Forsyth_Well Abandonment_20230213

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: r WELL ABANDONMENT DETAILS
Rf ri/l e`i l l Y l- 1 de)(Q...{p� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Nalpre(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
9 D q 0 "- wells abandoned: llI
r'
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): iti A (gal.)
n
t C) L O i I i t�G� FOR WATER SUPPLY WELLS ONLY:
J s J ✓
Company Name Q' 1
7c.Type of disinfectaut used: Ic /!
2.Well Construction Permit#: A., A l; '
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 0 O Z
3.Well use(check well use): I ,
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 11 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) &]'Residential Water Supply(single) 0 Sand Cement Grout - 0 Dry Clay •
❑Industrial/Commercial ❑Residential Water Supply(shared) 'ncrete Grout • ' 0 Drill Cuttings
❑irrigation 0 Specialty Grout - 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
:Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount-.of materials used:
I .,.„.l )u P i p-,-.
i tip. 4_ f
❑Aquifer Recharge 0 Groundwater Remediation : �1 r.��4 i , 1 l- +' ^.�1.^ 'I }
:Aquifer Storage and Recovery 0 Salinity Barrier I F�D S 7 n
❑Aquifer Test ❑Stormwater Drainage L, L+
0 Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the:abandofiineutlpr..t1'eetlumc.1 3 l"riY i
❑Geothermal(Closed Loop) ❑Tracer ` / ;; +;},3
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) P)u,t b,n c� ec'Met tc� �� �CV-1 c tri / -'' p lot- !
;A-(v Wet( Ai cw '-lti . tele/( /y.'0Y .40
4.Date well(s)abandoned: / ' 3 I - a J
5a:Well location: ✓ . t I
r 2;w, pipes
RObb,< O1ett2;-W i
Facility/Owner Name Facility 11)/1(if applicable) 8.Certification: I.
i' i
i OA), Z;11AZ 1e1_ r,�3;,ts-1Ln SA!pn. A..IC ��-o � /ff.1t I .2-l-a2.3
Physical Address,I kCity,and Zip Signature o Certified Well Contractor or Well Owner Date i,
I-c Q scq.F By signing this forgeI hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 S'1-jjCAC 02C.0100 or,2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I •
(ifwell field,one latfiong is sufficient) 9.Site diagram or additional well details: •
3 6.197 9/‘0 N 0 p 0-301-/-1--7 v W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
P
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)tfavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well i
abandonment to the following: `•
6a.Well ID#: �� II
Division of Water Resources,Information Processing Unit, E
6b.Total well depth: t� 1617 Mail Service Center,Raleigh,NC 27699-1617 }
d (ft)
• 10b.For Injection Wells: In additionitoi sending the form to the address in 10a s
6c.Borehole diameter: & (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: , '.'
•
• 1 g
6d.Water level below ground surface: (D t (ft) 'Division of Water Resources,Underground Injection Control. Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
h I
6e.Outer casing length(if known): .L4 A (ft) 10c.For Water Supply&Injection 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
6£Inner casing/tubing length(if known): M A (ft) abandoned.
r
6g.Screen length(if known): /Ut4 (ft)
t
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i

II
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J. Michael Venable 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30'is needed. Indicate TOTAL NUMBER of
NCWC-2079-A •
wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 130 • (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium Hy pochlorite
7c.Type of disinfectant used:
10
2.Well Construction Permit#: `
List all applicable well construction permits(i.e.UN,Corms,State,Variance,etc.)ifkmonn 4"oZ
7d.Amount of disinfectant used:
3.Well use(check well use): . •
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural ❑Municipal/Public 0 Neat Cement Grout ❑Bentonite Chips or Pellets
El Geothermal(Ileating/Cooling Supply) ®Residential Water Supply(single) 0 Sand Cement Grout Mt Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) I Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring - - ❑Recovery •
Injection Well: 7f.For each material selected above,provide amount of4:materiafs used: „ i'
❑AquiferRecharge ❑Groundwater Remediation well mix - 2 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier F tl3 I a 1Ui13
❑Aquifer Test ❑Stormwater Drainage clean clay-9 yard
❑Experimental Technology ❑Subsidence Control
I, Irgc.,••i u;lz II Pt.-`.:JWnv,'rnr Ural
7g.Provide a brief description of the abandonment procedure:G dnr Q/13Ji:;
0 Geothermal(Closed Loop) OTracer i
OGeothennal(Heating/Cooling Return) ❑Other(explain under 7g) removed plumbing; dewatered;
chlorinated; filled with well mix to form
4.Datewell(s)abandoned; 2/8/23 plug; topped with clean clay
5a.Well location:
Daughters Properties LLC „
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4892 McCracken Rd., Kernersville, NC 27284 f � ,X- e- 2.
