Nd Wuzc:oI 800E SE AQN