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Home My WebLink AboutGuilford_Well Abandonment_20220527 WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS I Billy Joe Payne Jr 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 constrnction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of 4532-B wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'4 (gal.) Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY: Company Name Chlorination-Ca(0CI)2 7c.Type of disinfectant used: 2.Well Construction Permit#: 001-16-MW 1-RWO List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 3—oz 7d.Amount of disinfectant used: 3.Well use(check well use): s Water Supply Well: 7e.Sealing materials used(check all that apply):❑Agricultural ❑ �/MunicipatTublic a Neat Cement Grout S Bentonite C�b41 2022 ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Cl_ ay__� n P9 U ❑Industrial/Commercial ❑Residential Water Supply(shared) s Concrete Grout ❑Drill uttings EAVaIBOG ❑Irri ation ❑ Specialty Grout ❑ Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g) RMonitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-8-lb Bentonite 33-lb ❑Aquifer Storage and Recovery ❑Salinity Barrier Concrete-8-lb. ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology El Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and ❑Geothermal(Heating/Cooling Return) ❑Other explain under 7g) filled casing with Bentonite pellets and poured neat cement 4.Date well(s)abandoned: 04.29.2022 until approx. 1-fbgl and poured concrete inside casing to near the Sa.Well location: TOC and placed the lid on the manhole of the well. SM 782 00-0-0000013106 Facility/Owner Name Facility ID#(if applicable) 8. fication: 1401 N MAIN ST, HIGH POINT, NC 27235 05.24.2022 Physical Address,City,and Zip St o Certifi Well C ntmctor or Well Owner Date GU ILFORD 6891807765 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.0200 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. Sb.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° 58' 24.27" N N -80°.01' 04.83"W 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-1 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: —35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniection Wells: In addition to sending the form to the address in 10a 4 above, also submit one copy of this form within 30 days of completion of well 6c.Borehole diameter: (in.) abandonment to the following: 6d.Water level below ground surface: —20.55' (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 0'-25' (ft.) 10c.For Water Sunnly&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): (ft.) abandoned. 6g.Screen length(if known): 25'-35' (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 Billy Joe Payne Jr 7a..For Geoprob&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 4532-B wells abandoned...' 1 NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '� (gal.) Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:' Company Name CM,lorinatlon-Ca(OCl)2 '7c,Type of disinfectant used: 2.Well Construction Permit#: List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 3-oz 7d,Amount of disinfectant used: � r 3.Well use(check well use): Water Supply Well: 7e.Sealing materi 202 als used(check all that apply): MAY _2 � 2 ❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑D�yl taza i Procu4m' g Vm4 ❑Industrial/Commercial ❑Residential Water Supply(shared) W Concrete Grout ❑Drill Cuttings-Amr'oG ❑hri ation O Specialty'Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) CMonitoring, ❑Recovery Injection Well: 7f.For,each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-8'=Ib Bentonite 28=lb ❑Aquifer Storage and Recovery El Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage Concrete=8=1b ❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) filled casing.with Bentonite'pellets and poured neat cement 4.Date well(s)abandoned: 04.29.2022 until approx. 1-fbgl and poured concrete inside casing to near the 5a.Well location: TOC and placed the lid on the manhole of the well. SM 782 00-0-0000013106 Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1401 N MAIN ST, HIGH POINT, NC.'27235 05.24.2022 Physical Address,City,and Zip Si cf Certified fell Contra or or Well Owner Date GUILFORD 6891807765 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.0100 or 1C.0200 Well Construction Standards and that a copy of"this record has been provided to the well owner. Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details: 350 58' 24.27" N N -800.01' 04.83" W 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 constructionlabandonment,you can submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#• MW72 abandonment to the following: Division ofWiter Resources,Information Processing Unit, 6b.Total well depth: -30 (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: 4 (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: —19.12' (fL) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 0'-15' (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): (ft.) abandoned. 