WM0100489_Monitoring Well Construction Report_20210609

WELL CONSTRUCTION RECORD (GW4
le Well Contractor Information:
Print form
For Internal Use Only:
Jason Chiorazzi
Well Contractor Name
3379
NC Well Contractor Certification Number
VERCO
Company Name
2. Well Construction Permit#: WMO 100489
List all applicable well construction permit's (i.e. UIC, Coun, State, Variance, etc.
* Well Use (cheek well use).
Water Supply Well:
Agricultural
Geothermal(Heating/Cooling Supply)
Industrial/Commercial
Irri ation
Non -water Supply vl�
3monitoring
Injection Well:
3Aqulfer arg
A u i er Storage and Recovery
Aquifer Test
Experimental Technology
Geathennai (Closed Loop)
Geothermal (Heating/Coo Return)
[3Municipal/Public
�IResidential Water Supply (single)
Residenfial Water Supply (shared)
Recovery
Groundwater leediation
Salinity Bier
l Stonnwater Drainage
OSubsiden
OTracer
Other (e
ee Control
lain under #21 Remarks
4. Date Well(s) Completed: 5/6/21 Well ID# SB-1
a. Well Location:
Facility/Owner Name
7607 US 25, Marshall, NC
Physical Address, City, and Zip
Madison
County
Facility ID# of applicable)
Parcel Identification No.(PIN)
5b. Latitude and longitude in degrees/rW*nutes/seconds or decimal degrees:
(if Nvell field, one lat/Iang is sufficient)
35.81980 6 520591676 N-82.7046061 04487$4 W
6. Is(are) the well (s) 0 Permanent or �Te�nparary
7. is this a repair to an existing well: Yes or No
�f this is a repair, fill out knovm well eonstruction information and explain the nature the
repair under # l remarks section or on the back of t isfor .
. For G ro a DPT or Closed -Loop Geothermal wells having the same
construction, only I GW-1 is needed. hidicate TOTAL NUMBER of wells
drilled;
. Total well depth below land surface:. 14
- � *i�Y I 1 -I+1��1 1 ■11■ Irl I I■.11 li
'o r m ultiple well's list all depths rf different (examp le- 3 Cw,2 o } and � '
i 3.65
to. Static water level below top of casing,,
If water level is above asr , use
1. Borehole diameter; 3
12. Well construction methods Direct Push
(i.c. anger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
ta* Meld p Method of test:
I3h. Disinfection type: Amount:
1, WATER ZONES
FROM
TO
DESCRfPTION
14 T-
3.6,5 fte
1 & OUTER CASINGmulti-eased a LINER (if ap fi abt
FROM
TO
DIAMETER
THICKNESS
MATERIAL
t*.
.DER CASING OR TUBING l cl
FROM
TO
RTAKETR THICKNESS
MATERIAL
PVC
ft%
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THWKNESS.
MATERIAL
14 ' .4
1 i
0.010
PVC
fto
tt}ind
Igo GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD AMOUNT
ft,
fto
19. SANDRAVEL PACE if a !e
FROM
To
MAT R L
EMPLACEMENT ?1 THo
ft.
ft.
ft*
,
. DRULLING LOG ttach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, h of a es, soflc # c, M sue, etc.)
ft a
fte
ft 0
t.
't.
ft.
i
t*
t.
t
fin
21. REMARKS
. Certification:
Signature -
Well
Contractor
5/28/21
Date
By signing this form, I here certify that the well(s) was (were) constnicted in accordance
ace
with ]JA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy, qj'this record s been provided to the well owner.
3. Site diagram or additional well detailso.
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
for AllG Is: Submit this form within 30 days of completion of well
clo.ustmetion to the o owing
Division of Water Resources, Information Processing unit,
1617 Mail Service Center, RaleigI4 NC 276994617
b. For Lnjection Wells: In addition to sending the form to the address in 24a
above,, also submit one copy of this form within 30 days of completion of well
construction to the Following:
Division of Water Resources, 'Underground I j ection Control Program,
1636 Mail See Center, Raleigh, NC27699-1636
c. For 'water SuRply & Injection a In addition to sending the fo to
the address above, also submit one copy of this form within 30 days o
completion of will construction to the county health department of the county
where constructed,
Form. GW-1 North Carolina Department of Environmental Quality -Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1
Print Form
For Internal Use only:
1. Well Contractor Information:
Jason Chiorazzi
Well Contractor Name
3379
NC well Contractor Certitiatl*on Number
VERCO
Company Name
. Well Construction Permit ; WMO 100489
_P�p -
List all applicable we17 construction permits i. e. UIC, Couni, State, Variance, , etc.)