Physical Address,City,and Zip Signature of Certified Well Contractor or IVell Owner Date
Forsyth By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I•
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.134026 N -80.119569 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
— CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED- _ SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Form ultiple injection or non-water supply wells
ONLY with the same construction/abandonment,pm can submit one form.
10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 22 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
e�
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 20 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
14 Division of Water Resources,Un
derground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): - (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county, health department of the county where
6L abandoned.inner casing/tubing length(if known): (ft.)
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 For Internal Use ONLY:
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPTorClosedJLlop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GWF3 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:t
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLYWELLSONLY:
Company Name
W 1400523 - 7e.Type of disinfectant used: +
2.Well Construction Permit#: i,
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)if known
7d.Amount of disinfectant used:' -
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout M Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge •Groundwater Remediation 1/4 bag
❑Aquifer Storage and Recovery OSalinity Barrier
•
❑Aquifer Test _ ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
Poured bentonite chips down hole until reached surface.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
h
! F
4.Date well(s)abandoned: 1/1 3/2023 i ?t:i,,�,r-e c iI:
5a.Well location: FEB 1 S 2023
Former Salem Uniform Services Facility - - I, r
Facility/Owner Name Facility 1Dl1(if applicable) 8 tification: I tr—AA T
J Jr3OQ
4015 Cherry St., Winston Salem NC, 27105 4 `' U j 1/25/2023
Physical Address,City,and Zip t ature of Certified Well Contractor or'Well Omer Date
Forsyth County ,,
By signing this form, I hereby ceri�that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.01100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional wellidetails:
You may use the back of this page:Ito provide additional well site details or well
N W abandonment details. You may also;attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED 'I
Attach well construction record(s)if available. For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
ONLY with the saute construction abandonment.you can submit one form. 1•
FS 201 a 10a. For All Wells: Submit this;iform within 30 days of completion of well
6a.Well ID#: abandonment to the following: i'
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 47 . (ft.)
G 10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 .`� (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: n/a (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) IOc.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
.....— ,.,_.,.'r..-..c.,.,ne...,.,,,,o.,,,.r❑..,,i.,..,,,,..i.1 rl„ality-rlivicinn of Water Recnurrac Revised 7-77-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW J3O is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:r I 1
NC Well Contractor Certification Number 7b.Approximate volume of water remainingI in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
WI400523_ 7c.Type of disinfectant used:
2.Well Construction Permit#: i
List all applicable well construction permits(i.e.UIC.County.State.Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural 0 Municipal/Public 0 Neat Cement Grout M Bentonite Chips or Pellets
•
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge UGroundwater Remediation 1/4 bag 1
• ❑Aquifer Storage and Recovery OSalinity Barrier 1!
❑Aquifer Test _ ❑Stormwater Drainage - I
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer 11
Poured bentonite chips down hole-until reap
surface.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1 "'t'• • —., � a z s"a
— • �.tm,.:...7tr ;-@; rLi
ii
4.Date well(s)abandoned: 1/1 3/2023 FEB I S zuZ3
5a.Well location:
Intormt-Aion Pm a,z!ng Uri
Former Salem Uniform Services Facility -• - - Dt>fDl-'(l,
Facility/Owner Name Facility ID#(if applicable) 8.Certification: i
4015 Cherry St., Winston Salem NC, 27105 (,,,e- " , 1/25/2023
Physical Address,City,and Zip S afore of Certified Well Contractor or Well Owner Date
I.
Forsyth County By signing this form, 1 hereby certify that the well(s) was (were) abandoned in -
• County Parcel Identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N W You may use the back of this page to provide additional well site details or well
- --- abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS I_
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells I
ONLY with the same construction abandonment,you can submit one form.
FS 201 b 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: i;
Division of Water Resou ices,Information Processing Unit,
6b.Total well depth: 41 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I'
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 •5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1, •
n/a Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) i
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 1Oc.For Water Supply&IniectionIWells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

it
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 1 1
7a.For Geoprobe/DPT or Close�di Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G Wl-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:' 1 1
NC Well Contractor Certification Number 7b.Approximate volume of wate rI r maining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
t
Company Name 7c.Type of disinfectant used: i '
2.Well Construction Permit#: WI400523 .
!'
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)if known „ ,
7d.Amount of disinfectant used:, .
3.Well use(check-well use):
Water Supply Well: 7e.Sealing materials used(check'all'that apply):
❑Agricultural ❑Municipal/Ptiblic 0 Neat Cement Grout Al Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) . ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry , 0 Other(explain under 7g)
❑Monitoring ❑Recovery - . . - .