6g.Screen length(if known): 15'-30' (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 Bill Joe Payne Jr y y 7a For GeoprobelDPT or Closed-L'oop 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 4532-B wells abandoned: 1.0 NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): Excel-SRP Environmental FOR WATER.SUP.PLY-WELLS,ONLY: CompanyName Chi orination-Ca(OCI)2 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown ` -O "+ 7d.Amount of disinfectant used: `3Z t� 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): MAY .9 7 2022 ❑Agricultural ❑Municipal/Public a Neat Cement Grout S Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Cla)NOU -4��LCe6aMq`n ❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings t 0(3 ❑Irri ation ❑ Specialty Grout ❑ Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) AMonitoring ❑Recovery - Injection Well: 7E For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-1b: Bentonite 28-lb ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage Concrete-8.=1b ❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abanA6nment procedure: ❑Geothermal(Closed Loop) ❑Tracer Dropped'Calcium Hypochorite tablet into well casing and ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) filled casing,with Bentonite'p�ellets•and poured neat cement 4.Date well(s)abandoned: 04.29.2022 until approx. 17tbgl.and poured concrete inside casing to near the 5a.Well location: TOC and placed the lid.on the manhole of the well. SM 782 00-0-0000013106 Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1401 N MAIN ST, HIGH POINT, NC 27235: ' fied _ 05.24.2022 Physical Address,City,and Zip Si Certi it ontra or or Well Owner Date GUILFORD' 6891807765 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.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: 350 58' 24.27" N N -800.01' 04.83"W 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 ornon-watersupply 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-3 abandonmerifto the'following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: —30 (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: 4 (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: '-'23.79' (f�) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 0'-15' 10c.For Water Supply&Iniection Wells: In addition to sending the form to the 6e.Outer casing length(if known): (ft.) address(es)above,also submit one copy of this form within 30 days of completion of well abandonment to the county health department of the county where 6L Inner casing/tubing length(if known): (ft.) abandoned. 6g.Screen length(if known): 15'-30' (ft.) I 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 Billy Joe Payne Jr 7a.For Geoprolie/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 4532-B wells abandoned: NC Well Contractor Certification Number 7b.,Approximate volume of water,remaining in well(s):-1'8 - (gal.) Excel-SRP Environmental FOR WATER SUPPLY WELL+S' NLY: Company Name 7c.T ail�I�ype of disinfectant used:' lonnatlon-Ca(OCI)2' 2.Well Construction Permit#: List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.)ifknown 3—oZ'.. 7d.Amount of disinfectant used., 3.Well use(check well use): o D Water Supply Well: 7e.Sealing materials used(check all that,apply):❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Ch P e y 20 22 ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ET Dry Cl%, rvad�w Pray ❑lndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ElDrill.Cuttings 9 UMDti'��aG ❑hri ation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry. ❑Other(explain under 7g) CMonitoring ❑Recovery - Injection Well: 7f.For each material selected above,provide amount ofmaterials used: ❑Aquifer Recharge ❑GroundwaterRemediation . Neat Cement-8=1b Bentonite 28-lb ❑Aquifer Storage and Recovery El Salinity Barrier t Concrete-871b ❑Aquifer Test ❑S ormwat r e Drainage ❑Experimental Technology ❑Subsidence Control 7g,Provide'a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and- ❑Geothermal(Heating/Cooling Retum) El Other(explain under 7g) filled.casing.with Bentonite,pellets.and poured neat cement 4.Date well(s)abandoned: 04.29.2022 until approx. 1-fbgl and poured.concrete inside casing to near the 5a.Well location: TOC and placed the lid.on, the manhole of the well. SM 782 00-0-0000013106 Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1401 N MAIN ST, HIGH POINT, NC 27235 05.24.2022 Physical Address,City,and Zip S f erti r el on for or We11 Owner Date GUILFORD' 6891807765 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.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lat/long is sufficient) 9.Site diagram or additional well'details`: 35° 58' 24.27" N N -80°.01' 04.83"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 ornon-watersupply wells ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: 'Submit this form within 30 days of completion of well 6a.Well ID#: MW-4 abandonment to the following: Division of Water'Resources;Information Processing Unit, 6b.Total well depth: —30 —(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniectiou Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 4 (in.) above,also submit'one copy of this'form within 30 days of completion of well abandonment to did following: 6d.Water level below,ground surface: —18.75' (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 0'-15' (fh) 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): (ft.) abandoned. 6g.Screen length(if known): 15'-30' Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL.ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Bill Joe Payne Jr Y Y 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 4532-8 wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.4 (gal.) Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type ofdisiufectantused: Chl(Dri.hation-Ca(OCI)2 2.Well Construction Permit#: WE List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown A LD • 7d.Amount of disinfectant used: -�Z RECE 3.Well use(check well use): MAY 2� Zl'nn 22 Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public a Neat Cement Grout 9 Ben1VAX *0&Pd59Qo=g UrtA ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay DkVQ/BC)G ❑hidustrial/Commercial ❑Residential Water Supply(shared) e'Concrete Grout ❑Drill Cuttings ❑Irri ation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) RMonitoring ❑Recovery Injection Well: 7f.For each,material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-8-lb .Bentonite 28-lb ❑Aquifer Storage and Recovery ❑Salinity Barrier []Aquifer Test ❑StormwaterDrainage Concrete-8-lb ❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Dropped'Calcium Hypochorite tablet into well casing and ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) filled casing;With Bentonite'pellets and poured neat cement 4.Date wells abandoned: 04.29.202Z () until approx. 1-tbgl and poured concrete inside casing to near the 5a.Well location: TOC and placed the lid on the manhole of the well. SM 782 00-0-0000013106 Facility/Owner Name Facility ID#(if applicable) 8.C lcation: - 1401 N MAIN ST, HIGH'POINT, NC 27235 05.24.2022 Physical Address,City,and Zip Si Certifie Well Con for or Well Owner Date GUILFORD 6891807765 By signing this form, I hereby certify that the well(s) was(were)abandoned in County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. Sb.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: 350 58' 24.27" N N -800.01' 04.83"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 oneform. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#• MW-5 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: -30 00 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection'Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 4 (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: -21.15' (fL) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 0'-15' 10c.For Water Sunnly&Injection Wells: In addition to sending the form to the 6e.Outer casing length(if known): (ft.) address(es)above,`also sitbmit 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): (ft.) abandoned. 15'-30' 6g.Screen length(if known): (ft.) I 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 Billy Joe Payne Jr 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 4532-B wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 5.6 (gal.) Excel-SRP Environmental FOR WATER SUPPLY WELLS-ONLY. Company Name Chlorination-Ca(OCI)2 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used 3-OZ. RFC-ER/ C-E`` / 6J ! 3.Well use(check well use): A Water Supply Well: 7e.Sealing materials used(check all thatapply): MAY 2; (y .2022 ❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentottiii s gr Pellets ,CO�4�J Ur❑Geothermal(Heatin Coolin Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑Drill Cuttings ❑Irri ation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) CMonitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-8-lb Bentonite 28-lb ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage Concrete-8-lb ❑Experimental Technology El Subsidence Control 7g,Provide a brief description'of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) filled casing with Bentonite,pellets and.poured neat cement 4.Date well(s)abandoned: 04.29.2022 until approx. 1-fbgl and poured concrete inside casing to near the 5a.Well location: TOC and placed the lid..on the manhole of the well. SM 782 00-0-0000013106 Facility/Owner Name Facility ID#(if applicable) fication: 1401 N MAIN ST, HIGH POINT, NC 27235 4)"� 05.24.2022 Physical Address,City,and Zip Stgabtre6fCcrtified _ 1 Contract or Well Owner Date GUILFORD 6891807765 By signing this form,I hereby certify that the wells) was (were) abandoned in County Parcel Identification No.(PIN) accordance with I5A 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° 58� 24.27�� N N -800.01 04.83��W 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 ornon-watersupply 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#: VEW-1 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: —55 (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: 4 (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: -20.74' (ft) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 0'-50' (fk) 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 6E Inner casing/tubing length(if known): (ft.) abandoned. 6g.Screen length(if known): 50'-55' (ft) I Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 a a' r N O 0 kA V Z y Ea Q p o O x ^y Z F .x E a p p G F o u a d oa° -- L o o w W ° y y J C .a..O_ O y C C O y N � y�j u r [- � `O U •° ° ° my o �. i" LQ a� ° ° ° au � W o > > O 6�F,LLJ z rtw. c o � u I ��III .h fah 13 r z �w o o a s O o'� o,� ._ cn O � z CD I i Z �E o cn ti •• V P� J / / cc / • 0� i N � I ' O \ o ado I IS J � w -.�F N�U D�PpOPPO � ~ � O -J J cyj__�_� I � I