. Well Use (cheek well use)
Water Supply Well;
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
irrigation
Non -Water Supply Well:
3Monitoring
Injection Well:
JAquifer Recharge
IAquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Coo Return)
MunicipaUPi€b[ic
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
Stormwater Drainage
DSubsidence Control
Tracer
Other (explain under 921 Remarks)
4. Date Well(s) Competed: 5/6/21 Wei ID# S B 2
5. Well Location:
Facility/owner Name
7607 US 25, Marshall, NC
Physical AddY•ess, City, and Zip
Madison
County
F ac i l i ty l # if applicable)
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees;
(if well field, one ]at/long is sufficient)
35,819806520591676 N-82.70460610448784 W
6. Is(are) the well(s)oPermanent or Temporary
'. Is this a repair to any exisdug weft: V.. Yes or FmNo
I, 'this i's a repair, fill out known well construction information and explain the natureqJ'the
repair under #21 r em r y section or on the back ofthisform.
. For Geoprobe I PT orClosed-Loop Geothermal Wells having the same
construction, only f W-1 is needed. Indicate TOTAL NUMBER of weUs
drflled*
9. Total well depth below land surface:(ft)8
For multiple -wells list all depths if different (example- 3@200 ' and @1
1. Static pater level below top of casing:
if water level is above casing, use "+ "
Dry
11. Borehole diameter:(in.)3
12. Well construction method: Direct Push
i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS (1N1.;Y:
13a.. Yield (gpm)
Method of test:
I3b. Disinfection type: I Amount:
149 WATER ZONES
FROM
TO
DFWREPUON
ft*
ft.
fte
fL
15. OUTER CASING (for multi -cased ' fl LINE11 bl
FROM
TO
DUMIETER
TMCKNES
MATERIAL
ft,
ft.
in.
i DER CASING OR TUBING them. dosed4 1
FROM
TO
DLAMIETER
THICKNESS
MATERIAL
.
PVC
t.
ft.
in.
17. SCREEN
FROM I
To
DUNIETER
SLOTSIZE
THICKNESS
MATERIAL
t.
ft.
1 in.
0.010
PVC
ft.
i
in.
18, G o t]'r
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
€t.
f b
1 9_ SANIGAVPL PACK Hebl
FROM
To
NIATFIUAL
EMPLACEMMNT METHOD
t*
ft@
ft&
ft.
o. DRILLING LOG (attach additional sheets if near
FROM
To
DESCRIPTION olor, hardness, m"Urec ,, grahm nrt� etc.)
ft...
ft.
ft.
fto
fts
fte
ft0
t. RERAN
. Certification:
Signature
Well Contractor
5/28/21
Date
. signing this form, I hereby certhat the i(were) constructed in f7ccordance,
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy of - this record has been provided to the well owner.
3. Site diagram or additional well details:
You may use the back ofthis page to provide additional well site details or well
construction details. You may also attach additional pages if necessary,
SUBMITTAL INSTRUCTIONS
. 'or All 111 s: S b t this on-n within 3 d .ys of completion f well
co straction to the following..
(ft-b)Division of Water Resources, Information Processing Unit,
1. 17 Mail Service Center, Raleigh, NC 7 -161
h. For Injection Rs: In addition to sending the form to the address in 2 a
above, also submit one copy of this form within 30 days of eomptetlon of well
construction to the following:
Division ion t r Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC27699-1636
2 c. for Water Supply & Lnjection wells: In addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fox W-1 No1#h Carolina Department of Environmental Quality - Division of Water resources Devised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1
Print Form
For Fraternal Use Only:
1. Well Contractor Information:,
Jason Chiorazzi
W el l Contractor Name
3379
NC Well Contractor Certification Number
VERC 0
Company Name
2, Well Construction Permit #: WM0100489
List al applicablevvel constm on permits(i.e. IC, ur i y, State, Variance, etc.
. Well Use (check well use):
Water Supply Well;
Agricultural
]Geothen-nal (Heating/Cooling Supply)
]Industrial/Commercial
IhTiaation
Non -Water Supply Well:
Monito in
In a tlon Well.
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Rehun)
4. Dade Well(s) Completed: 5/6/21
a. Well Location:
Facility/Owner Name
7607 US 25, Marshall, NC
Physical Address, City, and Zip
Madison
County
Municipal/Public
�IResidential Water Supply (single)
�IResidential Water Supply (shared)
Recovery
r""IGrounciwater Remediation
rm"lSalinity Barrier
WE"Stormwater Drainage
�f Subsidence Control
DTracer
Other (explain under #Z 1 Remarks)
Well ID# SB-3
Facility ID# (if applicable)
Parcel Ide ti-ati o n No. (PIN)
3b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/lang is sufficient)
35.819806520591676 N-82.7046061 0448784 W
6. Is(are) the wells)oPermanent or Temparary
7. Is this a repair to are existing well: ; Yes or No
If t i is a repair, fill out known well constmctioii information and explain the mature of the
repair- under 421 remarks section or on the bare of thisform.
