WS-29656_48783_CA_WR_20240201

\\EMPLOYEES.ROOT.LOCAL\ENV\ECC\GREENVILLE\WPGVL\PJT2\539311\0000\000007\L5393110000PH7-002 - WELL ABANDONMENT.DOCX

February 2, 2024
Mr. Gene Mao
Hydrogeologist
Guilford County Government
400 West Market Street
Greensboro, North Carolina 27401
Subject: Well Abandonment Report – January 2024 (Incident Number: 48783)
Dear Mr. Mao:
This letter is being provided to document the permanent abandonment of monitoring wells MW-01 and
MW-02A along with temporary monitoring wells TMW-04 and TMW-05 at the TForce Facility located at 4411
Groometown Road, Greensboro, North Carolina. These wells had been installed as part of a Comprehensive Site
Assessment required by the North Carolina Department of Environmental Quality (NCDEQ).
Monitoring wells MW-01 and MW-02A along with temporary monitoring wells TMW-04 and TMW-05 were
permanently abandoned on January 10, 2024, by Redox Tech, LLC a North Carolina certified well driller. A map
of the well locations is provided in Attachment 1. Soil boring and well construction logs are located in
Attachment 2. The total depth of each monitoring well was measured and recorded prior to abandonment.
Monitoring wells MW-01 and MW-02A along with temporary monitoring wells TMW-04 and TMW-05 were
abandoned in place by completely filling, from bottom to top, with neat cement grout in accordance with North
Carolina Well Standards. Copies of the completed well abandonment forms, submitted to the Division of Water
Quality by the driller, are provided in Attachment 3.
Should you have any questions or require additional information regarding the well abandonments, please
contact me at 864-420-3976.
Sincerely,
TRC Engineers, Inc.

David Szynal
Project Manager
Attachments
cc: Bill Preece, TForce
Rachel Brown, TForce
Lisa Clark, TRC
James Brown, NC DEQ Regional Supervisor, Winston-Salem Regional Office.

\\EMPLOYEES.ROOT.LOCAL\ENV\ECC\GREENVILLE\WPGVL\PJT2\539311\0000\000007\L5393110000PH7-002 - WELL ABANDONMENT.DOCX
Attachment 1 Well Abandonment Map
DATE:
APPROVED BY:
CHECKED BY:
DRAWN BY:PROJ. NO.:Path:Plot Date:JANUARY 2024
539311.0.0
Well Abandonment Map1.mxd
TFORCE FREIGHT, INC.4411 GROOMETOWN ROADGREENSBORO, NORTH CAROLINA
D. SZYNAL
T:\1-PROJECTS\TForce\Greensboro, NC\2024\Well Abandonment Map1.mxd1/26/2024, 08:00:47 AM by DSZYNAL -- LAYOUT: ANSI B(11"x17")Map Rotation:Coordinate System:0NAD 1983 2011 StatePlane North Carolina FIPS 3200 Ft US (Foot US)L. CLARK
1:3001 " = 25 '
0 25 50Feet
µ
LEGEND
TRC - GISTRC - GISFIGURE 1
D. SZYNAL
ABANDONED MONITORING WELL LOCATIONSJANUARY 2024
FILE NO.:
TITLE:
PROJECT:
NOTES:1. © 2022 Microsoft Corporation © 2022 Maxar ©CNES (2022) Distribution Airbus DS.2. Well surveyed June 2023 by McKim & Creed. Llocations referenced to NC GRID NAD 83 (2011).
50 International Drive, Suite 150Patewood Plaza ThreeGreenville, SC 29615Phone: [phone]www.TRCcompanies.com
Approximate location of Former20,000-gallon Diesel UndergroundStorage Tank
Former Diesel Fuel Pipe and Vent Lines
Monitoring Well Location@?<
Abandoned Monitoring Well Locations(January 2024)@?<
Approximate Extent of Excavation
Approximate location of Former Fuel Dispensers

