Wilson_Well Abandonment_20240301

I !!
WELL ABANDONMENT RECORD For Internal Use ONLY: !
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 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
• 4328-B wells abandoned:One I 1
•
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 5.4 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: •
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 G Neat Cement Grout IN 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: 0 Bentonite Slurry i, , 0 Other(explain under 7g)
('Monitoring . DRecovery I I , --
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 2.5 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite 50 pounds j
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Grouted well in place.
4.Date well(s)abandoned: 2-12 &2-13-2024 - MAR 0 1 2024
5a.Well location:
Ryder Truck Rental Ryder Wilson NC LC0025 tt►'orr�a.t"t�,rr. ti.�t✓�*
R
Y DVietillOG
•
Facility/Owner Name Facility ID#(if applicable) ,8.Certification: '
2237 Whitley Road, Wilson, 27893 2-13-24
Physical Address,City,and Zip Signature o fie Well Contractor or Well Owner Date
Wilson 3732-23-3424.000
By signing this form, I hereby certifythat 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 1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.435699 N 77.524960 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. I -
lOa. For All Wells: Submit this(form within 30 days of completion of well
6a.Well ID#: DW-1 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
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 7 (ft.) Division of Water Resources,iUnderground Injection Control Program,
1636 Mail Service +Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectiin 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): 35 (ft.) abandoned.
6g.Screen length(if known): 5 (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 •
JeffreyGrant
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
4328-B wells abandoned:One 1
NC Well Contractor Certification Number 7b.Approximate volume of water2.5
remaining in well(s): (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELIS,ONLY:
Company Name •
7c.Type of disinfectant used: I. ,
2.Well Construction Permit#: ;
. 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): .
is
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public • a Neat Cement Grout • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout - • 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation •
❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry !. ❑ Other(explain under 7g) •
•Monitoring ❑Recovery . -
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 2 Ga!Ions
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite 20 pounds
•
❑Experimental Technology ❑Subsidence Control � .
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed.Loop) -. DTracer t ;=y �.,._
Grouted well in place. rr "�r
OGeothermal(Heating/Cooling Return) - ❑Other(explain under 7g) - .t�.- . ► I fir' ,,
•
1. MAR ) 1 2021
4.Date well(s)abandoned: 2-12 &2-13-2024
-5a.Well location: , ,, l iWC!!B:}ZS7
' Ryder Truck Rental Ryder Wilson NC LC0025
•
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2237.Whitley Road,,W ilson, 27893 / I` 2-13-24
Physical Address,City,and Zip Signature o`i- '�/We Contractor b r Well Owner Date
Wilson 3732-23-3424.000 , I'
By signing this form, I hereby certin)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: is
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.435699 N 77.524960 �, 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. -
10a. For All Wells: Submit this form within 30 days of completion of well
•
6a:Well ID# MW-1 . 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
i.
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (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 7 (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): 1 2 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.) '
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i

1 '.
WELL ABANDONMENT RECORD For Internal Use ONLY:
1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JeffreyII
Grant7a.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
• 4328-B wells abandoned:One
NC Well Contractor Certification Number 7b.Approximate volume of water2.5
remaining in well(s): (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Nanie j
7c.Type of disinfectant used:
2.Well Construction Permit#:
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 •Neat Cement Grout • 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.
❑Irrigation 0 Specialty Grout j : 0 Gravel
Non-Water Supply Well: - ❑ Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery ` 1
•
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 2 GallOns
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite 20 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Retum) - 0 Other(explain under 7g) GrOUted Well In place.
2-12 &2-13-2024 "'i E C EL F ``''
. 4.Date well(s)abandoned: — • ' MAR 0.1 20Z�
5a.Well location: �. C
Ryder Truck Rental Ryder Wilson NC LC0025 M+:'r r lc . . ::.5 LA.
CANCEr OG
Facility/Owner Name Facility ID#(if applicable) S.Certification:
2237 Whitley Road, Wilson, 278932-13-24
Physical Address,City,and Zip Signature of Cstrei.,/-
1 Contractor or Well Owner Date
Wilson 3732-23-3424.000
By signing this form, I hereby cert5 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:
35.435699 N 77.524960 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 m:duple injection or non-water supply 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 ID#: MW-2 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
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 7 (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): 12 (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

