NCG510482_Rescission_20201209

Weaver, Charles
From: Weaver, Charles
Sent: Wednesday, December 9, 2020 7:23 AM
To: 'Wayne Watterson'
Cc: Brad Webb; Gonsiewski, James J; Mike Andrews
Subject: RE: Rescission of NPDES Certificate of Coverage NCG510482
Importance: High
Tracking: Recipient Delivery
'Wayne Watterson'
Brad Webb
Gonsiewski, James 1
Mike Andrews
Delivered: 12/9/2020 7:23 AM
The Division received your request to rescind the subject Certificate of Coverage (CoC). We do not
object to this request.
NPDES CoC NCG510482 is hereby rescinded, effective immediately. This message is to close the
file for the Division, and for your records.
If in the future your company wishes to discharge wastewater to the State's surface waters,
you must first apply for and receive a new NPDES permit.
If you have any questions concerning this matter, simply reply to this message.
PLEASE NOTE: as part of the Division's conversion to paperless communication, this email is the
only notification you will be sent regarding the CoC rescission. No hard copy will be mailed.
CHW
From: Wayne Watterson <[e-mail]>
Sent: Tuesday, December 8, 2020 8:33 AM
To: Weaver, Charles <[e-mail]>
Cc: Brad Webb <[e-mail]>; Gonsiewski, James J <[e-mail]>; Mike Andrews
<[e-mail]>
Subject: [External] rescission of general wastewater permit, certificate of coverage NCG510482
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good morning Mr. Weaver. Please confirm that you received the attached documents. We are anxious to close this
matter. Thank you and take care
Wayne H. Watterson, P.E.
Senior Engineer / Group Leader
1

S&ME
r�
8646 West Market Street, Suite 105
Greensboro, NC 27409 map
111 S M: 336.908.7653
www.smeinc.com
au I L r FOP Linkedln I Twitter I Facebook
vER5ATIIITV
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Weaver, Charles
From: [e-mail]
To: Brad Webb
Sent: Wednesday, December 9, 2020 7:24 AM
Subject: Delivered: Rescission of NPDES Certificate of Coverage NCG510482
Your message has been delivered to the following recipients:
Brad Webb ([e-mail])
Subject: RE: Rescission of NPDES Certificate of Coverage NCG510482

Weaver, Charles
From: [e-mail]
To: Mike Andrews
Sent: Wednesday, December 9, 2020 7:24 AM
Subject: Delivered: Rescission of NPDES Certificate of Coverage NCG510482
Your message has been delivered to the following recipients:
Mike Andrews([e-mail])
Subject: RE: Rescission of NPDES Certificate of Coverage NCG510482

Weaver, Charles
From: Microsoft Outlook
To: 'Wayne Watterson'
Sent: Wednesday, December 9, 2020 7:23 AM
Subject: Relayed: RE: Rescission of NPDES Certificate of Coverage NCG510482
Delivery to these recipients or groups is complete, but no delivery notification was sent by the
destination server:
'Wayne Watterson' (WWatterson(slsmeinc.com)
M
Subject: RE: Rescission of NPDES Certificate of Coverage NCG510482

ONTOOR
Kontoor Brands, Inc.
PO Box 21488
Greensboro, NC 27420
KontoorBrands.com
November 19, 2020
NCDEQ / DWR / Water Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Attention: Mr. Charles Weaver
Reference: Request to Rescind NC General Wastewater Permit
VF Jeanswear/Lee Apparel Facility
Certificate of Coverage NCG510482
1401 US 601, Mocksville, North Carolina
Dear Mr. Weaver:
Kontoor Brands, Inc. requests the above referenced general wastewater permit be rescinded. The groundwater
remediation system that discharged to surface waters under the permit is no longer in use. S&ME provided
documentation of the remediation system status to Mr. Jim Gonsiewski with the North Carolina Department of
Environmental Quality in a letter dated November 2, 2020. Mr. Gonsiewski stated in a letter dated November 9,
2020 (attached) that you should be contacted to request permit rescission. Please let me know if you need
additional information to rescind the general wastewater permit.
Sincerely,
r � Lk
Brad Webb
Director— Facilities & Equipment Engineering
Kontoor Brands, Inc.
1421 S. Elm -Eugene Street
Greensboro, NC 27406
cc: Jacky Spivey — Mocksville
Jerry Rhodes — Mocksville
Mike Andrews — Greensboro
Wayne Watterson — S&ME (Electronic Copy)
Jim Gonsiewski — NCDENR (Electronic Copy)
Attachment — NCDEQ letter of November 9, 2020

