Guilford_Well Abandonment_20230227

WELL ABANDONMENT RECORD For Internal Use ONLY:
-
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or ClosedlLuop 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
`
, )7.7 7 3 lc" wells abandoned:
4229-B L. .s[ a r CU I I <2
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
EnviroCheck of Va, Inc FEB 2 7 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name {n orn-athn Pri": w<;4F. flint 7c.Type of disinfectant used:
2.Well Construction Permit#: 2022-04-18-MW0OtRW01
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)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 0 Neat Cement Grout . , I Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: - 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 60 lbs
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of,the abandonment procedure:
OGeothermal(Closed Loop) OTracer
Filled annulus with bentonite,removed top 24",capped to match existing.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
1,
4.Date well(s)abandoned: 2/15/23 .
5a.Well location: ,'
Lassew do NSRC •
Facility/Owner Name -Facility ID#(if applicable) 8.Certification:
101 S. Swing Road ej74 G2( 0/7/Z,�
Physical Address,City,and Zip Si re of Certified Well Con r or Well Owner Date
•
Guilford • y signing this form,I hereby certf&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: , 1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.075593 N 79.708439 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)if available.For multiple injection or non-water supply wells
ONLY with the same�con�struction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M V A V-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24 (ft) 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: 6.75 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
: I
6d.Water level below ground surface: 22 (ft,) Division of Water Resources;Underground Injection Control Program,
• 1636 Mail Service i'Center,Raleigh,NC 27699-1636
,1 i`
6e.Outer casing length(if known): 24 (ft,) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(i known): 15 (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
Jacob L. Rhudy, III _ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandonii5giw Il b hist/lier propeer<yi� ) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4229-B -" wells abandoned:
NC Well Contractor Certification Number F E B 2 7 2023 7b.Approximate volume of water,.remaining in well(s): <2 (gal.)
1' ,
EnviroCheck of Va, Inc lnform3yizm Pri:C?xr,?sir>j Ur;i FOR WATER SUPPLY WELLS,ONLY:
Company Name • 4 e`lttF3:1i'
2.Well Construction Permit#:
2022-04-18-MW06-RW01 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County State,Variance,etc.)ifknown
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 0 Neat Cement Grout U Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout I 1 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well:_ 0 Bentonite Slurry 0 Other(explain under 7g)
EMonitoring ORecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 50 lbs -
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
Filled annulus with bentonite,removed top 24',capped to match existing.
0 Geothermal(Heating/Cooling Return) DOther(explain under 7g)
1
I
4.Date well(s)abandoned: 2/15/23
I;
Sa.Well location: I
Lassew do NSRC •
Facility/Owner Name Facility IDI�(if applicable) 8.Ce ''cation: 1
101 S. Swing Road a ‘ 2/17/23
Physical Address,City,and Zip Si ure of Certified Well Con or Well Owner Date
Guilford 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 1at/long is sufficient) 9.Site diagram or additional well details:
36.075593 N 79.708439 • 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)((available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
It A10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:,21 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6.75 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I ,
6d.Water level below ground surface: 19 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
21 10c.For Water Supply&Injection 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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 1 0 (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:
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abanndoningwelt. his/hei.pg3 er&r well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4229-B l'',.t,. ->� 6 `kL�; • wells abandoned:
NC Well Contractor Certification Number FEB �f 7 2023 7b.Approximate volume of water,remaining in well(s): <2 (gal.)
EnviroCheck of Va, Inc _ 1 1r;t FOR WATER SUPPLY WELLS'ONLY:
Company Name tfiiCtiH•co•r4.11Q Ots t
7c.Type of disinfectant used:
2.Well Construction Permit#: 2022-04-18-MW06-RW01
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:.
3.Well use(check well use): "
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural iiMunicipal/Public 0 Neat Cement Grout II, II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 50 lbs
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
Filled annulus with bentonite,removed top 24",capped to match existing.
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 2/1 5/23
5a.Well location:
Lassew do NSRC •
Facility/Owner Name Facility 11)11(if applicable) 8.Certification:
101 S. Swing Road- 2/17/23
Physical Address,City,and Zip Si of Certified Well Contract Well Owner Date
Guilford signing thisform, I herebycertt that the well(s)was(were) abandoned in
y sus fv
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: .
36.075597 N 78.708436 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 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-6 abandonment to the following: : '
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 23 (fk) 1617 Mail Service Center,Raleigh,NC 27699-1617
G 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: V'75 (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: 1 9 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I, I
6e.Outer casing length(if known): 23 (ft) l0c.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
6f.Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016