. For Geopro e DPT or Closed -loop Geothermal Wells having the same
construction, only l GWA is needed. Indicate TOTS NUNMER of wells
dr'll d:
9. Total we1l depth below land surface: 12.5 (k)
`or multiple we Us list at1 depths ff different (example- 3 W 00 ' airr 2 � 1 00'
10. Static water level below top of easing: 5.0� .
If water level is aboire casing, use CC+ ,
�
1. Borehole diameter:(in.)
�
12. Well construction method: Direct Push
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY ELLS ONLY:
1_ Yield (gpm) Method of test:
1 h. Disinfection type
Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
12.5 ft
ft*
ft,
ft*
15. OUTER CASING (tor nitl-eased wells) OR LINER ff applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft,
ft.
Y .
j 16. INNER CASING OR TUBING (geothermal closed -loop) E
FROM
TO
DIAMETER
THICK-NETHICK-NESS
MATERIAL
2.5 ft.
0 ft.
1 in.
PVC
■
in.
17. SCREEN
FROM
TO
DIAMETER
LOT S I
THICKNESS
L
MATERIAL
12.5 -
t.
1 �
0.010 o
PVC
fL
ft.
in.
18. GROUT
FROM
TO
A"rERIAL
EMPLACEMENT METHOD & AMOUNT
fte.
fte
f t.
ft.
ft.
19. SANDJGRAVEL PACK if applicable)
FROM
To
MATERIAL
EMPLACEMMNT METHOD
HOD
ft.
ft.
ft.
ft.
20. DRILLING L (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock tye, grain size, etc.)
i
ft.
fte
1
ft.
t .
fte
ft.
fte
ft,
te
ft.
ft.,
I. REMARKS
2. Certifietlo:
5/28/21
SigAture of Cc)tffied Well Contractor Date
By signing this forin, I hereby cert that the well was were constructed in accordance
with I NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
copy of this record has been provided to the well owner.
2. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
4a. For All WeRs: Submit this on within 30 days of completion of well
conttlon to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center., RalelgNC 2 9-1 17
24b. For injection ye: In addition to sending the fora to the address 'n 2
above, also submit one copy of this form within o days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & Injection Wells: In addition to sending the f'orm t
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fora W-1 North Carolina p i-tment of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION_ RECORD (GWml
Print Form
For Internal Use Only:
1. Well Contractor Information:
Jason Chiorazzi
Well Contractor Name
3379
IBC Well Contractor Certification Number
VERCO
Company Name
2. Well Construfion Permit #: WM01 00489
Li,yt all applicable well co -ue�iopermits i.e. UIC, Calm , State, Variance,, etc.)
3. Well U (check well use):
JAgricultural
]Geothermal (Heating/Cooling Supply)
�I industrial/Commercial
]Irrigation
Nan -Water Supply Well:
JMonitoring
Injection Well:
-Aquifer Recharge
Aquifer Storage and Recovery
JAquifer Test
7JExpen-mental. Technology
Geothermal (Closed Loop)
Geothermal (Heating/Coolm'g Retum)
. Date Well(s) Completed:
5a. Well Location:
Facility/Owner Name
QlMunicipal/Public
DResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediatian
�ISalinity Barrier
Ql Stormwater Drainage
Subsidence Control
OTracer
Other (explain under #21 Remarks)
5/6/21 Well ID# S B -4
7607 US 25, Marshall, NC
Physical Address, City, and Zip
Madison
County
Facility ID# (if applicable)
Parcel Identification No- (PIN)
5b_ Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35m8l9806520591676 N-82.70460610448784 W
b. Is(are) the well(s)oPermaneat or Temporary
7. is this a repair to an existing weH: Yes or N
If this is a repair, fill out known well construction information and explain the nature of` he
repair under #1 remarks section or on the back ofthisform.
. For Geoprobe PT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW -1 -is needed. Indicate TOTAL NUMBER f wells
n' lled:
, 'Total well depth below land surface: 9.3
f
For multiple wells fast all depths if d erent in e- @2' and @1 '
10. Static water level below top of casing:
If water level is above casing, use
11. Borehole diameter: 3
3.7
12. Well construction method* Direct Push
i.. auger, rotary, cable, direct push., etc,)
FOR WATER SUPPLY WELLS ONLY+
1 a. Yield p Metbod of Lest:
1 b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
�rI
9.3 t.
3.7 ft.
