Forsyth_Well Abandonment_20220817

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WELL tilliDLillVp®N10![El t A gran:Q® ForfatemalUseUNLY:
This form can be used for single or multiple wells
L WWell Contractor Information: WELL ABANDONMENT DETAILS
Retiben W.Clayton. III 7a.Number ofwelis being abandoned:
atillisliiZ r r mtdtipte In)ecttan or tmnyrau:r "qVj• ttxlls ONLY frith the. Tmne
1VcIi CuauactorNnlne(orvrell or�spe�ssouallS obandaoin5 7 file- vnrcrion shamla)mtent,3TU C=Jubmit nilejarn
2241-A , --
FP r .
n 7b.Approximate volume of water temaittiag in wcll(s)- 00 (gal.)
NC Well Contractor Ccttifitation NumberQ.J r 2l'22
Aqua Drill, Inc. FOR iWATERSUPPLYii°ELLS ONLY:
(2
1"Tfle53i✓• {"1 .':.'.:•-v?'.!c U tii Z�! Q
CampfmyName I / L/ VV /
�^ .�t ;t., ��� 7e T}°pe o€disinfectant used:
2.Well Construction Pcrmito:t'��e-- �z!' �p �,�
List all applicable trdipetadis(ie CotmV.State.Fradwim InJeeuon,etc)Tknotrn 7d.Amount of disinfectant used /F/ 0
3.Well use(check well use):
Water Supply Welh 7e.Sealing materials used(check all 4hat apply):
❑Agricultural ❑ tcipallPublic ❑Neat Cement Grout 0Bentonite Chips or Pellets
OGeothermal(HeatineCooling Supply) [�Rcsidendal Water Supply(single) ❑0SS d Cement Grout 0 Dry Clay
Olndustriat/Commercial ❑Residential Water Supply(shared) �Concrete Grout 0 Drill Cuttings
❑Itri anon
❑Specialty Grout ❑Gravel
Non-Water Supply'Well: ❑BentoniteSlurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
7£For each material selected above,provideamanat of materials used:
Injection Well:❑Aquifer Recharge 0GronndsvrterRemediatinn f h- kZ�
❑Aquifer Storage and Recovery ❑Salinity Barrier f�'—
❑AquiferTest ❑StGrumaterDraimlge
DExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Gcothetmai(Closed Loop) l7l racer !'CL/ Pl f-0 6JI-1-7X'-C�.f Ais 1'✓/1z�✓r,
OGeothermal(Heating/CoolingReturn) ❑Other(a%plain under 7".)
4:Datewdl(s)abandoned:
5a.Well location:
F�tl rox.fe r�t,t�> S.Certification:
FaeilityfOwnerivamo
12-'V'2
Physical Address.City;and Zip Z.- �J2,3 Sigttnauc of CcWficd Nell Cc r or tVell 0%%mer c
'A�"o'excf msor By signing this jaml,1 hereby eerily){that the st eil(s)was(mere)abandoned in
Can parcel Identification No.M) accordance with I5A NC4C 02C.0100 or 2C.0200 Well Construction Standards
and that a copy ojdiis record has been provided to the well rntmer:
Sb.Latitude and longitude in d—rewindautestseconds or decimal degrees: 9.Site diagram or additional well details
(ifr.•ctl field,one latllongissufficiem)
You may use the back of this page to provide additional well site details or svdl
TV abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRIXTIONS.
Atlacit null cbnslntctian recatdfs)if mailable. For mttlupie inJeetimt or nun urttersupply
trells ONLY trld+dfcsantecroatruclimrabundmmremyon can submitmteform. Ios.For All Well Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well MY:
Division o€heater Resources,Information Processing Unit,
J, 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth:
nob:Far Infection Wells. In addition to sending the form to the address in 10a
above,also submit one copy of this form mithin 30 days of completion of well
tic.Borehole diameter: ( ) abandonmentto the follovdns
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: —(K) 1(,36 plait Setvice''Ceuter,Raleigh,NC 27699-1636
loc.For Water Sunn1y or Iniection Wells: In addition to sending the fort to
de.Outer casing lengtit(if lmown): A) 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
%%ficre abandoned.
6£Inner casing/tubiug length(i€known): lam)

I
WELL ABANDONMENT RECORD Far Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Todd Mueneh 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
3371 wells abandoned:1
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): 1.63 (gal.)
Parratt-Wolff, Inc. r' r.__N` 5 'th! t,��a.,t FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: QI J , 1 Ll
List all applicable well construction pernties(i.e.U1C,County.State, Variatr(;K, t�.� known
)t1i Gi'etrtic�=.
Y;;�:'fi'•'° 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 a 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 5.82 Gallons
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 7-15-22
5a.Well location:
Clarios
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
2701 Powering Progress Drive, Kernersville 27284 � a a-
Physical Address.City.and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth
By signing this form. /hereby certify that the wells) 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 indegrees/minutes/seconds or decimal degrees: and that a copy of this record has b een provided to the well owner.
(ifwell field.one lat/long is sufficient) 9.Site diagram or additional well details:
36.1192739 N -80.1584860 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
Auach well construction record(s)ij'aradable. l�or multiple injection or non-water supply wells
ONLY with the.same construcuon abandonmem,you can submit one jbrm.
