WQ0015102_Well Abandonment Record(s) (GW-30)_20230512

WELL ABANDONMENT RECORD
I. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Nmnber
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (Ke. UIC, County, Mate, Parlance, etc.) ifknown
3. Well use (check well use):
For Internal Use ONLY:
WELL ABANDONMENT RETAILS
- -
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having
the same
well constiuction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: _
�f
7b. Approximate volume of water remaining in well(s): 2.65
(gal.)
FOR WATER SUPPLY WELLS ONLY:
1
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
Water Supply Well: 7e. Sealing materials used (check all that apply):
❑Agricultural ❑MunicipaVPublic ❑ Neat Cement Grout s' Bentonite Chips or Pellets
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustriaVCommercial ❑Residential Water Supply (shared) 91 Concrete Grout ❑ Drill Cuttings
Non -Water Supply Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heatine/Cooline
❑Recovery
❑Groundwater Remediation
❑salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
82 Ibs of Bentonite
10 lb concrete
❑Tracer 7g. Provide a brief description of the abandonment procedure:
❑Other (explain under 7g)_ I Pour/tremmie
4. Date well(,) abandoned: 05/08/2023
5a. Well location:
Walser Service 00-0-0000012046
Facility/Owner Name Facility M# (ifapplicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson 1400-2000-00016A
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.934625 N 80.331430
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
8. Certification:
05/12/23
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 15.4 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:
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.
Attach well construction record(s)ifavailable. For nwlnpleinjection ornon-watersupplywells
ONLY with the same construction/abandonment you can submit one form.
6a. Well M#: MW-1
6b. Total well depth: 56.79 (ft-)
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: 40.53 (ft.)
6e. Outer casing length (if known): n/a 00
6f. Inner casing/tubing length (if known): un known (ft.)
6g. Screen length (f known): unknown
(ft.)
SUBMITTAL INSTRUCTIONS
10a. For Ail Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Marl 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
10c. For Water Supph & Inip tion 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.
Form CW-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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) ffRnovm
3. Well use (check well use):
Water Supply Well:
❑Agricultural
[]Geothermal (Heating/Coohng Supply)
❑ IndustriaUCommcroial
Non -Water Supply Well:
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
❑Geothermal (Heatin, jCooling Return
❑Other (explain under 7t.. i
4. Date well(s) abandoned: 05/08/2023
5a. Well location:
Walser Service 00-0-0000012046
Facility/Owner Name Facility ID# (if applicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson 1400-2000-00016A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.934625 N 80.331430
WELL ABA1tiDOMMENTDETAA.S
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): 1.26 (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
M 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:
69 Ibs of Bentonite
10 lb concrete
7g. Provide a brief description of the abandonment procedure:
Pour/tremmie
8. Certification:
05/12/23
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:
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 5 BEING ABANDONED
Anachwellconstrwdi;rrrecord(s)ifovallable. For multiple injection ornon-warersupplywells
ONLY with the same construction/abandonment, you can submit one four.
6a. Well ID#: M W-2
6b. Total well depth: 49.07
6c. Borehole diameter: 2 _ _ _(in.)
6d. Water level below ground surface: 41 .32 (ft )
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 Centf'r, Raleigh, NC 27699-1617
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
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): n/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
6LInner casing/tubing length (if known): unknown (ft.) abandoned.
6g. Screen length (if known): unknown (fL)
Form OW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD Forlot .1 Use ONLY;
1. Wen Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
_Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) y nown
3. Well use (check well use):
Water Supply Wen:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
H Monitoring ❑Recovery
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: r�
7b. Approximate volume of water remaining in well(s): 2.82 (gaL)
FOR WATER SUPPLY WELLS ONLY: - -'
7e. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
L Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ DryClay
* Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gmve(
❑ Bentonite Slurry
❑ Other (explain under 7g)
rnjecuon Wen: 7f. For each material selected above, provide amount of materials used:
❑Aquifer Recharge ❑ Groundwater Remediation 167 Ibs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier 100 lb concrete
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g, Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ! Pour/tremmie
❑Geothermal (Heating/Cooling Return) ❑Other (explain under 7g]
4. Date well(s) abandoned: 05/08/2023
5a. Well location:
Walser Service
00-0-0000012046
Facility/Owner Name
Facility M# (if applicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson
1400-2000-00016A
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lawong is sufficient)
35.934625 N 80.331430
Additional cement and hole plug used to
fill majority of vault.