ROY COOPER
Covemor
MICHAEL S. REGAN
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
November 9, 2020
Mr. Brad Webb, Director — Facilities & Equipment Engineering
Kontoor Brands, Inc.
1421 South Elm — Eugene Street
Greensboro, North Carolina 27406
SUBJECT: Compliance Evaluation Inspection
NC General Wastewater Permit NCG510000 for Discharge of Wastewater from a
Groundwater Remediation System
Certificate of Coverage: NCG510482 for Kontoor Brands, Inc., Mocksville, Davie
County, North Carolina
Dear Mr. Webb:
Jim Gonsiewski of the NC Division of Water Resources (DWR) Winston-Salem Regional Office
(WSRO) visited your facility on October 12, 2020 to perform a compliance evaluation inspection
of your facility's groundwater remediation system. Details of that inspection are included in the
attached EPA Water Compliance Inspection Report.
It is our understanding that the remediation system at the facility operated until December 2004
when activity at the site was terminated due to a directive from the WSRO Underground Storage
Tank (UST) Section. It was determined that, based on the risk level of the site, it was not necessary
to continue remediation at the site. A No Further Action Letter was issued for the site on July 27,
2018 by the WSRO UST Section. At the time, VF Jeanswear decided to keep the permit current.
The following observations were noted during the recent inspection:
Is The remediation system unit has been disconnected but is still located on the site. In August
2018, the monitoring and recovery wells at the site were abandoned by a licensed driller. The
3-inch PVC effluent line that transported treated water from the remediation unit to a drainage
ditch which emptied into the site stormwater system was still in place. This line was capped at
the location where it discharged into the ditch on October 26, 2020.
It is our understanding that Kontoor Brands, Inc. wants to rescind this permit. A request for
recession of this permit should be made by letter to:
NC DENR / DWR / Water Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Attn: Charles Weaver
North Carolina Department of Environmental Quality I Division of Water Resources
Winston-Salem Regional Office 1 450 West Hanes Mill Road, Sulte 3001 Winston-Salem, North Carolina 27105
336.776.9800

If you have any questions regarding this matter, please contact Mr. Gonsiewski by phone at 336-
776-9704 or by email at iim.gonsiewskiCa ncdenr.gov.
Sincerely,
9xOW"by:
145849EMC94EA..
Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
Attachments:
1. NCG510000 General Wastewater Permit
2. NCG510000 Technical Bulletin
3. EPA Water Compliance Inspection Report
cc: Wayne Watterson — S&ME (Electronic Copy)
WSRO Electronic Files
Laserfiche Files

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C. 20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expires8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 IN 1 2 15 1 3 I NCG510482 I11 12 20/10/12 17 181r 1 191 S I 201 I
21III111 IIIIIIIIIII IIIIIII11IIIII IIIIII1II11 f6
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 CA ------ -------------- Reserved ---------- --------
671 I 701, J I 71 L] 72 I N 731 I 174 71 I I I I I I I80
I� LI I
Section B: Facility Data _LJ
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Dale
POTW name and NPDES permit Number)
02:15PM 20/10/12
16/11/21
VF Jeanswear/Lee Apparel Company
Exit Time/Date
permit Expiration Date
1401 US Hwy 601 S
Mocksville INC 27028
03:25PM 20/10/12
20/09/30
Names) of Onsite Representative(s)Ttles(s)/Phone and Fax Number(s)
Other Facility Data
Name, Address of Responsible Oi(cialTtle/Phone and Fax Number
Contacted
Mike Jenkins,1401 US Hwy 601 S Mocksville INC 27028//336-936-2107/3369362149
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit 0 Facility Site Review
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Names) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Dale
Jim J Gonsiewski Do�asieaed by: DWR/Division of Water Quality/336-776-9704/
��11/10/2020
E
Ei1B]B68FFF1179D45F__
and Fax Numbers Dale
Signature of Management Q &R,%viegigin.
,iinLaw 'r 5m1w 11/10/2020
F�Agency/Office/Phone
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#