15. OUTER CASING `or multi -cased wells) OR LM if applicable)
FROM
To
DUMETER
THICKNESS
MATERIAL
1; BIER CASING OR TUBING(geothermal el-loo
FROM
To
DIAMETER
THICKNESS
IA°IERUL
*t.
i4k
f1.
in4
17. SCREEN
FROM
To
DIAMETE R
SLOT SIZE
THICKNESS
MATERIAL
. t
I ,
0.010
PVC
18. God`
FROM
TO
MATERIAL
EMPLACENTENT METHOD & AMOUNT
fti
ft*
ft.
ft,
19_ SAND/GRAVEL PACK ifapplicabl�)
FROM
To
MATERIAL
EMPLACEMENT T ME T METHOD
ft i
ft•
It.
It.
. DRILLING LOC (attach additional sheens if necessa
FROM
TO
DES RJPTION (color, haTdns, sol'Wrock type, graiffn stize, etc.)
It.
It.
iti
fti
fte
ft.
ft.
It.
ft&
1.
REMARKS
. Certification:
5/28/21
Signatur��`+�. Eet��ed Well Contractor Date
By signing thizv form, I hereby r* that the well ) was (were) constructed in accordance
ance
with 13A NCAC 02C.0100 or 15A NCAC 02C.0200 Well "orrstr etion Standards and that a
cps qj'this recordhas been provided to the well owner_
3. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if -necessary.
SUBMITTAL INSTRUCTIONS
4 . For At1 Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft') Division ofWater Resources, Information Processing Unit,
1617 Mail Service Center., Raleigh, NC 99-1 1
4b. For Injection Wells: In addition to sending the form to the address in 2 a
above, also submit one copy of this form within 30 rays of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
c. For Water �_ _UM -& In��w . 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 construction to the county health department of the county
where constructed.
Foy w-1 Nosh Carolina Department of Environmental Quality - Division of w t r Resources Revised - -- 1

WELL ABANDONMENT RECORD
I For Internal Use ONLY:
1. Well Contractor Information:
Jason Chiorazzi
Well Contractor Name {or well owner personally abandoning well on his/her property}
3379
IBC Well Contractor Certification Number
VERCO
Company Kano WM01 00489
. Well Construction Permit # .
List all applicable well cmi tr ction permits (i.e. UIC, County.7, State, Variance, etc.) ifknomlz
. Well use {check well use):
Water Supply well:
ElAoltural
D Geothermal (Heating/Cooling Supply)
0 Industrial.C o mere i 1
D Irri .ti n
Non -Water Supply Well:
IMMonit rin
Injection Well:
DA uifer recharge
CA ui er Storage and Recovery
O Aqui f r Test
OlExperimental Technology
EDGeothermal (Closed Loop)
D Geothermal (Heating/Cooling I etum
4. Date well(s) abandoned: 51612
a. Well location:
1
OMunicipal/Public
❑Residenrial Water Supply (single)
OResidential Water Supply (shared)
CIeoer
O Groundwater Remediation
❑$alinity Barrier
O Stormwater Drainage
Subsidence Control
0 Trac er
❑other (explain under 7g)
ALL ABANDONMENT DETAILS
7 . For opro D T or Closed -Loop Geothermal 'Wells having the sarne
well c nstruc ion depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I
7 . Approximate volume of water remaining lb
in eve" s :
FOR WATER SU-PPLV WELLS ONLY:'
7. Type of disinfectant used:
17d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply)*
a Neat Cement Grout 0 Bentonite Chips or Pellets
❑ Sand Cement Grout
Il Concrete Grout
Q Specialty Grout
❑ Rentonite Slurry
El Dry Clay
Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7L For each material selected above, provide amount of materials used:
-4-gal
7g. Provide a brief description of the abandonment procedure.
tremmie
Facility/Owner Dame Facility ID## (if applicable) 8. Certification;
7607 US 25, Marshall, NC
Physical Address, City, and Zip
Madison
County
Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweil field, one lat/long is sufficient)
35.819806520591676 N 82870460610448784 w
CONSTRUCTION DETAILS of WELL(S) BEING ABANDONED
st ela well construction record of available. For multiple injection or non -water supply y wells
ONLY A4th the same construction abandonment# you can submit oneform.
. Well 1Da SB�l
. Total well depth:
14
c. Borehole diameter: 3
6d. Water level below ground surface: 3,65
e, outer casing length if known):
Est.}
(ft.)
f. Inner casing/tubing length if known): 4 (ft.
. Screen length if known):
10
(ft.)
5/28/21
Signor�ofified Well Contractor or Well owner Date
(gal.)
By signing ft. form, I hereby certift that � s w (were)abandoned h2
accordancewith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record as been provided to the well owner.
. 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,
SUBNHTTAL INSTRUCTIONS
l a. For All wells: Submit this form within 30 day& of completion of well
abandonment to the following -
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 7 -1 1
10b. For lLrijection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form vita 30 days of completion of well
abandonment to the following:
Division of water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC27699-1636
14c. 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 will abandonment to the county health department of the county where
abandoned.