1 1
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant I
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
4328-B wells abandoned:one
NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): 2'5 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
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 'Neat Cement Grout P 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) ❑ Concrete Grout , 1 ❑Drill Cuttings
❑Irrigation -. ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
'Monitoring ❑Recovery 1 -
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 2 Gallons
• ❑Aquifer Storage and Recovery ❑Salinity Barrier { -
❑AquiferTest l0StormwaterDrainage Bentonite 20 pounds
❑Experimental Technology - ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) - ❑Tracer I
Grouted well in place.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) lam'7—,>^, --
4.Date well(s)abandoned: 2-12 &2-13-2024 MAR 0 1202.4
5a.Well location: r P,yl g r...z u
Ryder,Truck Rental Ryder Wilson NC LC0025 C:.' r
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
I
2237 Whitley Road, Wilson, 27893 ,
��j 2-13-24
Physical Address,City,and Zip Signature of Certi (' ell r ontractor or Well Owner Date
Wilson 3732-23-3424.000 i
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!01I00 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:
35.435699 N 77.524960 �, 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 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#: MW-3 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
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this'form within 30 days of completion of well
abandonment to the following: l
6d.Water level below ground surface: 7 (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&Iniectionwells: In addition to sending the form to the
address(es)above,also submit ones 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): 12 (ft.) abandoned.
6g.Screen length(if known): 1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

1 !
WELL ABANDONMENT RECORD For Internal Use ONLY: '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JeffreyGrant 1
7a.For Geoprobe/DPT or Close -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 .
4328-B wells abandoned:One I '
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'5 (gal.)
- • JG.Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
i
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
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 s Neat Cement Grout II Bentonite Chips or Pellets
DGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout, 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout + ' 0 Gravel- .
Non-Water Supply Well: j:1
0 Bentonite Slurry I ❑ Other(explain under 7g) .
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 2 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite 20 pounds
oExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) - ❑Other(explain under 7g) Grouted well in place.
9 la .. ar l"'.i ,
m. t "*.Li
4.Date well(s)abandoned: 2-12 &2-13-2024
MAC 20Z
5a.Well location:
. Ryder Truck Rental Ryder Wilson NC LC0025 to'o':• 1 �r Y y ,�Uhist
Facility/Owner.Name Facility ID#(if applicable) 8.Certification: 1.
2237 Whitley Road, Wilson, 27893 ' 2-13-24
Physical Address,City,and Zip Signature of d II Contractor or Well Owner Date
Wilson 3732-23-3424.000 I
By signing this form, I hereby cert fy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C 101100 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:
' 35.435699 N 77.524960 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also1attach 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.
10a. For All Wells: Submit this form within 30 days of completion of well
• MW-4 abandonment to the followin I.
6a.Well ID#: g
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 22 (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: 2 (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: 7 (ft.) Division of Water Resources,1Uhderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectil n..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): 12 (ft.) abandoned.
6g.Screen length(if known): 10 (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
1.Well Contractor Information: WELL ABANDONMENT DETAILS
(
Jeffrey Grant 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
4328-B wells abandoned:Ono I 'I
NC Well Contractor Certification Number 7b.Approximate volume of water Iemaining in well(s): 2 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS iONLY:
Company Name •
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 I Neat Cement Grout II 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
❑irrigation 0 Specialty Grout I 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry _ _ 0 Other(explain under 7g) _ Y__
u Monitoring ❑Recovery I 'i
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 2 Gallons
❑Aquifer Storage and Recovery ID Salinity Barrier I
❑Aquifer Test ❑Stormwater Drainage Bentonite 20 pounds 1
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) Grouted well in place.
4.Date well(s)abandoned: 2-12 &2-13-2024 .L; r'Lit'It
o i L
5a.Well location: rSA't' U ! 2024
Ryder Truck Rental Ryder Wilson NC LC0025 jftwi rr4e 7 ar....
Facility/Owner Name Facility ID#(if applicable) 8.Certification: D'(t`=at .``2°WC
2237 Whitley Road, Wilson, 27893 ! 2-13-24
Physical Address,City,and Zip Signature‘,1/
ified ell Contractor or Well Owner Date
Wilson 3732-23-3424.000
By signing this form, I hereby certifi,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 latllong is sufficient)
9.Site diagram or additional well details:
35.435699 77.524960 W You may use the back of this page 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 '
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.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well m# MW-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this.form within 30 days of completion of well
6c.Borehole diameter: 2 (in.)
abandonment to the following: i
7 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.) 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
0
6f.Inner casing/tubing length(if known): 1 (ft.) abandoned.
6g.Screen length(if known): 1 (ft.)
,I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016