Injection Well: 7f.For each material selected above,provide amount of materials used:
0 Aquifer Recharge •Groundwater Remediation 1/4 bag ii
❑Aquifer Storage-and Recovery ❑Salinity Barrier 11
Aquifer Test - ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control I'
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer I!
.
❑Geothermal(Heating/Cooling Return) .❑Other(explain under 7g) Poured bentonite chips down hole until reached surface.
4.Date well(s)abandoned: 1/12/2023
rta I a 2023
5a.Well location: 1
Former Salem Uniform Services Facility - - I Inivirn eibn Pr1::c.w.c^.•!no Ur.. _
Facility/Owner Name Facility ID#(if applicable) S.Certification: DWQJOG
4015 Cherry St., Winston Salem NC, 27105 . (A— I .1/25/2023
Physical Address,City,and Zip Sign a of Certified Well Contractor ors Well Owner Date
Forsyth County it '
By signing this form, I hereby cert ij that the well(s) was (were) abandoned in -
County Parcel Identification No.(PIN) accordance with 1.511 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beeniprovided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 9.Site diagram or additional well'details: „-ei.
You may use the back of this page'to,provide additional well site details or well
N W abandonment details. You may also1.attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i.
Attach well construction record(s)ifavaitable. For multiple injection or non-water supply wells
ONLY with the same construction-abandonment,you can submit one form.
10a. For All Wells: Submit this I'form within 30 days of completion of well
6a.Well[D#:
FS 202a abandonment to the following: I:
Division of Water Resouces,Information Processing Unit,
6b.Total well depth: 55 (ft.) 1617 Mail Service Canter,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 1 .5 (in.) above, also submit one copy of thi form within 30 days of completion of well
abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: n/a (ft.)
1636 Mail Service Centeer,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection'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 countty health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
c,,,,.,rw_zn Morth Carolina Denartment of Environmental Oualitv-Division of Water Resources I Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY: I
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPTorClosed-Lolp Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30i is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:'
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): n/a (gal.)
•
Clarke Generations Drilling LLC • FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
W 1400523 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout PI Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout • 0 Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout i 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge (Groundwater Remediation 1/4 bag
❑Aquifer Storage and Recovery ❑Salinity-Barrier -
❑Aquifer Test ❑Stormwater Drainage e
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer .
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Poured bentonite chips doWh hole until reached surface.
li ;\.. f--ii..r` %o t
4.Date well(s)abandoned: 1/12/2023 v+ ""'�'
- FEB 1 r 20LJ
5a.Well location:
Former Salem Uniform Services Facility - - - I 1„f.r1-.1;,. .,,,trris<;.y:.2'42t3`Di2
Facility/Owner Name Facility ID#(if applicable) 8.C cation: v °'0
4015 Cherry St., Winston Salem NC, 27105 P„ 1/25/2023
Physical Address,City,and Zip Signature of Certified ell Contractor orlWell Owner Date
Forsyth County Bysigning thisform, I herebycerti that the well(s) was (were) abandoned in
� g fv'
County Parcel Identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: di<,•
You may use the back of this page provide additional well site details or well
N W abandonment details. You may alsotattach additional pages if necessary.
i. •
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells i;
ONLY with the same construction abandonment,you can submit one form.
FS 202b 10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
1
. Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 43 (ft.)
10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: Il
n/a Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 1Oc.For Water Swill/&Injection We
lls:ells: In addition to sending the form to the
address(es)above,also submit one co p'y of this form within 30 days of completion
• of well abandonment to the courty health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
•c...,.,raxr_Vh North('arnlina Department of Fnvironrnental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT-RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS ' •
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:' f 1
NC Well Contractor Certification Number 7b.Approximate volume of watir Iemaining in well(s): n/a (gal.) -
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:WI400523
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check,all that apply):
❑Agricultural 0 Municipal/Public 0 Neat Cement Grout Al Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty-Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry " 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge •Groundwater Remediation 1/4 bag
❑Aquifer Storage and Recovery ❑Salinity Barrier —"
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of'the abandonment procedure:
OGeothermal(Closed Loop) OTracer
Poured bentonite chips down hole until reached surface.
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned: y r �`"' j ___
Sa.Well location: l-t ` 2023
Former Salem Uniform Services Facility - lr.:'"':'•y° , ,k-.— ,.,, /r $
r
Facility/Owner Name Facility ID#(if applicable) 8.C frcation: , `;Ve QtsJG
4015 Cherry St., Winston Salem NC, 27105 C6e,
, 1/25/2023
Physical Address,City,and Zip Si t e of Certified Well- one tractor orgWell Owner Date
Forsyth County By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
di a-a"
You may use the back of this page ito provide additional well site-details or well
N W abandonment details. You may also.!attach additional pages if necessary.