Fora GW- o North Carolmna Department of Environmental Quality - Division of Water Resources Revised - .- 1

`'YELL ABANDONMENT RECORD
I For Internal Use ONLY
. Well Contractor Information:
Jason Chiorazzi
Well Contractor Name or well owner personally abandoning well on his/her property
3379
NC Well Contractor Certification Number
VERCO
Company Name
WMO 100489
. Well Construction Permit # :
List all applicable well construction permits(Le. UIC, ' ti; State, Variance, +, i; 'knvn
. Well use (check weH use):
Water Supply Wefl:
❑agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndus UCommer ial
_EllffiLation
Non -water Supply well:
MMo itoring
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal {Closed Loop}
❑ Geothermal (Heating/Cooling Retum)
4. Date well(s) abandoned: 5/6/2
1
a. Well location:
❑MunicipaUPublie
❑Residential Water Supply (single)
OResidential Water Supply (shared)
❑ ecer
❑Groundwater Re edi ati on
❑ S al nity B am- er
❑ Stormatr Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under 7g)
Facility/owner Name Facility ID# (if applicable)
7607 US 25, Marshall, NC
Physical Address, City, and Zip
Madison
County
Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/lang is sufficient)
35.819806520591676 N 82.704fi06'10448?'S4 W
CONSTRUCTION DETAILS OF WEDS) BUNG ABANDONED
Attach well construction record(s)if `available. For multiple injection or non -water supply ells
ONLY with the same constnictionlabandonment, you can submit oneform.
a. Well ffW4h S B�2
i
h. Total well depth.8 (ft.)
e. Borehole diameter. 3 (in.
6d. Water level below ground surface: D RY
e. Outer easing length (if known)*
6L Inner in to bing length (if known): 3
g. Screen length (if known): 5 ft'
WELL ABANDNMNT DETAILS
7a. For Geoprohe DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
ells abandoned: I
7. Approximate volume of water remaining in yells:
I FOR WATER SUPPLY WELDS ONLY:
1 7. Type of disinfectant used;
17d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
IN Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Concrete Groat
❑ Specialty Grout
❑ Bentonite Slurry
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain ender 7g)
7f. For each material selected above, provide amount of materials used:
2 gal
7g# Provide a brief description of the abandonment procedure:
tremmie
8. Crtireatlo n
5/28/21
Sianatuk,of Ced Well Contractor or V4'e!1 Owner Date
(gal.)
17 ig ing this form, I hereby er ift, that the w was (were) abandoned h
accordance with 15,4 NCAC 02C. 0100 r 2C. 0200 Well Construction Standards
and that u cupy of this record has been provided to the well owner.
. Site diagram or additional well details:
You may use the back of this page to provide ide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
i Oa. For All Wells: Submit this fora within 30 days of corn letion of well
a andonnrent to the following:
Division of Water Resources, Information Processing Unit,
117 Mail Service Center, Raleigh, N -1 17
1 h. For In;eetton Wells: In addition to sending the form to the address in 10a
above, also subinit one copy of this form within 30 days of completion of well
abandom,nent to thefollowing:
division of Water Resources, Underground Injection Control Program,
1636 Mail Service Venter, Raleigh, NC 7-1 3
10c. For Water Supply &Injection Wells: In addition to sending the farm to the
address(es) above, also submit one copy of this farm within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form W- o North Carolina Department ofEnvironmental Quality - Division of Water Resources Revised 2.- - of

WELL ABANDONMENT RECORD
I For Internal Use ONLY:
1. Well Contractor Information;
Jason Chiorazzi
Well Contractor Name (or well owner personally abandoning well on his/her property)
337 9
NC Well Contractor Certification Number
VERCO
�m_n.moon■_m■n■.■.n�•�r..■yr..rrr+�rn�w i ■ i i � ■ ■ . � �r y—rrry�i�rM����i�u.nuia_ni_mn—ice■■�r�w—r��.■•.��r - � i�� .
Company Dame
2. v eU Construction Permit* WM01 00489
List zpplicable well const ction permits (Le. UIC, Comm)� State, Variance, eta) if
3, Well use (check well use):
Water Supply WedJD
Ogriltral
ElGeothermal (Heating/Cooling Supply)
ation
Non -water Supply Well:
©Monitoring
Injection Weld:
D.ler Recharge
Eluifr Storage and Recover
❑ Aquifer Test
ElExpedmental Technology
D Geothermal (Closed Loop)
E G of en al_(Heatin g/Co olln lets
4. Date well(s) abandoned: 5/6/21
a. Well location:
QMunicipavPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
DRecovery
ElGrou.nd eater r eme iation
Salinity Barfier
El Stor w .ter Drainage
[]Subsidence Control
OThacer
❑Other (explain under 7g)
Facitity/dwner Name Facility iD# (if applicable)
7607 US 25, Marshall, NC
Physical Address, City, and Zip
Madison
County
Parcel Identification No. (FIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field, one ladlang is sufficient)
35.819806520591676
N 82o7O460610448784 W
CONSTRUCTION DETAILS OF WEI�LLS) REING ABANDONED
Attach well construction record(s) rf a al abl . "or multiple i ,F ction or non -water supply wells
ONLY Kith the same constru tionlaba r onmen , you can submit ore form.
a. We H)41& S Bwm3
6h.'otaZ wefl depth: 12 6
ft.