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: 35.7 (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:
6 (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: unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Supply&Iniectiion 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
611 Inner casing/tubing length(if known): 25.7 (ft) abandoned.
6g.Screen length(if known): 10
Form G W-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 DETAILS
Todd Mueneh 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
wells abandoned:1
3371 _ _ _ _ _
NC Well Contractor Certification Numbers p° 5*r�• r 7b.Approximate volume of water'remaining in well(s): 1.63-(gal.)
''w-1�-..fir,>"5...w V�J'` k,�,..I.. �
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Alit,
7c.Type of disinfectant used:
2.Well Construction PermitCa'^g Un14
Llvi all applicable n•ell c•on.siruc•tion permus(i.e.UK',County,St/Z)}�,hf"hl�i6�cj it known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 6.37 Gallons
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 7-15-22
5a.Well location:
Clarios
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
2701 Powering Progress Drive, Kernersville 27284�
Physical Address,City.and Zip Signature of Certified Well Contractor or Wei?Owner Date
Forsyth
By signing this form. 1 hereby certify that the we1!(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:
36.1211765 N -80.1595183 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 well construction record(s)ifavadahle. Far multiple inlection or non-irater.supply mel/s
ONLY frith the same construc6oarabandonment,you can submit one fbrm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 39.1 (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: 6 (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): (ft.) 10c.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 well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 29.1 (ft.) abandoned.
6g.Screen length(if known): 10
i'
Form G W-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
i
Todd Mueneh 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-i30 is needed. Indicate TOTAL NUMBER of
3371 wells abandoned:
NC Well Contractor Certification Number (� e 4.``"'D 7b.Approximate volume of wateNremaining in well(s): 5'18 (gal.)
Parratt-Wolff, Inc. y FOR WATER SUPPLY WELLS ONLY:
Company Name - i
7c.Type of disinfectant used:
2.Well Construction Permit#: ' a r rz,';?.o•,...qj
Unh
Lisi all applicable well construc•rion permier(i.e.UIC,Coun/v.St(rJc%NWrA8 y� Rc.)Ijknown
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 a 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
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 7.73 Gallons
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 7-15-22
5a.Well location:
Clarios
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
2701 Powering Progress Drive, Kernersville 27284 �, a
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth By signing this form, l 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.
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:
36.1194215 N -80.1613941 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 records)ifavadable. For multiple injection or non-water suppl y wells
ONLY with the sane construction abandonment,you can submit one,form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 46.8 (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: 6 (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): (ft.) loc.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit oneicopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY: 't
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Todd Mueneh 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
3371 wells abandoned:
"'. . d 7b.Approximate volume of water remainin in wells: 4.12 al
NC Well Contractor Certification Number �t�j�Y—'�' ��. , � PP g O (gal.)
A N Km�FY • � e:....G..o.i
Parratt-Wolff, Inc. 1t FOR WATER SUPPLY WELLS ONLY:
Company Name A = 17, _ 7c.Type of disinfectant used:
2.Well Construction Permit#: a:.z Pr^^t:, ^:? Unil
List all applicable uvell construction permits(i.e. I riun(y, etc.)i(knoun
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 a 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 5.75 Gallons
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 7-15-22
5a.Well location:
Clarios
Facility/Owner Name Facility ID#(ifapplicable) 8.Certi cation:
2701 Powering Progress Drive, Kernersville 27284 � g, � , a-
Physical Address,City,and Zip Signature of Certified Well tontractur or Well Owner Date
Forsyth By signing this form, /hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.6100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.1169875 N -80.1594982 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
Aitach well construction records)ifarailable. For multiple injection or non-firmer 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-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35.3 (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:
6 (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): (ft.) 10c.For Water Suouly&Infection Wells: In addition to sending the form to the
address(es)above,also submit oneicopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 10
I
i
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
I
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Todd Mueneh 7a.For Geoprobe/DPT or Closedi 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 ii 30 is needed. Indicate TOTAL NUMBER of
3371 _ wells abandoned:
t1ai 1
7b.Approximate volume of water remaining in wells 5.98 al.
NC Well Contractor Certification Number nn PP g O� (gal.)
Parratt-Wolff, Inc. A(Jr1 R 212Z FOR WATER SUPPLY WELLS ONLY:
Company Name ;���r�.y„ ,;,; g Uri;,
)(lfiv�
�ft3M :• 7c.Type of disinfectant used:
2.Well Construction Permit#: U�°�IcS
List all applicable well c•on,siruction permits(i.e.UK'.County,State. Variance,etc.)i(known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 7.61 Gallons
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 7-15-22
5a.Well location:
Clarios
Facility/Owner Name Facility ID#(ifapplicable) 8/Certi'fiic`ation:
2701 Powering Progress Drive, Kernersville 27284''
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth
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 Iat/long is sufficient) 9.Site diagram or additional well details:
36.1190946 N -80.1594982 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(v)ifavailable. For multiple injectionornon-waiersupplvwells
ONLY with the same construction abandonmem,you can submit one form.
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: 46.7 (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: (ft.) Division of Water Resources,(,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suanly&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): (ft.) abandoned.
6g.Screen length(if known): 10
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016