I.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED p
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells I
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: FS 202c abandonment to the following: 1
I
li
Division of Water Resources,Information Processing Unit,
• 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 28 (ft.)
I '
10b. For Injection Wells: In addition to sending the form to the address in 10a
1 .5 above, also submit one copy of this farm within 30 days of completion of well
6c.Borehole diameter: (in.) I i
abandonment to the following: I
6d.Water level below ground surface: n/a (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one cop' of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) 1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:' I I
NC Well Contractor Certification Number 7b.Approximate volume of water remainingi in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY: _
Company Name
7c.Type of disinfectant used: .
2.Well Construction Permit#:
W 1400523
List all applicable well construction permits(i.e.UIC County.State.Variance.etc.)if known 1'
7d.Amount of disinfectant used:.
3.Well use(check well use): it
Water Supply Well: 7e.Sealing materials used(check!all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout M Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry r 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
• ❑Aquifer Recharge Groundwater Remediation 1/4 bag
❑Aquifer Storage and Recovery ❑Salinity Barrier .
❑Aquifer Test - ❑Stormwater Drainage '
0 Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Poured bentonite chips down hole until reached surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
r •
1/12/2023 - �_
4.Date well(s)abandoned: i `*,:.,�,z,,,,, .. ' `Rt'
I
s..z
5a.Well location: F tEi 1.S 2023
Former Salem Uniform Services Facility- I,
I Facility/Owner Name Facility ID/I(if applicable) 8.Ce •'cation: l lrtCIFi'bfl �^a��f �_'��"�g Il(i
4015 Cherry St., Winston Salem NC, 27105 c 1/25/2023
Physical Address,City,and Zip ature of Certified Well Contractor or Well Owner Date
Forsyth•County • ``
By signing this form. I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A IVCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i' ,
(if well field,one le/long is sufficient) 9.Site diagram or additional well details: ,gr e,
You may use the back of this page;'to provide additional well site-details or well
N W abandonment details. You may also'attach additional pages if necessary.
t .
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED ii
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
FS 203a 10a. For All Wells: Submit this',form within 30 days of completion of well
6a.Well ID#: abandonment to the following: ;l '
!I
Division of Water Resources,Information Processing Unit,
1617 Mail Service CelInter,Raleigh,NC 27699-1617
6b.Total well depth: 42 (ft.)
10b. For Infection Wells: In additlioti to sending the form to the address in l0a
6c.Borehole diameter: 1 '5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: I
6d.Water level below ground surface: n/a (ft.)
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Slunk/&Injection}I ells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): - (ft.)
M.N.-rt.r.,.,,c.,a n,.,.an..,P.,r nFFn,drnnn nral f)nality-Division of Water Resnnrres Revised 2-27-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-1 30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:'
NC Well Contractor Certification Number - 7b.Approximate volume of water remaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLSiONLY:
•
Company Name
7c.Type of disinfectant used: '
2.Well Construction Permit#:
WI400523
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known i
7d.Amount of disinfectant used:i
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that apply): •
❑Agricultural 0 Municipal/Public 0 Neat Cement Grout a Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout • 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation _ 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery .
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge lGroundwater Remediation 1/4 bag I,
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 1 '
❑Experimental Technology ❑Subsidence Control '
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
• Poured bentonite chips down hole until reached surface.
❑Geothermal(Heating/Cooling Return). ❑Other(explain under 7g)
4.Date well(s)abandoned: 1/12/2023 j' 6, , r. ,-,..
( 1-- ,`3 Y 2023
5a.Well location: 1,
Former Salem Uniform Services Facility f,,-4,, p ,.
Facility/Owner Name - Facility ID#(if applicable) 8.C 'f cation: 1: D'°0i,r OG
4015 Cherry St., Winston Salem NC, 27105 1/25/2023
li
Physical Address,City,and Zip Signature of Certified e I Contractor or Well Owner Date
Forsyth County 1,
By signing this form, 1 hereby certij5)that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
il
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: ti-•-,-
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also'attach additional pages if necessary.
1
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)iifavailable. For multiple injection or non-water supply wells ;i
ONLY with the same construction abandonment,you can submit one form. i
FS 203b 10a. For All Wells: Submit this!form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• 10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 5 (in.) 1 1
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
; I
6d.Water level below ground surface: n/a (ft,) Division of Water Resources,Undi rground Injection Control Program,
1636 Mail Service Center,l Raleigh,NC 27699-1636
•
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where -
6f.Inner casing/tubing length(if known): . (ft.) abandoned.
