Guilford_Well Abandonment_20220701

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary SImCOX 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
29448 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s).'4 (gal.)
S&ME, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit H:
List all applicable sell construction permits(l.e.UIC,County.State,Variance,etc.)ljibtown
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 ❑Neat Cement Grout ■Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
OIrrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Si Y ❑Other(explain under 7
B)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 11 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Exptrtimrntal Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled well casing with bentonite chips and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
then hydrated. Removed manhole cover and
4.Date well(s)abandoned:06/27/2022 concrete pad.
50.Well location: ; z a 'l— n,
Lebanon Baptist Church s t
Facility/Owrner Name Facility iD#(if applicable) 8.Certification: I I L p 2022
4635 Hicone Road, Greensboro, NC 27405 J ,,r,�;J Q/ p22
Physical Address,City;and Zip Signature of Certified Well Contractor or 1VllliUptltt" t,ai !M:,(;Qatc
Guilford By signing this form,I hereby cer16 that the well(s)was(were)abandoned in
County Patecl identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude In degreeslminutes/stxoads or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 09' 11.40" N 79 42'44.71" N You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auachwellronstrualonrecord(s)ijavallable.Formuldpleirr/eclionornon-wntersupplyVWl/s
ONLY with the some mnstruaion/abandonment,you can submii one form. 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:LBC-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:28.5 A) 1617 Mail Service Center,Raleigh,NC 27699-1617
Job.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: .
6d.Water level below ground surface•20.59 (fG) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if!mown): (ft) loc.For Water Sunnly&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 well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (fL) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary SirricoX 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
29448 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):.2
SWE, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:_
2.Well Construction Permit N:
List all applicable nrll construction permits(i.e.UIC,County,State,Variance,etc.)(fknoxre
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 ❑Nest Cement Grout ■Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
DIrripation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
EMonitoring ❑Recovery
Injection Wen: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 9 Ibs
[3Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled well casing with bentonite chips and
❑Geothermal(HeatingtCooling Return) ❑Other(explain under 7g)
then hydrated. Removedpanho�e coven d
t
4.Date wen 06/27/2022s)abandoned. concrete pad.
511,Well location: J U L 0 1 2022
Lebanon Baptist Church
Facility/Owner Name Facility IDll(ifapplicablc) 8.Certification: ! I M03w""nq IUR i
4635 Hicone Road, Greensboro, NC 27405 06/27/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford By signing this form,I hereby certJ6u that the well(s) was(were)abandoned In
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the xtell owner.
(if well field,one IatAong is sufficient) 9.Site diagram or additional well details:
36 09' 11.75n N 79 42'44.66" N, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach nrll construction record(s)ifavailable.Formultiple injection ornon-xntersupplynrlls
ONLY tsith the same ronstruction/ab andonment,ynu can submit one form. 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well IDA LBC-2 abandonment to the following:
22.5 Division 17 Man Water
ervice urcesrtrmation Processing Unit,
6b.Total well depth: (ft.) Raleigh,NC 276994617
10b.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:
6d.Water level below ground surface:'18.84 (n,) Division of Water Resources,Underground Injection Control Program,
1636 Man Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) i0c.For Water Suooly&inlectfon 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(f known): ft.) abandoned,
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department of Environtrcntal Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary SimeoX, 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Corw2ctorName(or wrll owner personally alimWoning well on Itisiherproperty) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2944E -.- -- wells abandoned:, -
NC Well Contractor Certification Number 7b.Approximate volume of water remaining to well(s):.3 (gal.)
SBtME, Inc.. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit
List all applicable xellcomnuction permles(i.e.UIC County,Stale,Variance,etc.)ijknoxn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultuml ❑MunicipatIPublic ❑Neat Cement Grout ■Bentonite Chips or Pellets
❑Geothermal(Hating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustrialfCommeroial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Oftrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7L For each material selected_above,provide amount of_materials used:
❑Aquifer Recharge ❑Groundwater Remediation ;11 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storinweter Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide■brief description of the abandonment procedure:
❑Geothermai(Hatin Coolie Return ❑Other(explain under7 Filled well casing with bentonite chips and
—'I —
!hen hydrated.
06/27/2022
4.Date well(s)abandoned:
SR.well location: JUL 0 _ 1UZZ
Lebanon Baptist Church
B.Certifiation: Info n.0—n ';.^renewing I.Inh
Facility/Owner Name Facility ION(if applleablc)
4635 Hicone Road, Greensboro, NC 27405 06/27/2022
Physical Address,City,and Zip Sipaturo of Certified Well Contractor or Well Owner Date
GUIIfOrd By signing this form,I hereby cerrrhr that the well(s)was(were)abandoned in
County Parcel identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees: and that a copy ojthls record has been provided to the well owner.