3
. Borehole diameter: RP
d. Water level below ground surface:5 0.
4MMEPWft.
e. voter casing length (if known): t.
L Inner casing/tubing length (if known): __2_*,.. -- - - ■ ....... _ _ ft.
5g. Screen length (if known): 10
7a. For eo o e/DPI` or Closed -Loop Geothermal Wells having the same
well con traetion ept , only I GW-30 is needed_ Indicate TOTAL NUMBER of
wells abandoned:
7 . Approximate ate volume of water remaining in weH(s): gal.)
o WATER SUPPLY ELLS ON
� 7 . Type of disinfectant used:
17d. Amount of disinfectant used:
7e. Sealing materials used (check A th
11 Neat Cement grout
El Baal Cement Grout
0 Concrete Grout
❑ Specialty Grout
❑ Benfonite Slurry
at apply):
0 Bentonite Chips or Pellets
0 Dry Clair
0 Drill Cuttings
Gravel
O Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
4 gal
7 . Provide a r"ef description of the abandonment procedure:
e m ie
. Certification;
5/28/21
SignatJc�ified We#1 Contractor or Well Owner Date
By � igni finis folM, here y certify that the e s -cis(were) in
accordance with 15A NCAC 02C -0100 or 2C.0200 Well Construction Standards
and that a copy of thky record hav heen providedto the well " r.
. 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.
SUBTTAL INSTRUCTIONS
--- � � •u �n� i. iw.r�ur i�r■r. iim■err.
a. For All Welk: Submit this forte within 30 days of completion. of well
abandonment to the following:
Division or Water Resources, Information Prar-essing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lob. for Injection Wells: 1h addition to sending the form to the address in 10a
above, also subI t one copy of this form with 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
hoc. for water Su In'eetion Wells: I aitox to sending the'orr to the
address(es) above, also submit one copy of this form wihl'n 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 ofWater Resourccs Revised - 2- 01

WELL ABANDONMENT RECORD
For Internal Use ONLY-.
1. well Contractor Information:
Jason C
Well Contractor Name or well owner personally abandoning well on his/her property)
3379
NIC well Contractor Certification Number
VERCO
Company Name
WMO 100489
. Well Contr-utlo Permit
i t all applicable well construction permits (Le. UIC, Counti?, State, Variance, etc.) ifkn;n
3. Well use (cheek well use):
WaterSupply We:
DAgricultural
❑Geoth rrna.l(Heating/Cooling Supply)
❑ Industrial/Commercial
❑.lrri ation
Non -water Supply well:
M Monitoring
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Vest
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal eatln/Cooling Return
4. Date well(s) abandoned: 5/6/2
a. Well location:
Facility/owner Name
1
❑Munioip l ubli
❑ Residential water Supply (single)
EIcsideotial water Supply (shared)
EIRecavery
❑ Groundwater Remediation
❑ S al lnity arri er
❑ Ston eater Drainage
[]Subsidence Control
[]Tracer
OOther (explain under 7g)
Facility ID# if applicable
76-07 US 25, Marshall, NC
Physical Address, City, and Zip
Madison
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.819806520591676 N 82m7O460610448784 W
O ST UC 140N DETAILS of '' LL BEING ABANDONED
Attach well construction record available. For multiple injection non -water supply wells
ONLY with tine same constructionlabandonment, you can submit one* or .
6a. well III##OF
: S B-4
b. Total well depth:(ft.)9 3
. Borehole diameter: 3
bd. Water level below ground surface: 3'
7
e. Outer casing length (if known): - ft.
f. Inner casinWtubing length it known):
6g. Screen length (if known): 10
(ft.)