\\EMPLOYEES.ROOT.LOCAL\ENV\ECC\GREENVILLE\WPGVL\PJT2\539311\0000\000007\L5393110000PH7-002 - WELL ABANDONMENT.DOCX
Attachment 2 Soil Boring and Well Construction Logs
MC
MC
MC
MC
MC
MC
50
100
100
100
100
75
SW-SM
SP-SM
SW
SP
3.0
8.0
10.0
11.0
25.0
0 '- 3 ' Asphalt and gravel.
8 '- 10 ' (SP-SM) Grey and brown, SILTY UNSORTED SAND (SP-SM),
dry, petroleum odor.
10 '- 11 ' (SW) Tan, FINE SAND (SW), dry, petroleum odor.
petroleum odor.
Refusal at 27.0 feet.
Top of casing
Grout
2" Sch. 40PVC
Bentonite Seal
Morrie #2
Silica Sand0.01- Slot 2"Sch. 40 PVC
End Screen,End Boring
PID = 66
PID = 13
PID = 53
PID = 105
PID = 145
PID = 89
PID = 312
PID = 280
PID = 183
PID = 253
PID = 178
PID = 255
PID = 103
PID = 85
NOTES Analytical sample collected from 11 to 12 ft. bgs. Refusal at 27'
GROUND ELEVATION
LOGGED BY Caitlin Serowik
DRILLING METHOD Hollow Stem Auger
HOLE SIZE 4 inch
AT TIME OF DRILLING ---
AT END OF DRILLING ---
AFTER DRILLING 16.50 ft
DEPTH(ft)0
5
10
15
20
25 SAMPLE TYPENUMBERPAGE 1 OF 1
WELL NUMBER MW-01/SB-01
PROJECT NAME TForce-Greensboro
PROJECT LOCATION Greensboro, NC
CLIENT TForce
GENERAL BH / TP / WELL - TRC_WINDSOR_STD.GDT - 1/31/23C:\USERS\CSEROWIK\ONEDRIVE - TRC\DESKTOP\GREENSBORO TFORCE LOGS_REV01.GPJRECOVERY %U.S.C.S.MATERIAL DESCRIPTION
GRAPHICLOGWELL DIAGRAM
EnvironmentalData3 '- 8 ' (SW-SM) Tan, SILTY FINE SAND (SW-SM), dry, petroleum odor.
PID = 136
PROJECT NUMBER 463648.0000.0000
11 '- 25 ' (SP) Light brown, tan, and gray, UNSORTED SAND (SP), dry,
CHECKED BY David Szynal
Bottom of borehole at 27.0 feet.
DRILLING CONTRACTOR Parratt-Wolff GROUND WATER LEVELS:
DATE STARTED 12/19/22 COMPLETED 12/19/22
25.0
28.0
29.530.0
33.033.534.0
36.0
0 '- 25 ' Not logged.
25 '- 28 ' No recovery.
28 '- 29.5 ' CLAYEY COARSE SAND (SW-SC), saturated, petroleum odor.
29.5 '- 30 ' SILTY COARSE SAND (SW-SM) with some clay, saturated, petroleum odor.
30 '- 33 ' No recovery.
33 '- 33.5 ' COARSE SAND (SW-SM) with some gravel, saturated, slight petroleum odor.
33.5 '- 34 ' SILTY COARSE SAND (SW-SM) with some clay, saturated, slight petroleum odor.
34 '- 36 ' CLAY (CL) with some coarse sand, micaceous, damp, no odor.
Top of casing
Grout
2" Sch. 40
PVC
Bentonite Seal
Morrie #2
Silica Sand
0.01- Slot 2"
End Screen,End Boring
NOTES
GROUND ELEVATION
LOGGED BY Ryan Culp
DRILLING METHOD Hollow Stem Auger
HOLE SIZE 4 inch
DRILLING CONTRACTOR Bridger Drilling GROUND WATER LEVELS:
CHECKED BY David Szynal
AT TIME OF DRILLING 28.00 ft
AT END OF DRILLING ---
AFTER DRILLING ---DEPTH(ft)0
5
10
15
20
25
30
35 SAMPLE TYPENUMBERPAGE 1 OF 1
WELL NUMBER MW-2A/SB-02A
PROJECT NAME TForce-Greensboro
PROJECT LOCATION Greensboro, NC
CLIENT TForce
GENERAL BH / TP / WELL - TRC_WINDSOR_STD.GDT - 6/29/23\\EMPLOYEES.ROOT.LOCAL\ENV\ECC\GREENVILLE\PROJECTS\CLIENTS\TFORCE\GREENSBORO\SOIL BORING LOGS\GREENSBORO TFORCE LOGS_REV01.GPJMATERIAL DESCRIPTION
GRAPHICLOGWELL DIAGRAM
Sch. 40 PVC
Borehole terminated at 36.0 feet.
PROJECT NUMBER 539311.0000.0000
DATE STARTED 6/12/23 COMPLETED 6/12/23
No soil boring log or well construc�on diagram for TMW-04

Installa�on Date = May 24, 2023
Prepacked screen = 15-25 feet
Well diameter = 3/4 inch
Total depth = 25 feet