NPDES yr/mo/day Inspection Type (Cont.)
I NCG510482 Ill 1 20/10/12 17 18ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Jim Gonsiewski of the NC Division of Water Resources (DWR), Winston-Salem Regional Office
(WSRO), visited the facility on October 12, 2020, to perform a compliance evaluation inspection of the
facility's groundwater remediation system.
The remediation system at the facility operated until December 2004 when activity at the site was
curtailed due to a directive by the WSRO LIST Section. VF Jeanswear decided to keep the permit
current. A No Further Action Letter was issued for the site on July 27, 2018 by the WSRO UST
Section.
The following items were noted during the inspection:
In August 2018 the monitoring and recovery wells at the site were abandoned by a licensed driller. The
remediation system unit was disconnected, but is still located on the site. The 3-inch PVC effluent line
that transported treated water from the remediation unit to a drainage ditch which emptied into the site
stormwater system was still in place. This line was capped at the location where it discharged into the
ditch on October 26, 2020.
The DEQ understands that the permittee wishes to rescind the permit.
Page#

Permit: NCG510482 Owner - Facility: VF Jeanswear/Lee Apparel Company
Inspection Date: 10/1212020 Inspection Type: Compliance Evaluation
Permit Yes No
NA
NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new
❑ ❑
0
❑
application?
Is the facility as described in the permit?
❑
❑
❑
# Are there any special conditions for the permit?
❑ 0
❑
❑
Is access to the plant site restricted to the general public?
0 ❑
❑
❑
Is the inspector granted access to all areas for inspection?
0 ❑
❑
❑
Comment: The remediation system has been shut down The monitoring and recovery
wells have
been abandoned and the effluent line from the remediation system was capped
off.
Page# 3

November 2, 2020
NCDEQ — Division of Water Resources
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105
Attention: Mr. Jim Gonsiewski
Reference: NPDES Permit Closure
VF Jeanswear/Lee Apparel Company, Inc.
Mocksville, NC
S&ME Project No. 4358-20-062
Dear Mr. Gonsiewski:
S&ME, Inc. (S&ME) submits this letter report on behalf of our client, Kontoor Brands, documenting tasks
performed to close out NPDES permit (certificate of coverage NCG510482) for the former groundwater
remediation system at the VF Jeanswear/Lee Apparel Company facility in Mocksville, North Carolina. These
services were performed in general accordance with S&ME's proposal 43-2000841, dated October 19, 2020.
Following e-mail and telephone correspondence between Brad Webb of Kontoor Brands, Jim Gonsiewski of
NCDEQ, and Wayne Watterson of S&ME in October 2020, and a site visit by Mr. Gonsiewski and Gary Simcox of
S&ME on October 12, 2020, Mr. Gonsiewski requested the following services be performed in order to close the
NPDES permit.
Install a glued PVC cap on the end of the discharge pipe for the remediation system and provide photo -
documentation.
2. Provide copies of monitoring well and recovery well abandonment forms and
3. Provide the date the groundwater remediation system was shut down.
Mr. Webb requested that S&ME assist in accomplishing these tasks and providing the appropriate documentation
to NCDEQ.
On October 26, 2020, Gary Simcox of S&ME mobilized to the site to install a cap on the end of the discharge pipe
for the former groundwater remediation system. The system had bene previously dismantled. The screen that was
in place at the end of the pipe was cut off and a 2" PVC cap was glued on in its place. Photographs documenting
this are included as Attachment I.
As described in S&ME's Free Product Recovery Report dated January 11, 2010, active remedial measures were
suspended by NCDEQ in December 2004.
S&ME previously abandoned the monitoring wells and recovery wells at the site on August 14 and 15, 2018. The
monitoring well and recovery well abandonment forms are included as Attachment II.
S&ME, Inc. 13201 Spring Forest Road I Raleigh, NC 276161 p 919.872.2660 1 www.smeinc.com