(ifwcll field one IaUlong is sufficient) 9.Site diagram or additional welll details:
36 09' 11.43" N 79 42'44.23" 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
Anach xrll romtmcilon records)y'avallable.For multiple injection ornon-xaarersupply neRs
ONLY xdrh the same cromrrucNon/abandanmuu,you can submit one form 10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:LBC-3 abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth:28'3 01) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: in addition to sending the form to the address in l0a
6e.Borehole diameter: (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:20.51 00 Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer axing length(if(mown): (ft) Joe.For Water Suooly&injection Wells: in addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casfngltubiog length(if known): (fL) abandoned.
6g.Screen length(if known): 00
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: j
1.Well Contractor Information_: WELL ABANDONMENT DETAILS
Gary.SimcoX 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
29448 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water-remaining in weil(S):.1'4 (gal.)
$&ME, Inc. 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.)ifknow'n
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultuml ❑Municipal/Public ❑Neat Cement Grout ■Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commeroial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01rrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
EMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled well casing with Bentonite chips and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7
then hydrated. _
4.Date well(s)abandoned:06/27/2022
5a.Well location: 'Yti
Lebanon Baptist church
Facility/Owner Name Facility lD#(ifappllcablc) S.Certification: L O 1 2022
4635 Hicone Road, Greensboro, NC 27405 /—I-�P,- L . t��27�2022
Ph teal Address,City,and Z' ,•.--�v ^^^ a-A
Ys. Zip Signature of Ccrtificd Wcll Contractor or Wcll�lQ,�ioc' ate
Guilford By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0I00 or 2C.0100 Well Construction Standards
5b.Latitude and longitude to degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one latllong is sufficicrd) 9.Site diagram or additional well details:
36 09' 10.89" N 79 42'44.69" N, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anachuvilconsmwtionrecord(s){javallable.Formuldple injection ornon-warersupply wells
ONLY with the same eautruaion/abandonment you can su6mil onejam. 10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#•LB" abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:30.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter ((n•) 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:21.98 00 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length Of known): (n) 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): (fL) abandoned.
6g.Screen length(If known): (ft)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016

WELL ABANDONMENT RECORD for lntemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Simpox 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hisiber property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
29448 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s):2.6 (gal.)
SBtME, Inc. 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.Stare.Variance,eta)if Anown
7d.Amount of disinfectant used:.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaliPublic ❑Neat Cement Grout ■Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Obtrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ■GroundwaterRemediation 60lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
[]Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled well casing with bentonite chips and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
then hydrated
4.Date well(s)abandoned:06/27/2022 .'
So.Well location:
Lebanon Baptist church C14 0
Facility/Owtxr Name Facility lD#(if applicable) 8.Certification:
4635 Hicone'Road, Greensboro, NC 27405 "' %' oL 06/27/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford By signing this form.I hereby certify that the well(s) Aws(were)abandoned in
County Parcel identification No.(PiN) accordance with ISA NCAC 02C.0I00 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude to degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field one IaVlong is sutficicM) 9.Site diagram or additional well details:
36 09' 11.49" N 79 42'44.73" 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 will construction reeord(s)ifmnilable.Formultiple injection ornon-wnrersupply car is
ONLY with the same construction/abandonment you can submit one form. 102. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#•SP,G-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:36.3 at.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d Water level below ground surface:20,31 (fW 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 Sunoly&iniection Wells: in addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length Of known): A)
Form GW-30 North Carolina Dcpanment of Environmental Quality-Division of Water ResourceIs Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Si I'nc6x 7a.For GeoprobdOPT or Closed-Loop Geothermal Wells having the same
Well Contranor Name(or well owrer personally abandoning well on hislberproperty) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
29448 wells abandoned::
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s):
S&ME, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Nano
7c Type of disinfectant used:
2.Well Construction Permit M
List all applicable xell construction permits 0.e.UIC.County;State,Variance,eta)Y"Imown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ■Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Cormneroial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Oirristation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge EGroundwater Remediation 30 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storrnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandattmeat procedure:
❑Geothermal(Closed Loop) ❑Tracer -
❑Geothermal (Heating/Cooling Return ❑Other(explain under 7 Filled well casing with Bentonite chips and
then hydrated
4.Date well(s)abandoned:06/27/2022
Sa.Well location:
Lebanon Baptist Church
Facility/Owner Name Facility 1DO(ifapplicablc) 8.CerHneadon:
{. - - f1iC.irr�''D7 ?iC•��.^.2^ir;n�.l I �%1
4635 Hicone Road, Greensboro, NC 27405 i :,yo Ob�f27/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Dam
Guilford By signing this form,1 hereby cerflj�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
56.Latitude and longitude in degrces/mloutes/seconds or decimal degrees: and that a ropy of this record has been provided to the well owner.