l .1
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 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 GVr30 is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:One 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'5 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
I,
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)ifloiown
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 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 ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
• Non-Water Supply Well: 0 Bentonite Slurry 1 j, 0 Other(explain under 7g)
"Monitoring ❑Recovery - 11 I -_ - _—— -- - -- --
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 2 Gallons
['Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Bentonite 20 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) Grouted well in place.
4.Date well(s)abandoned: 2-12 &2-13-2024 II r'�,.o i....t�v Z Li
5a.Well location: MAR I ZVZ4
Ryder Truck Rental Ryder Wilson NC LC0025 ,tteurera4-m Prr V
Facility/Owner Name Facility ID#(if applicable) 8.Certification: , ' D {jj. 3
2237 Whitley Road, Wilson, 27893 Ili ,
2-13-24
Physical Address,City,and Zip Signature of Ce "t"• ,r Contractor or Well Owner Date
Wilson 3732-23-3424.000 I '
By signing this form, I hereby cert that the well(s) was (here) 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 1
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
35.435699 N 77.524960 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)jfavailable. 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#: MW-8 abandonment to the following: ,
Division of Water Resources,Information Processing Unit,
6b.Total well depth 19 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: 7 (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): 9 (ft.) abandoned.
I
6g.Screen length(if known): 1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016

i 11
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 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 j30 is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:One I ;1
• NC Well Contractor Certification Number 7b.Approximate volume of water lemaining in well(s): 2 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: i
•
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:•
1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ail that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout El Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout i 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout r I ❑ Gravel
Non-Water Supply Well: _ - ❑ Bentonite Slurry ' �. ❑_ Other(explain under 7g) ___ _ _
(Monitoring ❑Recovery 1 J
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 2 Gallons
•❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite 20 pounds
❑Experimental Technology •❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ,� ,,
Grouted.well in place. �, s
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) '�_�� &-,h �r' ,
, i
2-12 &2-13-2024 i -MAR 3 1 2E4
4.Date well(s)abandoned: ,
5a.Well location: i tn1COriYAh i•+t i::':..:..;suna;::y tirtr.
DWNQi'3 JG
Ryder Truck Rental Ryder Wilson NC LC0025
- Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2237 Whitley Road, Wilson, 27893 ', 2-13-24
11
Physical Address,City,and Zip Signature of Ce 11 Contractor or Well Owner Date
Wilson 3732-23=3424.000
By signing this form, I hereby ce'rtify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C 1000 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 latllong is sufficient) 9.Site diagram or additional well details:
35.435699 77.524960 �, You may use the back of this page to provide additional well site details or well
N
- - abandonment details. You may also l'attach additional pages if necessary.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)tfavailable.For multiple injection ornon-water supply wells _
ONLY with the same construction/abandonment,you can submit one form. i
10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#: MW-9 abandonment to the following: ' i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
iI
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
6c.Borehole diameter: 2 (in.)
• abandonment to the following: 1 1
6d.Water level below ground surface: 7 (ft.) Division of Water Resources,UJ I derground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft.) 1Oc.For Water Supply&Iniecti I tiWells: 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
0
6f.Inner.casing/tubing length(if known): 1 (ft.) abandoned.
I
6g.Screen length(if known): 1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016