I
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 For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well.construction/depth,only 1 GV(-10 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of watei remainingi in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
;l 1
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
W1400523
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.)if known b
7d.Amount of disinfectant used:
3:Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check,all that apply):
❑Agricultural ❑Iviunicipal/Public - 0 Neat Cement Grout II Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 1; 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 1 0 Drill Cuttings
El Irrigation 0 Specialty Grout 1' 0 Gravel
Non-Water Supply Well: • 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge EIGroundwater Remediation 1/4 bag I.
0 Aquifer Storage and Recovery - - OSalinity Barrier
0Aquifer Test _ ❑Stormwater Drainage_ - .
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
Poured bentonite chips down hole until reached surface.
❑Geothermal(Heating/Cooling Retum)-_ ❑Other(explain under.7g)
it
° f .s ,. .�
- --1/18/2023- _~,,, ��
4.Date well(s)abandoned:
5a.Well location: 1-t d I 2023
I'
Fonner'Salem Uniform Services Facility InsiD rR:+::;:1 PrZ.;C:C ;J,3 ii '?
Facility/Owner Name Facility ID#(if applicable) 8. tifcation: !' DVVO.P3`
G
4015 Cherry St., Winston Salem NC, 27105 1/25/2023
Physical Address,City,and Zip ignature of Certified Well Contractor orIWell Owner Date
Forsyth County By signing this form, I hereby cerit61 that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
ii
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: II!
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: ,11 1,
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also,attach additional pages if necessary:
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For nntltiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form. 1
10a. For All Wells: Submit thisform within 30 days of completion of well
6a.Well ID#: FS 204a abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 49 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i '
C 10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 '`� (in.) above, also submit one copy of this'form within 30 days of completion of well
abandonment to the following: 1 j
Division of Water Resources,Un dl rground Injection Control Program,
6d.Water level below ground surface: n/a (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
l
l
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&IniectionWells: 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 ihealth department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Fnnn C:W-30 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV
7a.For Geoprobe/DPT or Close-dt-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:, I I
NC Well Contractor Certification Number 7b.Approximate volume of water r I remaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS'!ONLY:
Company Name 7c.Type of disinfectant used: i•
2.Well Construction Permit#: W1400523
List all applicable well construction permits(i.e.UIC,County.State,Variance.etc.)if'mown
7d.Amount of disinfectant used:'
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout I'1 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation .0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
0 Monitoring 0 Recovery l
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge •Groundwater Remediation 1/4 bag
❑Aquifer Storage and Recovery" OSalinity Barrier I '
❑Aquifer Test --_- _ ❑Stormwater Drainage
,
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the•abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Poured bentonite chips down hole until reached surface.
l
- - -1-/18/2023 ,,m' _ ..
4.Date well(s)abandoned: r3'k{s �
5a.Well location: 1-1.-:1 1 ,ti•
Former Salem Uniform Services Facility - - `- LJ���'
r:,
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1,T,r " ''t liif '>�
', „ �
v lliVQ/I.
9 jjr
4015 Cherry St., Winston Salem NC, 27105 l' Y1/25/2023
Physical Address,City,and Zip Si afore of Certified e Contractor or Well Owner Date
• Forsyth County l
By signing this form, 1 hereby certj that the wells) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has ben provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: .:9.
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS is '
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.
FS 204b 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 28 (ft.)
10b. For Injection Wells: In addition�to sending the form to the address in 10a
1•5 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
l
6d.Water level below ground surface: n/a (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) i
e,..-..rvi-in n red,f arnlina r)enartment of Fnvirnnmental t)uality-Division of Water Resnurcec 1 Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1,Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For GeoprobelDPT or ClosedLpop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:+ 1 i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 'I
2.Well Construction Permit#: WI400523
•
List all applicable well construction permits(i.e.U/C,County,State.Variance,etc.)if known
7d.Amount of disinfectant used:,
3.Well use(check well use): •
I`
Water Supply Well: 7e.Sealing materials used(check allithat apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 'I, 0 Drill Cuttings
_ 0 Irrigation 0 Specialty Grout 11 ' 0 Gravel • _
Non-Water Supply Well: 0 Bentonite Slurry j 0 Other(explain under 7g)
❑Monitoring ❑Recovery I; ,
ir
Injection Well: 7f.For each material selected above,'provide amount of materials used:
❑Aquifer Recharge Groundwater Remediation II
1/4 bag ,!