WELL ABANDONMENT DETAILS
7a. For eoprobe DPP or Closed -Loop Geothermal Wells having the same
well constr otion d pth, only I Gil- o is needed. Indicate TOTAL NUMBER of
wells abandoned: 1
7b. Appro l*mate volume of water remaining in ve 47gal.)
o WATER SUPPLY WELLS ONLY:'
7e. Type of disinfectant used:
7d* Amount of disinfectant used:
e. Sealing materials used (check all that apply):
M Neat Cement Grout ❑ Beutonite Chips or Pellets
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
0 BentonYte Slut-ty
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
f_ For each material selected above, provide amount or materials used:
3 gal
7. Provide a brief description of the abandonment procedure:
tremmie
8. Certification
Signature of
ell Contractor or well Owner
5/28/21
Date
it igni .sng this for., I hereby ce ift. that the well(s) was (were)abandoned i
accordance with 15A NCAC 02C.0100 or 2C� 2 Well Construction Standards
and that a copy ofthis record has been provided to the well o-vmer.
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.
SUBM TAL INSTRUCTIONS
I oa_ For All Wells: Submit this forrn within 30 days of completion of well
abandonment to the following. -
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC -1 1
lob. For Infection Wells: In addition to sending the form to the address in 1 oa
above, also subinit one copy of thi's form within30 days of completion of well
abando=eiat to the following:
Dillon of water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC27699-1636
10c. For Water Supply & Injection Wells; In addition to sending the form to the
address(es) above, also submit one copy of this form withi*n 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form W- o Forth Carolina Department of Environmental Quality - Division of water Resources Revised - - 01

TEST BORING REPORT
BORING NO.
'ROJECT.
BLE JOB NO.
PAGE NO. I of
LOCATION:
ELEVATION:GROUND
DATE START:
DATE FINISH:
DRILLER:
PREPARED BY:
�LIENt.
CONTRACTOR: �,�
EQUIPMENTUSED:
WATER
DEPTH TO:
CORE
CASING SAMPLER BARREL
DATE
HRS AFT
COMP
WATER
BOT. OF
CASING
BOT. OF
HOLE
TYPE
SIZE ID/OD
HAMMER WT
HAMMER FALL
PVC
XXX
TOB
XXX
24-Hr
XXX
XXX
XXX
DEPTH
IN
FEET
CASING
BLOWS
PER FT
SAMPLER
BLOWS
PER 6"
SAMPLE
NUMBER
PID
FIELD CLASSIFICATION AND REMARKS
10
15
20
�f
--
-
00tvwad
- X� ,Vs�
_
-
-
-
II _
II -
II
II -
II -
I _
57Y
BLOWS/FT DENS ITY(Sand/Gravel)
BLOWS/FT CONSISTANCY(Clay/Silt)
SAMPLE ID
WELLDESCRIPTION
0-4 VERY LOOSE
5-10 LOOSE
1 I-20 FIRM
21-30 VERY FIRM
31-50 DENSE
51+ VERY DENSE
0-2 VERY SOFT
3-4 SOFT
5-8 FIRM
9-15 STIFF
16-30 VERY STIFF
31-50 HARD
51+ VERY HARD
SS SPLIT SPOON
HP HYDROPUNCH
UD UNDISTURBED TUBE
G GRAB
C COMPOSITE
B BAG
NR NO RECOVERY
STICKUP =
TOP BENT. =
TOP SAND =
SCREEN =
SCREEN LENGTH =
END CAP =
WELL TD=
Total Drill Depth:
DTW: 7,6'
Screen Interval ( )
Sand Interval:
Bentonite Cap:
Highest PID Reading: ;,V,/
GW Sample Time / Date: // .Y/ dq -/4
Soil Sample Time / Date: 0"W c4
k "el -��l Y
Groute:

TEST BORING REPORT
BORING NO.
PROJECT: l-flx /9
BLE JOB NO.
PAGE NO. I of
LOCATION:
ELEVATION:
DATE START:
DATE FINISH:
DRILLER:
PREPARED BY:zq-
CLIENT:
CONTRACTOR:
EQUIPMENT USED: /b
GROUND
WATER
DEPTH TO:
CORE
CASING SAMPLER BARREL
DATE
HRS AFT
COMP
WATER
BOT. OF
CASING
BOT. OF
HOLE
TYPE
SIZE ID/OD
HAMMER WT
HAMMER FALL
PVC
XXX
TpB
XXX
24-Hr
XXX
XXX
XXX
DEPTH
IN
FEET
CASING
BLOWS
PER FT
SAMPLER
BLOWS
PER 6"
SAMPLE
NUMBER
PID
FIELD CLASSIFICATION AND REMARKS
WELL
10-
15
20
�/
►�"Y.