8. Certification: _.
05/12/23
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby cert#y that the well(s) was (were) abandoned in
accordance with 15.4 KCAC 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:
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 WELLL BEING ABANDONED
Attach well construction record(s) ifavatlable. For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well M#: MW-3
6b. Total well depth: 59.72 _ (ft-)
6c. Borehole diameter: 4
6d. Water level below ground surface: 42.41 . (ft.)
6e. Outer casing length (if known): n/a
(ft.)
6f. Inner casing/tubing length (if known): u n kn own (ft.)
6g. Screen length (f known): u n kn own
(ft)
SUBMITTAL INSTRUCTION
10a. For All Vvells: 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 Irdection Wells: In addition to sending the fora 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
10c. For Water Sunny & Iniection Wells: In addition to sending the form to the
addresses) 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.
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:
Matthew Steele _
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, Counry, State, Variance, etc.) ifknown
3. Well use (check well use):
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating(Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commcrcial ❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Recovery
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
[]Geothermal +Heatinp'Coolin� Return)
❑Other (explain under 7g)
4. Date well(s) abandoned: 05/08/2023
59. Well location:
Walser Service
00-0-0000012046.
FaciliWOwnerName
Facility ID# (ifapplicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson
1400-2000-00016A
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.934625 N 80.331430 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s)ifavailable. For multiple injection ornon-watersupplywells
ONLY with the same construcdonlabandonment you can submit one form.
6a. Well ID#: MW-4
6b. Total well depth: 50.05 (ft.)
6c. Borehole diameter: ,2 (in.)
6d. Water level below ground surface: 44.75 (fL)
6e. Outer casing length (if known): n/a A)
6f. Inner casing/tubing length (if known): unknown (ft.)
6g. Screen length (if known): unknown
WELL ABAND NW..NT 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): 0.86 (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
a Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
!e Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
70 Ibs of Bentonite
10 lb concrete
7g. Provide a brief description of the abandonment procedure:
Pour/tremmie
& Certification:
05/12/23
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby ceH!fy 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.
SUBW=AL INSTRUCTI[] Nti 5
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 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
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of ibis form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW -30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
0
For internal Use ONLY:
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/herproperly)
4548 A _
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
Ltsi all applicable well construction permits (I.e. UIC, County, State, Variance, etc.) ifknown
3. Well use (check well use):
Water Supply Well:
[]Agricultural
❑Geothermal (Heating/Cooling Supply)
❑lndustrial/Commercial
❑Irrigation
Non -Water Supply Well:
Monitoring
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Hco6nelCoolintz
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
El Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (exolain under 7r.:
4. Date well(s) abandoned: 05/08/2023
52. Well location:
Walser Service
00-0-0000012046
WELL ABA.NDONIV1ENT DFTA
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): 1.63 (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
a Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
G Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
58 Ibs of Bentonite
10 lb concrete
7g. Provide a brief description of the abandonment procedure:
Pour/Tremmie
Facility/Owner Name Facility ID#(ifapplicable) S.Certification: y
6431 Highway 150 N, Lexington, NC 05/12/23
Physical Address, City, and Zip Signature of Certified Well Contractor or Well Owner Date
Davidson 1400-2000-00016A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lattlong is sufficient)
35.934625 N 80.331430
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0/00 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:
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 WELI 5 BEING ARANMONED
Attach well construction record(s) ifavailable. For multiple injection or non-watersupply wells
ONLY with the same consirucdon/abandonment, you can submit oneform.
6a. Well M#: M W-5
6b. Total well depth: 49.97 (ft.)
6c. Borehole diameter: 2 (in.)
6d. Water level below, ground surface: 41.63 (ft.)
6e. Outer casing length (if known): n/a (ft.)
6E Inner casing/tubing length (if known): unknown (ft.)
6g. Screen length (f known): unknown (ft.)
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 Injection Wells: In addition to sending the form to the address in 100
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
10c. For Water Supply & In(ection 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.
Form OW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information,.
Matthew Steele
Well Contractor Nate (or well owner personally abandoning well on histher property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: NIA
List all applicable well construction permits p.e. UIC, County, State, Variance, eic.) if known
3. Well use (check well use):
fferrA Use ONLY:
WELL AB&-%DOMffNT 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):
FOR WATER SUPPLY WELLS ONLY:
{
1 7c. Type of disinfectant used:
7d. Amount of disinfectant used:
Water Supply Well:
7e. Sealing materials used (check all that apply):
❑Agricultural
❑MunicipaVPublic
❑ Neat Cement Grout P Bentonite Chips or Pellets
❑Geothermal (Heating/Cooling Supply)
❑Residential Water Supply (single)
❑ Sand Cement Grout ❑ Dry Clay
❑lndustrialtCommereial
❑Residential Water Supply (shared)
P Concrete Grout ❑ Drill Cuttings
_❑ration
❑ Specialty Grout ❑ Gravel
Non -Water Supply Well:
❑ Bentonite Slurry ❑ Other (explain under 7g)
HMonitoring
❑Recovery
Injection Well:
7L For each material selected above, provide amount of materials used:
❑AquiferRccharge
❑GroundwaterRemediation
63 Ibs of Bentonite
❑Aquifer Storage and Recovery
❑Salinity Barrier
_
10 lb concrete
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geotbermal(Closed Loop)
❑Tracer
7g. Provide a brief description of the abandonment procedure:
Pour/tremmie
[]Geothermal (Heating/Cooling Return)
❑Other I cxrlain under 7g)
4. Date well(s) abandoned: 05/08/2023
Sa. Well location. -
Walser Service 00-0-0000012046
Facility/Owner Name Facility 1Dil (if applicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson 1400-2000-00016A
uounv
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iavlong is sufficient)
35-934625 N 80.331430
8. Certification:
t 05/12/23
Signature of Certified Well Contractor or Well Owner Date
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
CONSTRUC— ION_ DETAILS OF WELL(S1.BEING ABANDONED
Attach well construction record(s) ifavai/able. For multiple injection ornon-water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: M W-6
6b. Total well depth: 45.19 00
6c. Borehole diameter- . Ain.)
6d. Water level below ground surface: 38.37 (ft.)
6e. Outer easing length (if known): n/a (ft.)
6LInner casing/tubing length (if known). unknown
6g. Screen length (if known): unknown
.. — UP
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 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
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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
abandoned.
Form GW-30 North Carolina Department of Environawatal Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, Coun(p, State, Parlance, etc.) ifbnown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
dGeothermal (Heating/Cooling Supply)
❑Industrial/Commercial
Non -Water Supply Well:
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
F Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑SalinityBarrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geotbermal (Closed Loop)
❑Tracer
[]Geothermal (Heating /Coolia • Return)
❑Other t ex -plain under 7g'
4. Date well(s) abandoned: 05/08/2023
5a. Well location:
Walser Service 00-0-0000012046
Facility/Owner Name Facility M# (if applicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson 1400-2000-00016A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutea/seconds or decimal degrees:
(if well field, one latnong is sufficient)
35.934625 N 80-331430
For hrtemal Use ONLY:
WELL AB,t,S'DONNMN'T 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).. 0.91 (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
�-76' Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
r- Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonitc Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
67 Ibs of Bentonite
10 lb concrete
7g. Provide a brief description of the abandonment procedure:
Pour/tremmie
8. Certification: t✓��
_ 05/12/23
Signature ofCertified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the wells) was (were) abandoned in
accordance with ISA 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:
R, 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.
CONSTRt'CT[ N DETAILS OF WELL S) BEING ABANDONED
Attach well construction record(s) Ifavailable. FOP multlpleinfectionornon-water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-7
6b. Total well depth: 48.1 1 (ft.)
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: 42.53 _ (ft.)
6e. Outer casing length (if known): n/a (ft.)
6C Inner casing/tubing length (if Imown): u n known ( )
6g. Screen length (if mown): unknown (ft.)
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 Iniection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this forth 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
10c. For Water Sufnih & 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
abandoned.
Form OW-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 -
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on bis/ber property)
4548 A
NC Well Contractor Certification Number
WELL AEkNDONMENT DET
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): 0.73 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c. Type of disinfectant used:
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. WC, County, State, Variance, etc.) ifbrown 7d. Amount of disinfectant used:
3. Well use (check well use): -
Water Supply Well:
❑Agricultural
❑MunicipaVPublic
❑Geothermal (Heating/Cooling Supply)
❑Residential Water Supply (single)
❑htdustrial/Commercial
❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
r- Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑ Salinity Barrier
❑Aquifer Test
Cl Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
❑Geothermal (Heating/Cooling Retum)
❑Other (explain under 7E)
4. Date well(s) abandoned: 05/0812023
5a. Well location:
Walser Service 00-0-0000012046
Facility/Owner Name Facility ID# (if applicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson 1400-2000-00016A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35-934625_- N 80.331430 R W
CONSTRUCTION DETAILS OF_WELLiSI BEING ABANDONED
Attach well construction record(s) ifavallable. For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment, you can submit oneform,
6a. Well ID#: MW-8
6b. Total well depth: 48.25 (ft.)
6c. Borehole diameter. 2 (in.)
6d. Water level below ground surface: 43.75 (ft.)
6e. Outer casing length (if known): n/a
(ft.)
6f. Inner casing/tubing length Of known): unknown (ft.)
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
1 Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
>r: Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
68 Ibs of Bentonite
10 lb concrete
7g. Provide a brief description of the abandonment procedure:
Pour/tremmie
8. Certification:
05/12/23
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certo 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
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
abandoned.
6g. Screen length (if known): unknown (N
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Ccrtification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County, Slate, Variance, etc.) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Municipal/Public
❑Geothermal (Heating/Cooling Supply)
❑Residential Water Supply (single)
❑industriaVCommercial
❑Residential Water Supply (shared)
❑Irri��tion
_ _
Non -Water Supply Well:
Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
�Geothetmal (Heating/Cooling Retum)
❑Other (explain under 7e i
4. Date well(s) abandoned: 05/08/2023
For Internal Use ONLY:
WELL ABANDONMENT DETAIL S
7a. For Geoprobe/DPT or Closed -Loop Geothermal We➢s having the same
well construction/depth, only 1 OW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 11..45 _ (g.L)
j FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cemcnt Grout I- 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:
116 Ibs of Bentonite
10 lb concrete
j 7g. Provide a brief description of the abandonment procedure:
IR Pour/tremmie
Sa. Well location:
Walser Service 00-0-0000012046 --
Facility/Owner Name Facility W# (if applicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson 1400-2000-00016A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.934625 N 80.331430 W
CONSTRUCTION DETAILS OF WELLJ 5 . BEING ABANDONED
Attach well construction rword(s) (%avallable. Formuluple injwtion ornon-waters*ply wells
ONLYwith the same constuction/abandonment you can submit oneform.
6a. Well ID#: MW-9
6b. Total well depth:. 114.86 (ft.)
6c. Borehole diameter: 2 --(in.)
6d. Water level below ground surface: 44.62 _ (ft.)
6e. Outer casing length (if known): n/a _ Aft.)
6f. Inner essing/tubing length (if known): u n kn own (ft.)
6g. Screen length (if known): unknown _ (ft.)
8. Certification:
05/12/23
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 1 SA NCAC 02C .0100 or 2C .0100 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 Iniection 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 Mat] Service Center, Raleigh, NC 27699-1636
10c. For Water Suonh & 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
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on hislber property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well constructionpermits (i.e. UIC, County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
Non -Water Supply Well:
R Monitoring
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Fleatin„/Cooling
❑MunicipaVPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
C
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (cx plain under 7g)
4. Date well(s) abandoned: 05/08/2023
5a. Well location:
Walser Service
00-0-0000012046
FacilitylOwnerName Facility M# (ifapplicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson 1400-2000-00016A
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/loog is sufficient)
35.934625 N 80.331430
For Internal Use ONLY:
FELL ASA NMN3_DFTAILS
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): 2.82 (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
R Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
15 Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
169 Ibs of Bentonite
100 lb concrete
7g. Provide a brief description of the abandonment procedure:
Pour/tremmie
Additional concrete and hole plug used to
fill in majority of vault.
8. Certification:
05/12/23
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:
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
Attach well construction record(s) ifavailable. For multiple injection Orman-watersupply wits
ONLY with the same construction/abandonment, you can submit one form.