❑Aquifer Storage and Recovery ❑Salinity Barrier- P
❑AquiferTest_ . ❑StormwaterDrainage_
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Poured bentonite chips down hole until reached surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
...o ---
4.Date well(s)abandoned: Il - "' t�-�c 1- '
1/18/2023 -.#
t1
5a.Well location: ' r td 1 1 2023
Former Salem Uniform Services Facility if vi3F3�S� I PP;`C^^
Facility/Owner Name Facility IN(if applicable) 8.Cer'fication: nta.. " '"'3( rii
4015 Cherry St., Winston Salem NC, 27105 c t j; . 1/25/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth County By signing this form, I hereby certify that the well(s) was (were) abandoned in-
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100;or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lon sufficient) ll
g is 9.Site diagram or additional well details: °fr
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS I'
Attach well construction records)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction abandonment.you can submit one form. '
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: FS 205a • abandonment to the following: I.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I :
G lob. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1•`� (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: n/a (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ceni er,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one cody of this form within 30 days of completion
of well abandonment to the county' health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
•
" Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

lI
WELL ABANDONMENT RECORD For Internal Use ONLY:
l, '
1.Weil Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV
. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:
•
NC Well Contractor Certification Number 7b.Approximate volume of water emaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:•
2.Well Construction Permit#: WI400523
List all applicable well construction permits(i.e.(1/C,County State,Variance,etc)if known •
7d.Amount of disinfectant used:.
3.Well use(check well use): -
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout IB Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay •
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
_ 0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slur
ry ,' ID Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
li
❑Aquifer Recharge Groundwater Remediation
1/4 bag
❑Aquifer Storage and Recovery ❑Salinity-Barrier --- ,
1.
❑Aquifer Test __ ❑Stormwater_Drainage _
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer • Poured bentonite chips down hole until reached surface.
❑Geothermal(Heating/Cooling Return) ❑other(explain under 7g) --
4.Date well(s)abandoned: F tB i n
5a.Well location:
Inf.A-�,: a .,
Former Salem Uniform Services Facility - - - - - L;5 e, -a3G W "4
Facility/Owner Name Facility ID#(if applicable) 8. 'frcation:
4015 Cherry St., Winston Salem NC, 27105 �.' 1/25/2023
Physical Address,City,and Zip ignature of Certi red Well Contractor or Well Owner Date
Forsyth County
By signing this form, i hereby tern'that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: add-
.
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also'attach additional pages if necessary.
I.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the sane construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: FS 205b abandonment to the following: i
• Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 29 (ft.)
lOb.For Injection Wells: In addition!to sending the form to the address in l0a
6c.Borehole diameter: 1.5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
n/a Division of Water Resources,Underground I Injection Control Program,
6d.Water level below ground surface: (ft.) r i
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 1Oc.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copylof this form within 30 days of completion
of well abandonment to the county' health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) •
Form GW-30 North Carolina Department of Enyironmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY: I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV •7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:' l 1
NC Well Contractor Certification Number 7b.Approximate volume of orate rIemaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLYWELLSONLY:
Company Name 7c.Type of disinfectant used: • I
2.Well Construction Permit#:WI400523
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):- - -
1
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout v Al Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout I 0 Dry Clay
0 Industrial/Commercial • ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 1 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
0 Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge UGroundwater Remediation 1/4 bag jj
❑Aquifer Storage and Recovery - - OSalinity Barrier I.
❑Aquifer Test ._. _. .. _ ❑Stormwater Drainage II
• 1
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Poured bentonite chips down hole until reached surface.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1,
_ •
II
1/19/2023 - _- [ Y�,
4.Date well(s)abandoned: '• -
5a.Well location: " k 7+I'1
Fortner Salem Uniform Services Facility - - -- '- - i ' — �`�i
Facility/Owner Name Facility ID#(if applicable) 8.Certi tion: �C/l f icrT :is f[ta}r•-••• • }h p
4015 Cherry St., Winston Salem NC, 27105 c C r o`1/25/2023
Physical Address,City,and Zip Sigma re of Certified Well Contract. • 1••a Owner Date
I.
Forsyth County By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0,100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1,
1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: midi^
W You may use the back of this pagei'to,provide additional well site details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i'
Attach well construction records)iifavailable. For multiple injection or non-water supply wells
ONLY with the same construction abandonatent,you can submit one form. 10a. For All Wells: Submit this!form within 30 days of completion of well
6a.Well ID#: FS 206a abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I, '
10b. For Injection 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
6c.Borehole diameter: 1 •5 (in.) abandonment to the following:
'
n/aDivision of Water Resources,U1ndergroundI Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectio I Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
rr,.,,h r„nrna nenarrment of Environmental Ouality-Division of Water Resources i Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed I
-hoop Geothermal Wells having the same
Well Contractor Name(or,well owner personally abandoning well on his/her property) well construction/depth,only I GV1-I0 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:,
NC Well Contractor Certification Number 7b.Approximate volume ofwatei remaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.