l
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 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 Gi_30 is needed. Indicate TOTAL NUMBER of
4328—B wells abandoned:One I 1
NC Well Contractor Certification Number 7b.Approximate volume of water;remaining in well(s): 1S
' (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS1ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
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): '
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout NI Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout i j 0 Gravel
Non-Water Supply Well: _ _ _ Y ❑_Ben__tonite Slurry 1 ❑ Other(explain under 7g) _ __-
UMonitoring 0Recovery ! '
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑Groundwater Remediation Portland Cement 2 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite 20 pounds j
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Grouted well in place. -- —
i 3m41;: L:t Y E ..,.i
4.Date well(s)abandoned: 2-12 &2-13-2024 MAR 1 2074
5a.Well location: hiicOr7CAU Zri i'rr,,; 4 .-.r,I IRS
Ryder Truck Rental Ryder Wilson NC LC0025 uwiai.24,34:3 -
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2237 Whitley Road, Wilson, 27893 2-13-24
Physical Address,City,and Zip Signature of Cert/V ell 'ontractor or Well Owner Date
Wilson 3732-23-3424.000
By signing this form, I hereby cert that the well(s) was (were) abandoned in
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:
35.435699 N 77.524960 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)if available. 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#: MW-1 0 abandonment to the following: ;
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 16 (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: 2 (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: 7 (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): 6 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.) , I
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016
i ,

1 II
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JeffreyGrant
7a.For Geoprobe/DPT or Close -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
4328-B wells abandoned:One I 1
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): 1 (gal.)
JG.Drilling, LLC FOR WATER SUPPLY WELL'S'ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
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 a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout I 0 Drill Cuttings
❑Irrigation 0 Specialty Grout : I 0 Gravel
Non-Water Supply Well: __ 0 Bentonite Slurry 0 Other(explain under 7g)
(Monitoring ORecovery - - - I
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 1.5 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier - -
[Aquifer Test ❑StormwaterDrainage Bentonite 10 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) Grouted well in place. ..
•
'' 't,% . ,i..L f nano'
4.Date well(s)abandoned: 2-12 &2-13-2024 MAR 0 1 2024
•5a.Well location: in or•,p,a;;;r n a;-;,z. u
Ryder Truck Rental Ryder Wilson NC LC0025 CA`+Q J
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2237 Whitley Road, Wilson, 278931 ; 2-13-24
Physical Address,City,and Zip Signature of Certi/ ,ell Contractor or Well Owner Date
Wilson 3732-23-3424.000
By signing this form, I hereby certi,6)that the well(s) was (were) abandoned in
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: f
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.435699 N 77.524960 �, 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 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#: MW-12 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection 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: j
i
6d.Water level below ground surface: 7 (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&Iniection Wells: In addition to sending the form to the
address(es)above,also submit oneicopy 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 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

f ;
•
. WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 1
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
4328-B wells abandoned:One
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well 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 ail that apply):
❑Agricultural ❑Municipal/Public . C Neat Cement Grout • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑'Sand Cement Grout 0 Dry Clay
- Dlndustrial/Commercial OResidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
- ❑Irrigation -_ ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: _❑Bentonite L_ ❑ Other(explain under 7g) _-
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland Cement 1.5 Gallons
. I:
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Bentonite-1 O pounds
: I
❑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) GCOUted Well In pIBCe.
4.Date well(s)abandoned: 2-12 &2-13-2024 E.t re Le`L t F
5a.Well location: MAR 0 1 2024 Ryder Truck Rental Ryder Wilson NC LC0025
l j h1n3Pr"P`,afF.,'1 Pr—,... •
Facility/Owner Name Facility ID#(if applicable) 8.Certification: , srow:•a t.dt ;c
4!^y 0(.a
•
fe.±±____
2237 Whitley Road, Wilson, 27893 2-13-24
Physical Address,City,and Zip Signature of Ce Well Contractor or Well Owner Date
Wilson 3732-23-3424.000
By signing this form, I hereby cert that the well(s) was (were) abandoned in
County Parcel Identification-No.(PIN) accordance with 15A-NCAC 02C 101100 or 2C.0200 Well Construction Standards
and that a copy of this record has¢een provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J j
(if well field,one latilong is sufficient) 9.Site diagram or additional well details:
35.435699 N 77.524960 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.
10a. For All Wells: Submit this!form within 30 days of completion of well
6a.Well ID#: MW-13 • abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 13 (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: 2 (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: 7 (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.) 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): 3 (ft.) abandoned. j
6g.Screen length(if known): 10 (ft.) .
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016