NPDES Permit Closure
VF Jeanswear/Lee Apparel Company, Inc
Mocksville, NC
S&ME Project No. 4358-20-062
Based on the information provided in this letter report, S&ME, Inc. on behalf of our client, Kontoor Brands,
requests the closure of the NPDES permit for the former groundwater remediation system at the VF
Jeanswear/Lee Apparel Company facility in Mocksville, North Carolina (NCG510482).
Should you have any questions concerning the information provided within, please contact us by telephone or
email.
Sincerely,
S&ME, Inc.
Bryan S. Wence
Environmental Project Professional
[e-mail]
Wayne Watterson
Senior Engineer
[e-mail]
Attachments: Attachment I — Photo Log
Attachment II — Groundwater Monitoring and Recovery Well Abandonment Records
cc: Brad Webb, Kontoor Brands
November 2, 2020 2

Attachments

Attachment I - Photo Log

NPDES Permit Closure
=0
VF Jeanswear/Lee Apparel Company, Inc.
Mocksville, North Carolina
SWE Project No. 4358-20-062
Photo Description
View of the discharge pipe prior to placing PVC cap.
INZiy +(
,r ,fr
..-
Photscription

Attachment II - Monitoring Well and Recovery Well Abandonment
Records

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.60" N 800 33' 04.75" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: MW-1
6b. Total well depth: 30.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 19.94 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 72 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 56.56" N 800 33' 04.83" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: MW-10
6b. Total well depth: 31.5 (ft.)
6c. Borehole diameter: 1.0 (in.)
6d. Water level below ground surface: 22.93 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 33 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 5.0 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.77" N 800 33' 06.45" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-11
6b. Total well depth: 31.5 (ft.)
6c. Borehole diameter: 1.0 (in.)
6d. Water level below ground surface: 17.81 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 53 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 5.0 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.69" N 800 33' 02.15" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: MW-12
6b. Total well depth: 34.5 (ft.)
6c. Borehole diameter: 1.0 (in.)
6d. Water level below ground surface: 24.12 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0'40 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 5.0 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.29" N 800 33' 03.15" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: MW-13
6b. Total well depth: 36.0 (ft.)
6c. Borehole diameter: 1.0 (in.)
6d. Water level below ground surface: 22.15 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 54 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 5.0 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.14" N 800 33' 05.64" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: MW-14
6b. Total well depth: 32.4 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 16.25 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 2' 63 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.78" N 800 33' 06.22" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-15
6b. Total well depth: 31.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 16.51 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 2'44 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.20" N 800 33' 04.36" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: MW-16
6b. Total well depth: 31.1 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 16.01 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 2'46 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.47" N 800 33' 03.17" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-17
6b. Total well depth: 31.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 20.18 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 85 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.49" N 800 33' 05.34" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: MW-18
6b. Total well depth: 40.0 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 16.85 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 3' 77 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 65 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.05" N 800 33' 04.69" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-2
6b. Total well depth: 30.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 21.95 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 39 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.95" N 800 33' 04.31" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-3
6b. Total well depth: 30.0 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 22.40 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 24 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.85" N 800 33' 04.31" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-4
6b. Total well depth: 30.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 20.28 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 67 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.02" N 800 33' 03.93" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-5
6b. Total well depth: 30.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 20.18 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 68 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.23" N 800 33' 05.08" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-6
6b. Total well depth: 30.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 19.80 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 74 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.82" N 800 33' 04.85" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-7
6b. Total well depth: 30.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 20.73 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 59 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.34" N 800 33' 05.39" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-8
6b. Total well depth: 30.5 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 16.85 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 2'22 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.92" N 800 33' 05.42" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-9
6b. Total well depth: 30.0 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 18.58 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 86 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 50 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.38" N 800 33' 04.64" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-1
6b. Total well depth: 32.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 20.71 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 7'45 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 215 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.51" N 800 33' 06.24" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-10
6b. Total well depth: 60.3 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 16.99 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 28.58 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 400 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.23" N 800 33' 04.88" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-11
6b. Total well depth: 64.5 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 18.80 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 30.16 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 425 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.39" N 800 33' 04.01" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-12
6b. Total well depth: 64.5 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 18.30 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 30.49 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 425 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.08" N 800 33' 06.55" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-13