Well Construction Permit II: W I400523 Type of disinfectant used: I .
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.)if known
7d.Amount of disinfectant used:I'I I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check Tall that apply):
❑Agricultural ❑MunicipalPublic 0 Neat Cement Grout ` E Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge EGroundwater Remediation 1/4 ba II
9 l ;
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage _
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracerI
Poured bentonite chips down hole until reached surface.
❑Geothermal(Heating/Cooling Return) - ❑Other(explain under 7g) _
4.Date well(s)abandoned: u '"`, ""' �� �-�' 1
r Ed
-"v
5a.Well location: r ��I��
Former Salem Uniform Services Facility - IrGc,riri cr) sad--,:arlv4tJ,-4!JO
fication: v;`e` '30 r "
Facility/Owner Name Facility ILO(if applicable) 8. �'`
4015 Cherry St., Winston Salem NC, 27105 1/25/2023
Physical Address,City,and Zip Signature of Certified Well Contractor r Well Owner Date
Forsyth County
By signing this form, I hereby certini that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i.
(if well field,one las/long is sufficient) 9.Site diagram or additional well details: .diEh-
N W You may use the back of this page to provide additional well site details or well-
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
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.
FS 206b tOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: „ '
II
Division of Water Resources,Information Processing Unit,
31 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
G 10b.For Injection Wells: In addition i,to sending the form to the address in 10a
6c.Borehole diameter: 1 •`� (in.) above, also submit one copy of this'form within 30 days of completion of well
abandonment to the following: , {
6d.Water level below ground surface: n/a (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft.) 1Oc.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
•
1,Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:' l 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
m Company Maine
7c.Type of disinfectant used:
2.Well Construction Permit#:
WI400523
List all applicable well construction permits(i.e.UIC,County.State,Variance.etc.)if known Ii
7d.Amount of disinfectant used:i I
3.Well use(check well use): p t
Water Supply Well: 7e.Sealing materials used(check;all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout- 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout I'l 0 Drill Cuttings
❑Irrigation 0 Specialty Grout j . ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry I' 0 Other(explain under 7g)
❑Monitoring ❑Recovery I
Injection Well: 7f.For eeach material selected above,provide amount of materials used:
❑Aquifer Recharge EIGroundwater Remediation 1/4 bag 1.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage . . -
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Poured bentonite chips down.hale u, "
n iti reached surface.
❑Geothermal(Heating/Cooling Return) - ❑Other(explain under 7g) - - i r _>'• - x:-,r „ { (,,,
t
li
4.Date well(s)abandoned: 1/1 7/2023 _ I, FLU 1 2023
5a.Well location: I• nfo, nia;i m Przsc .;fig Un:2
r.a.,r,ro:r..-.
Fortner Salem Uniform Services Facility - .. .-"'�.
Facility/Owner Name Facility ID#(if applicable) S.Cer t ation: e
f
4015 Cherry St., Winston Salem NC, 27105 .4. 1/25/2023
Physical Address,City,and Zip Sign a of Certified WelltontmcrellOwner Date
Forsyth County Bysigning thisform, I herebycertt that the well(s) was (were) abandoned in
� g .lv
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.01,00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: «�
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
c
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS j:
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells i
ONLY with the same construction abandonment,you can submit one form.
FS 207a 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following: i,
6a.Well ID#: I;
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 48 (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1•5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:.
6d.Water level below ground surface: n/a (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection WI Ils: In addition to sending the form to the
address(es)above,also submit one copyjof this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
•
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: •WELL ABANDONMENT DETAI
LLS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW- 0 is needed. Indicate TOTAL NUMBER of
NCWC 4234—A wells abandoned:' I
NC Well Contractor Certification Number 7b.Approximate volume of watelr,emaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
W 1400523 7c.Type of disinfectant used:
2.Well Construction Permit#: 1
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.)if known
I
7d.Amount of disinfectant used'
3.Well use(check well use): -
Water Supply Well: 7e.Sealing materials used(checklall that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout Il I Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ! 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout • 0 Drill Cuttings
0 Irrigation ❑Specialty Grout 1, 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery II
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge (Groundwater Remediation 1/4 bag 1,
❑Aquifer Storage and Recovery - ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ii
❑Experimental Technology ❑Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) - ❑Other(explain under 7g) Poured bentonite chips dOWfl hole until reached surface.