-
-
-
II
_
II
II
I
II -
II -
BLOWS/FT DENSITY(Sand/Gravel)
BLOWS/FT CONSISTANCY(Clay/Silt)
SAMPLE ID
WELLDESCRIPTION
04 VERY LOOSE
5-10 LOOSE
11-20 FIRM
21-30 VERY FIRM
31-50 DENSE
51+ VERY DENSE
0-2 VERY SOFT
34 SOFT
5-8 FIRM
9-15 STIFF
16-30 VERY STIFF
31-50 HARD
51+ VERY HARD
SS SPLIT SPOON
HP HYDROPUNCH
UD UNDISTURBED TUBE
G GRAB
C COMPOSITE
B BAG
NR NO RECOVERY
STICKUP =
TOP BENT. =
TOP SAND =
SCREEN =
SCREEN LENGTH =
END CAP =
WELLTD=
Total Drill Depth: giQ
DTW: Cv
Screen Interval(
Sand Interval:
Bentonite Cap:
Groute:
Highest PID Reading: 6 , %
GW Sample Time / Date: M4
Soil Sample Time / Date: //� ev? �—l�
I

TEST BORING REPORT
BORING NO. -
PROJECT: ` ^
BLE JOB NO.
PAGENO. I of
LOCATION:
ELEVATION:
DATE START:
DATE FINISH:
DRILLER:
PREPARED BY:
CLIENT:
CONTRACTOR:
EQUIPMENT USED: /O ilj
GROUND
WATER
DEPTH TO:
CORE
CASING SAMPLER BARREL
DATE
HRS AFT
COMP
WATER 1
BOT.OF
CASING
BOT.OF
HOLE
TYPE
SIZE ID/OD
HAMMER WT
HAMMER FALL
PVC
XXX
TOB
XXX
24-Hr
XXX
XXX
XXX
DEPTH
IN
FEET
CASING
BLOWS
PER FT
SAMPLER
BLOWS
PER 6"
SAMPLE
NUMBER
PID
FIELD CLASSIFICATION AND REMARKS
WELL
Jll
15
Z0
-
-
I.
II -
II
0,
BLOWSXT DENSITY (Sand/Gravel)
BLOWS/FT CONSI.STANCY (Clay/Silt)
SAMPLE ID
WELL DESCRIPTION
0.4 VERY LOOSE
5-10 LOOSE
11-20 FIRM
21-30 VERY FIRM
31-50 DENSE
51+ VERY DENSE
0-2 VERY SOFT
34 SOFT
5-8 FIRM
9-15 STIFF
16-30 VERY STIFF
31-50 HARD
51+ VERY HARD
SS SPLITSPOON
HP HYDROPUNCH
LID UNDISTURBED TUBE
G GRAB
C COMPOSITE
B BAG
NR NO RECOVERY
STICKUP=
TOP BENT. _
TOP SAND =
SCREEN =
SCREEN LENGTH=
END CAP =
WELL TD=
Total Drill Depth: d' !r
DTW: S(i t
Screen Interval
Sand Interval:
Bentonite Cap:
Groute:
Highest PID Reading: Ov?
GW Sample Time / Date: A14e WWI 14
Soil Sample Time / Date: /60 , � 14 rf/
AVIA - � /�

TEST BORING REPORT
BORING NO. —
PRO CT.
BLE JOB NO.
PAGE NO. 1 of
LOCATION:
ELEVATION:
DATE START:
DATE FINISH:
DRILLER: /
PREPARED BY:
C T.
,0 CTOR:
EQUIPMENT USED:
GROUND
WATER
DEP TO:
CORE
CASING SAMPLER BARREL
DATE
HRS AFT
COMP
WATER
BOT. OF
CASING
BOT. OF
HOLE
TYPE
SIZE ID/OD
HAMMER WT
HAMMER FALL
PVC
XXX
TOB
XXX
24-Hr
XXX
XXX
XXX
DEPTH
IN
FEET
CASING
BLOWS
PER FT
SAMPLER
BLOWS
PER 6"
SAMPLE
NUMBER
PID
FIELD CLASSIFICATION AND REMARKS
WELL
5
10-
15
20
0
y
-
_
_
i
—
ii
019—
a-
�
BLOWS/FT DENSITY(Sand/Gravel)
BLOWS/FT CONSISTANCY(Clay/Silt)
SAMPLEID
WELL DESCRIPTION
04 VERY LOOSE
5-10 LOOSE
11-20 FIRM
21-30 VERY FIRM
31-50 DENSE
51+ VERY DENSE
0-2 VERY SOFT
34 SOFT
5-8 FIRM
9-15 STIFF
16-30 VERY STIFF
31-50 HARD
51+ VERY HARD
SS SPLIT SPOON
HP HYDROPUNCH
UD UNDISTURBEDTUBE
G GRAB
C COMPOSITE
B BAG
NR NO RECOVERY
STICKUP =
TOP BENT. _
TOPSAND=
SCREEN =
SCREEN LENGTH=
END CAP =
WELL IT) =
Total Drill Depth: 91 Highest PID Reading: 0,
DTW: * 3,91
GW Sample Time /Date:
Screen Interval ( ) /d
Soil Sample Time /Date: �
Sand Interval: / �/ �f
Bentonite Cap:
Groute: