Davidson_Well Abandonment_20231215

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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 G Wr-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
2957-A Unknown
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#: W-23-57
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 6 oz.
_ 7d.Amount of disinfectant used:
3.Well use(check well use): _
Water Supply Well: 7e.Sealing materials used`(check111.that apply,):-1---
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout DEC �7 ❑]Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) [I Sand Cement Grout DE y 4 Z©a Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ' �r D �,4. E1 Dt�riU t?yttings
❑Irri ation- ❑ Specialty Grout e•da•�;•� Gfavel [
Non-Water Supply Well: rvLa`'�
PP Y ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete mix 1 cubic yard
❑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 concrete directly into well casing
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
and filled to within3 feet of surface where
4.Date well(s)abandoned: 12/1/23
a concrete plug was installed on top.
5a.Well location:
Charlie Nifong N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: �
295 Welcome-Arcadia Rd. �,,L; Z9��- A 12/1/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Lexington, NC 27292 6728-02-78-3992 By signing this form, I hereby certify that the well(s) was(were) abandoned in
County VftYl Loiq Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has ieeh provided to the well owner.
(ifwell field one lattlong is sufficient) 9.Site diagram or additional well details:
35.911498 N 80.258049 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 wellconstructionrecord(s)rifavailable.rormtdtiple injection ornon-warersupplywells
ONLY with the same construction/abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 91 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Iniection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 6 (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: Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Suooly&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
6E Inner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

i
WELL. ABANDONMENT RECORD For Ihtemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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
wells abandoned:
2957-A Unknown
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#: W-23-58
List all applicable well construction permits(i.a UIC,County,State,Variance,etc.)ifknown '7 oz. _
_ 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 { ❑Bentonite Chips or Pqggts/
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay / ram. C 1 •)/� "':4
❑Industrial/Commercial ❑Residential Water Supply(shared) ® Concrete Grout ❑Drill Cuttings
❑Irrigation. ❑ Specialty Grout ❑Gravel ©; •�,
Non-Water Supply Well: t' }~ti 4''k
pp y ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑AquiferRecharge ❑GroundwaterRemediation Concrete mix 2 cubic yards
❑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 concrete directly into well casing-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
and filled to within 3 feet of surface where
4.Date well(s)abandoned: 12/1/23 a concrete plug was installed on top.
5a.Well location:
McKenzie Kepley N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
311 Welcome-Arcadia Rd. , Zq$�-�4 12/1/23
Physical Address,City,and Zip Signature of Certified Well Contractor or,Well Owner Date
Lexington, NC 27292 6728-02-79-3051
By signing this form,I hereby cei7ify that the wells) was(were)abandoned in
Caunty,P V-n San Parcel Identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one laUlong is sufficient) 9.Site diagram or additional welljdetails:
35.911522 N 80.258427 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 wellconstruclion record(s)ifavailable.For multiple injection ornon-watersapplywells
ONLY with the same constructiontabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ED#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 187 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (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
6E Inner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

i
WELL ABANDONMENT RECORD For Internal Use ONLY: !
i �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
i
WithersRavenel, Inc. FOR WATER SUPPLY WELLS'ONLY:
Company Name
7c.Type of disinfectant used: -
2.Well Construction Permit#: Not Applicable
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
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 ® Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gros: ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) s Concrete Grout r• (S, ,,d ;.: "�Dii^ll�Cuttings
❑Irri ation ❑ Specialty Grout 7 t"�t61 LrDel
Non-Water Supply Well: El Bentonite Slurry DEC j C J Other(explain under 7g)
CMonitoring ❑Recovery ;Fn,
Injection Well: 7f.For each material si&I&Pnllpapy Yp vide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips tiro ,�4, V1"��'10 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete Grout ! -35 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite chips were placed into well and tamped
to a depth one foot below the top of well casing.
4.Date well(s)abandoned: December 1, 2023 Remaining space with 11 in well and space within flush
5a.Well location: mount protective cover filled with concrete.
Sammy Zitawi 0-0-01630
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
215 National Highway, Thomasville, 27360 > 12-7-2023
Physical Address,City,and Zip Signa ure of Certified ell tractor or,Well Owner Date
Davidson -6788-03-21-7019
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 io the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(ifwell 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
35.891510 N -80.071460 -
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifm ailable.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#• M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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 -6.9 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Si y&Iniectial 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
6E Inner casing/tubing length(if known): 4.0 (ft) abandoned.
6g.Screen length(if known): 5.0 (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.
I
1.Well Contractor information: WELL ABANDONMENT DETAItiS'
Brian James Bellis 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 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: i
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout'"'
i ��I Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout
❑industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout DEC ❑"Dtifi�uttings
❑Irri ation ❑Specialty Grout G 20O.Pravel
Non-Water Supply Well: ❑Bentonite Slu*thi^F icn ❑ Other(explain under 7g)
hlMonitoring ❑RecoveryEr.�.`?r UR,
Injection Weil: 7f.For each material selected a ki,-- bvide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips -10 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout ^35 pounds
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite chips were placed into well and tamped
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
to a depth one foot below the top of well casing.
4.Datewell(s)abandoned: December 1, 2023 Remaining space within well and space within flush
5a.Well location: mount protective cover filled with concrete.
Sammy Zitawi 0-0-01630
Facility/Owner Name Facility ID#(if applicable) S.Certification:
215 National Highway, Thomasville, 27360 12-7-2023
Physical Address,City,and Zip Signature of Cenifi d W Contractor or,Well Owner Date
Davidson 6788-03-21-7019 By signing this form, I hereby cer1ify that the ivell(s) ivas (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:
- -35:89151"0- - - _ N -80.071460' -- N 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
Anach well consvuction records)ifavailable. For multiple injection or non-water supply wells
ONLY ivith 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#: M W 1 abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 8.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: $ 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: -5.1 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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): 3.5 (ft) abandoned.
6g.Screen length(if known): 5.0 (fit.) i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource) Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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) wet I construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit 4: Not Applicable
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)ifknown
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 Gr"R7 ® Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout" '" .�'& "' ' %D-Dry,Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 77 'CT-drill'Cuttings
❑Irri ation El Grout D�� t L 2,(11 Gravel
Non-Water Supply Well: ❑ Bentonite SIU>iy rP:'i�t ❑ Other(explain under 7g)
RMonitoring ❑Recovery U
1y5D� w
Injection Well: 7f.For each material selecte "abov,-'provide a- ount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —10 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete Grout ~35 pounds
❑Experimental Technology El Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite chips were placed into well and tamped
to a depth one foot below the top of well casing.
4.Datewell(s)abandoned: December 1, 2023 Remaining space within well and space within flush
5a.Well location: mount protective cover,filled with concrete.
Sammy Zitawi 0-0-01630
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
215 National Highway, Thomasville, 27360 -•-,u���e-=12-7-2023
Physical Address,City,and Zip Signature ofCertifie Well ntractor or Well Owner Date
Davidson 6788-03-21-7019
By signing this form, 1 hereby certify that the ivell(s) ivas (uvere) 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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
- 35-.891 51-0 N _80-0714.60 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable. For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
IOa. For All Wells: Submit this,form within 30 days of completion of well
6a.Well ID4: M W 2 abandonment to the following: i
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
10.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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: —3.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Sunoly&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): 5.0 (ft) abandoned.
6g.Screen length(if known): 5.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016