MC
MC
MC
MC
MC
MC
100
100
100
100
100
100
0.5
5.0
6.0
10.0
12.5
15.0
16.5
20.0
22.0
27.0
0 '- 0.5 ' Concrete.
0.5 '- 5 ' Red, CLAY (CL) with little silt, micaceous, dry, no odor.
5 '- 6 ' Red to orange, CLAY (CL) with silt, micaceous, dry, no odor.
6 '- 10 ' Dark orange to light brown, SILT (ML) with sand, micaceous, dry, no odor.
10 '- 12.5 ' Light brown, SILT (ML) with fine to medium sand, micaceous, moist, no odor.
12.5 '- 15 ' COARSE SAND (SW), micaceous, moist, no odor.
15 '- 16.5 ' Red to light brown, SILT (ML) with some clay, micaceous, moist, no odor.
16.5 '- 20 ' COARSE SAND (SW), micaceous, moist, no odor.
20 '- 22 ' Light brown, CLAY (CH), micaceous, saturated, no odor.
22 '- 27 ' COARSE SAND (SW), micaceous, moist, no odor.
NOTES
GROUND ELEVATION
LOGGED BY Ryan Culp
DRILLING METHOD Direct Push
HOLE SIZE 2 inch
DRILLING CONTRACTOR Bridger Drilling GROUND WATER LEVELS:
CHECKED BY David Szynal
AT TIME OF DRILLING ---
AT END OF DRILLING ---
AFTER DRILLING 14.92 ft
DEPTH(ft)0
5
10
15
20
25 SAMPLE TYPENUMBERPAGE 1 OF 1
BORING NUMBER TMW-05
PROJECT NAME TForce-Greensboro
PROJECT LOCATION Greensboro, NC
CLIENT TForce
GENERAL BH / TP / WELL - TRC_WINDSOR_STD.GDT - 6/29/23\\EMPLOYEES.ROOT.LOCAL\ENV\ECC\GREENVILLE\PROJECTS\CLIENTS\TFORCE\GREENSBORO\SOIL BORING LOGS\GREENSBORO TFORCE LOGS_REV01.GPJRECOVERY %MATERIAL DESCRIPTION
GRAPHICLOGBorehole terminated at 27.0 feet.
PROJECT NUMBER 539311.0000.0000
DATE STARTED 6/13/23 COMPLETED 6/13/23

\\EMPLOYEES.ROOT.LOCAL\ENV\ECC\GREENVILLE\WPGVL\PJT2\539311\0000\000007\L5393110000PH7-002 - WELL ABANDONMENT.DOCX
Attachment 3 Well Abandonment Form
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply)□Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irrigation
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
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For 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 this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply)□Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irrigation
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
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For 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 this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply)□Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irrigation
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
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (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 □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:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For 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 this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:
WELL ABANDONMENT RECORD
1. Well Contractor Information:
Blair Mitchell Well Contractor Name (or well owner personally abandoning well on his/her property)
NCWC 4419-C NC Well Contractor Certification Number
Red ox Tech, LLC Company Name
2. Well Construction Permit #: WI0400608-----------------List all applicable well constrnction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):Water Supply Well: □Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply)□Residential Water Supply (single)
□ Industrial/Commercial □Residential Water Supply (shared)□IrrigationNon-Water Supply Well:
�Monitoring □RecoveryInjection Well: □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 Return)□Other (explain under 7g)
4.Date well(s) abandoned: 1 f 1 Of2024
Sa. Well location:
TForce Freight Facility/Owner Name Facility ID# (if applicable)
4411 Groometown Road Greensboro, NC 27 407 Physical Address, City, and Zip
Guilford County County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient)
35.995785 N -79.863324 ------------
CONSTRUCTION DETAILS OF WELL{S} BEING ABANDONED
w
Attach well constniction record(s) if available. For multiple injection or non-water supply wells ONLY with the same constn1ction1abandonment, you can submit one form.
6a. Well ID#: TMW-05----------
6b. Total well depth: _2_7 ______ (ft.)
6c. Borehole diameter: _2 ______ (in.)
6d. Water level below ground surface: _~_1_6 ______ (ft.)6e. Outer casing length (if known): _________ (ft.)
6f. Inner casing/tubing length (if known): ______ (ft.)
6g. Screen length (if known): ___________ (ft.)
I fa Internal Use ONLY,
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the samewell construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of wells abandoned:_1 _______________ _
7b. Approximate volume of water remaining in well(s): _O ______ (gal.)
FOR WATER SUPPLY WELLS O:NL Y:
7c. Type of disinfectant used: _______________ _
7d. Amount of disinfectant used: ______________ _
7e. Sealing materials used (check all that apply):
� Neat Cement Grout
□Sand Cement Grout□Concrete Grout
□Specialty Grout
□Bentonite Slurry
□Bentonite Chips or Pellets
D Dry Clay □Drill Cuttings
□Gravel
□Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Type 11/11 Portland Cement ~25 lbs.
7g. Provide a brief description of the abandonment procedure:
Portland cement tremie grouted from depth to surface
filling well vault
8. Certification: E� � 1/15/2024 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 15A NCAC 02C .0100 or 2C .0200 Well Constrnction 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 wellabandonment 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 10aabove, 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, l\"C 27699-1636
10c. For Water Supplv & 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 2-22-20 I 6
Monitoring Well Abandonment Report

TForce – Greensboro
4411 Groometown Road, Greensboro

Permit #: 2022-12-22-MW2-RW0
Customer ID: 202494

January 15, 2024