6b. Total well depth: 59.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 16.98 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 27.73 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 400 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.45" N 800 33' 05.88" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-14
6b. Total well depth: 64.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 18.28 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 30.18 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 425 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.74" N 800 33' 05.28" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-15
6b. Total well depth: 59.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 18.15 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 26.96 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 400 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.88" N 800 33' 06.61" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-16
6b. Total well depth: 63.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 17.29 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 30.17 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 425 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.68" N 800 33' 03.74" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-17
6b. Total well depth: 62.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 21.00 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 27.06 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 425 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.85" N 800 33' 05.62" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-2
6b. Total well depth: 64.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 16.41 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 31.41 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 425 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.46" N 800 33' 05.67" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-3
6b. Total well depth: 66.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 19.08 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 30.97 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 435 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.88" N 800 33' 05.04" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-4
6b. Total well depth: 66.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 19.70 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 30.56 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 435 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.01" N 800 33' 04.16" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-5
6b. Total well depth: 67.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 21.15 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 30.26 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 435 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.23" N 800 33' 03.54" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-6
6b. Total well depth: 66.5 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 21.80 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 29.50 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 435 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.01" N 800 33' 06.03" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-7
6b. Total well depth: 66.5 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 18.65 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 31.58 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 435 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.29" N 800 33' 05.31" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-8
6b. Total well depth: 62.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 17.90 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 29.11 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 425 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.81" N 800 33' 03.62" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-9
6b. Total well depth: 60.0 (ft.)
6c. Borehole diameter: 4.0 (in.)
6d. Water level below ground surface: 22.18 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 24.96 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 400 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
• •
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.07" N 800 33' 05.27" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: S-1
6b. Total well depth: 15.3 (ft.)
6c. Borehole diameter: 1.0 (in.)
6d. Water level below ground surface: 15.22 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 00 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 3 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 57.95" N 800 33' 05.35" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: SVE-1
6b. Total well depth: 22.0 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 19.72 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 37 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 35 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.07" N 800 33' 05.09" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: SVE-2
6b. Total well depth: 23.4 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 19.31 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 67 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 35 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.28" N 800 33' 05.56" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: SVE-3
6b. Total well depth: 17.4 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 15.70 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0'28 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 20 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.41" N 800 33' 05.23" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: SVE-4
6b. Total well depth: 22.0 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 17.95 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 66 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 35 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.35" N 800 33' 05.45" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: SVE-5
6b. Total well depth: 14.0 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: Dry (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 00 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 20 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.02" N 800 33' 04.35" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: SVE-6
6b. Total well depth: 24.8 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 19.70 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 83 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 40 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 59.12" N 800 33' 04.18" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: SVE-7
6b. Total well depth: 26.1 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 19.50 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 08 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 40 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Gary Simcox
Well Contractor Name (or well owner personally abandoning well on his/her property)
2944-B
NC Well Contractor Certification Number
S&ME, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned:
5a. Well location:
VF Jeansware
8-15-18
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
1401 US-601 Mocksville, NC 27028
Physical Address, City, and Zip
Davie
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 51' 58.28" N 800 33' 04.61" W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. wen ID#: VE-1
6b. Total well depth: 56.0 (ft.)
6c. Borehole diameter: 2.0 (in.)
6d. Water level below ground surface: 22.28 (ft.)
6e. Outer casing length (if known):
6f. Inner casing/tubing length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 5' 50 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout N Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Bentonite 90 lbs.
7g. Provide a brief description of the abandonment procedure:
Backfilled the well casing with bentonite and hydrated.
8. Certification: "'z n
J/ 9-5-2018
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016