69. well ID#: V E RW-1
6b. Total well depth: 58.67
6c. Borehole diameter: 4
6d. Water level below ground surface: 41 .37
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 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
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): n/a UP 10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(cs) 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): unknown (ft.) abandoned.
6g. Screen length (if known): unknown Aft.)
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/herproperty)
454.8 A
NC Well Contractor CertificationNarrrbcr
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County, Stare, Varionce, etc.) {/known
3. Well use (check well use):
Water Supply Weil:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
Non -Water Supply Well:
A Monitoring
1 i:T,L 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): `i • 93 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑Municipal/Public ❑ Neat Cement Grout t: Bentonite Chips or Pellets
❑Residential Water Supply (single) ❑ Sand Cement Grout ❑ Dry Clay
❑Residential Water Supply (shared) A Concrete Grout ❑ Drill Cuttings
❑Recovery
[]Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal(Closed Loop)
❑Tracer
❑Geothermal (Heating/Cooling Returns
_ ❑Other (explain under 7g)
4. Date well(s) abandoned: 05/08/2023
5a. Well location:
Walser Service
00-0-0000012046
Facility/Owner Name
Facility ID# (if applicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson
1400-2000-00016A
_ _
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.934625 N 80.331430
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
71, For each material selected above, provide amount of materials used:
90 Ibs of Bentonite
100 lb concrete
7g. Provide a brief description of the abandonment procedure:
Pour/tremmie
Additional cement and hole plug used to
fill majority of vault.
8. Certification:
05/12/23
Signature of Ccrtified Well Contractor or Well Owner Date
By signing this form, I hereby certj* that the well(s) was (were) abandoned in
accordance with 15A NCAC 01C .0100 or 1C .0100 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
W You may use the back of this page to provide additional wcll site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach wellconstnutionrecord(sffavailable. For nudtipleinjection ornon-watersapplywells
ONLY with the same constructionlabandonmew, you can submit one form.
6a. Well ID#: AI-1
6b. Total well depth: 64.45 (ft.)
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: 40.32 (ft.)
6e. Outer casing length (if known):.n/a (R,)
6f. Inner casingltubing length (if ]mown): u n kn own V .)
6g. Screen length (if known): unknown _ Aft.)
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 Iniection 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
1Oc. Fur Water Sunu Ir & Ini ection 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.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

For Internal Use ONLY:
WELL ABANDONMENT RECORD
WELL ABANDONNIFNT 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:
NC Well Contractor Certification Number 76. Approirimate volume of water remaining in well(s): 2.64 (gal )
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c. Type of disinfectant used:
2. Well Construction Permit #: NIA
List all applicable well construction permits O.e. UIC, County, State, Variance, etc.) ifknoxvt
7d. Amount of disinfectant used:
3. Well use (check well use):
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
Non -Water Supply Well:
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heatin�,.'Cooling Retum)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other ! ex - lain under 70
4. Date well(s) abandoned: 05/08/2023
5a. Well location:
Walser Service
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
00-0-0000012046
Facility/Owner Name Facility ID# (ifopplicable)
6431 Highway 150 N, Lexington, NC
Physical Address, City, and Zip
Davidson 1400-2000-00016A
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degreWadautes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35-934625 N 80.331430
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
9 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:
82 Ibs of Bentonite
100 lb concrete
7g. Provide a brief description of the abandonment procedure:
Pour/tremmie
Additional cement and hole plug used to
fill majority of vault.
8. Certification:
05/12/23
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby cert;Y that the well(s) was (were) abandoned in
accordance with 1 SA NCAC 02C .0100 or 1C .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:
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
Anach well construction record(s) ifavailable. For multiple infection or non -water supply wells
ONLY with the same construcdonlabandonment, you can submit one form.
68. wen ID#: AI-2
6b. Total well depth: 56.32 (ft.)
6c. Borehole diameter: 2 (in.)
SUBMITTAL INSTRUCTIONS
10a. For An 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
IOb. For Infection Wells: In addition to sending the form to the address in I Oa
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• 40.1 5 00 Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): n/a _ y _ _ (ft.) 10c. For Water Supply & In' lion 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): -unknown (R) abandoned.
6g. Screen length (if known): unknown (R )
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016