(if well field,one In ang is sufficient) 9.Site diagram or additional well details:
36 09' 11.58" N 79 42'44.75 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 urliconstructionrecord(s)(favailable.Formultipleirl%ectionornon-xatersupplyxYlis
ONLY with the some ronstrunion/abandonment,boa can submit one form, 10m.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:$VE-1 abandonment to the following: ,
Division of Water Resources,Information Processing Unit,
6b.Total well depth:18 (it-) 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:; pn.) 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:: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (D) 10c.For Water Suuuly&Injection Wells: in addition to sending the fotm 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
6L Inner casing/tubing length or known):. - (ft,) abandoned.
6g.Screen length(if known): 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For.Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Simcox 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on Mvhcrproperty) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
29448 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in weB(s):: (gal.)
S&ME, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit M
List all applicable xpDconstruction permits(t.e.U1C.County.State,Variance.a/c.)ftnoxn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ■Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01ni tion ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7!For each material selected above,provide amount of materials used:
❑Aquifer Recharge !Groundwater Remediation 30 ibS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 79.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled well casing with bentonite chips and
❑Geothermal(Hating/Cooling Return) ❑Other(explain under 7
then hydrated
4.Date well(s)abaodoocd.
06/27/2022 �.
to
Sa.Well location:
Lebanon Baptist Church (]ZZ
Facility/Owner Name Facility ID#(if applicable) S.Certification:
4635 Hicone Road, Greensboro, NC 27405 � i°'` * �� ?�4;.-•w
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford By signing this form,1 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
Sb.Latitude and longitude in degrees/roinutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner. ,
(ifwcll field,one Wong is sufficient) 9.Site diagram or additional well details:
36 .09' 11.59" N 79 42'44.62" N, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaachxrllronstruetionrecord(s)tfavallable•Formultiple Injection ornon-xntersupplywells
ONLY with the same constrocrion/abondonmeru,you can submit onejorm. 10a. For All Wells: Submit this form within 30 days of completion of well
6s.Well IM$VE-2 abandonment to the following: .
Division of Water Resources,Information Processing Unit,
6b,Total well depth: 7'1 (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
10b.For infection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter:. (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:. (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(If known): (tL) lOc.For Water Suonly&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 well abandonment to the county health department of the county where
6E Inner casing/tubiog length Of known): (fL) abandoned.
6g.Screen length(if known): A)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
I �.
1.Well Contractor Information: WELL ABANDONMENT DET41LS
Gary SlmcoX 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
29448 wells abandoned: - -
NC Well Contractor Certification Number 7b.Approximate volume of water remainlog In well(s): (gal.)
SWE, Inc.. FOR WATER SUPPLY WELLS ONLY:
Company Name
7a Type of disinfectant used:
2.Well Construction Permit ii:
List all applicable well constru ction permits(i.e.UIC,County,Stare,Variance.etc.)(/knoxn
7d.Amount of disinfectant used-'
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural OMunicipaVPublic ❑Neat Cement Grout ■Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
oirrigation ❑Specialty Grout O Gravel
Non-Water Supply Well: ❑Bentonite Slu
rry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected alcove,provide amount of materials used:
❑Aquifer Recharge ■Groundwater Remediation 25 Ibs
OAquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracc* Filled well casing with bentonite chips and
❑Geothermal(Hcating/Coolin Return) OOther(explain under 7
then hydrated ice,
4.Date well(,)abandoned:O6/27/2022 >a_r V —
IF
So.Well location: 7 2022
Lebanon Baptist Church
]ftl(`il YlY�iit^iil Pre-'zz. ng Umi
Facility/Owner Name Facility ID#(ifapplicable) g.Certification:
4635 Hicone Road, Greensboro, NC 27405 .06/27/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford B signing this form,I hereby Berri that the well(s)s was
Y gn g f Y fy (J (were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0I00 or 2C.0200 Well Construction Standards
and that a ropy 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/ong is sufficient) 9.Site diagram or additional well details:
36 09' 11.20:" N 79'42'44.78" W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach u,ell construction record(s)Vawllable.Formuldple injection ornon-wntersupply 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#:SVE-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:,14.5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:. (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: ({t,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer using length(if(mown):._ ({t) IOc.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
6L Inner easing/tubing length(if known): abandoned.
6g.Screen length(if known): (ft)
Fort GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016