1/17/2023 ~~-' (3--r,
4.Date well(s)abandoned: =,
C :i = LOCJ
5a.Well location: �`" y
Former Salem Uniform Services Facility -- — - i, �,j.,,a;,,,, ;.f Or.,���, ,
%. ...�lira
Facility/Owner Name Facility ID#(if applicable) 8.C• cation: •• ' Cit`°rtiu'0Ca
4015 Cherry St., Winston Salem NC, 27105 , c lr ' 1/25/2023 _
Physical Address,City,and Zip Si,, .tore of Certified Well Contractor or Well Owner Date
Forsyth County Il
By signing this form, 1 hereby cert fy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l
(if well field,one lat/long is sufficient) ,,•• 9.Site diagram or additional well details: •'•nr;
N W You may use the back of this page to provide additional well site details or well `
abandonment details. You may also attach additional pages if necessary.
i
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS I
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells i
ONLY with the same construction,abandonment,you can submit one form. P
FS 207b 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
r
II
Division of Water Resources;Information Processing Unit,
6b.Total well depth: 32 (ft.) 1617 Mail Service Cen',ter,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 .5 (in.) 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,
6d.Water level below ground surface: n/a (ft.)
1636 Mail Service Cen ier1 Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

I I •
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAIII!S •
Rawlins E Clarke IV k
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW'30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:,
NC Well Contractor Certification Number 7b.Approximate volume of water)remaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: WI400523
List all applicable well construction permits(i.e.UIC.County,State.Variance,etc.)ifknown
7d.Amount of disinfectant used:
1
3:Well use(check well use): - •
Water Supply Well: 7e.Sealing materials used(check I,ll(that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout i 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 1 0 Drill Cuttings
0 Irrigation 0 Specialty Grout I' 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 1 Cr Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
•
❑Aquifer Recharge •Groundwater Remediation 1/4 bag I: I -
i
:Aquifer Storage and Recovery ❑Salinity Barrier - ; i
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer p I •
Poured bentonite chips down hole until reached surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 1/17/2023 FEB 1
S
2023
5a.Well location:
Iriiurrt,i-lj :1 P iN,:;x .r.;,I l_lr;:
Former Salem Uniform Services Facility CAA. v�3h
Facility/Owner Name Facility IDff(if applicable) 8•C. 'cation: I ,
4015 Cherry St., Winston Salem NC, 27105 � !' 1/25/2023-
Physical Address,City,and Zip S'azure of Certified Well Contract r or Well Owner Date
Forsyth County Bysigning thisform, I herebycert0 that the well(s) was(were) abandoned in
� g fy
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.01001or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) "'"' 9.Site diagram or additional well dletails: • la•.,
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record(s)ifavatlable. For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS I
ONLY with the sante construction abandonment,,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: FS 208a abandonment to the following:
I,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 47 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• 10b.For Iniection Wells: In addition In sending the form to the address in 10a
6c.Borehole diameter: 1•5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: n/a (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cent er,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.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 count)) Health department of the county where
•
•
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
•
Form GW-30 North Carolina Department of Environmental Oualitv-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 4234-A wells abandoned:I I 1
NC Well Contractor Certification Number 7b.Approximate volume of water Iemaining in well(s): n/a (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
W 1400523 7c.Type of disinfectant used: 1!
2.Well Construction Permit#: II '
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.)if known r '
7d.Amount of disinfectant used:'
3:Well use(check well use):
i .
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I! Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout I 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry II 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge Groundwater Remediation 1/4 bag i;
❑Aquifer Storage and Recovery ❑Salinity Baer j Bath
❑Aquifer Test _. _ - _ . ❑Stormwater_Drainage.
r '
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the'abandonment procedure:
OGeothermal(Closed Loop) OTracer I
Poured bentonite chips down hole until reached surface.
_ ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 1/17/2023 .11 . 'L �n�A'a 1
5a.Well location: F i tj 3 Z<72�
Former Salem Uniform Services Facility (�����,.,.;V ^�1^. : _.
as.^-1 1 14. R^!tiO
Facility/Owner Name Facility ID#(if applicable) 8.Cer ' ation: J.e;a; '•�L� J S
4015 Cherry St., Winston Salem NC, 27105 ( 1/25/2023
Physical Address,City,and Zip Si tur of Certified Well Contractor or caner Date
Forsyth County it
By signing this form. I hereby cent&that the well(s) was (were) abandoned in —
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.01100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r ,
(if well field,one Iat/long is sufficient) 'ell r 9.Site diagram or additional well details: ,r car
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS ;i
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the sante construction abandonment,you can submit one form.
FS 208b 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: !.
I:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 31 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I'
10b.For Injection Wells: In addition Ito sending the form to the address in 10a
6c.Borehole diameter: 1•5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
n/a Division of Water Resources,UnIderground Injection Control Program,
6d.Water level below ground surface: (ft.) t
1636 Mail Service Center`,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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 count}) health department of the county where
6f.Inner easing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form C W-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016