Guilford_Well Abandonment_20230626

1'
WELL ABANDONMENT RECORD
For
1.Well Contractor Information: I
WELL ABANDONMENT DETAILS 1
David Hardy
7a.For ing the same
Well Contractor Name(or well owner personally abandoningwell on his/herproperty) welll construction/depth,only I GW 30 iT or s needed.Geothermal Wells
TOTAL NUMBER of
P Y
2906-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
(gal.)
Aqua Drill, Inc.
Company Name n FOR WATER SUPPLY WELLS ONLY:
2.Well Construction Permit#:(9 J1—0](i u 71T 64- UI 7c Type of disinfectant used: The �
er
List all applicable well construction permits(i.e UIG County,State,Variance,etc.)ffknown
7d.Amount of disinfectant used: ibl® a
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):❑Agricultural °Municipal/Public Q Neat Cement Grout 0 ye'
Bentonite Chips or Pellets
°Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Q Sand Cement Grout
❑IndustriaUCommcroial ❑Dry Clay
°Residential Water Supply(shared) fib Concrete Grout
°Irrigation ❑Drill Cuttings
Non-Water Supply Well: Specialty Grout 0 Gravel
QMonitorin ^> . l tonite Slurry
g ❑Recovery h,.,..,F `t ""'" L.' Q Other(explain under 7g)
Injection Well: .c t._r7 ,_ ,
7f.For each material selected above,provide amount of materials used:
°Aquifer Recharge °Groundwater Rentia'p 20 L3 6v��e/��°Aquifer Storage and Recovery °SalinityBarrier❑Aquifer Test ❑Stonnwater pinitimg n i-ifc,:-,af
A fo1j3 Ufa
°Experimental Technology ❑Subsidence Control [kt iCti'S'
7g.Provide a brief description of the abandonment procedure:
°Geotltetmal(Closed Loop) OTracer •
❑Geothermal(Heating/Cooling Return) °Other(explain under 7g) lfo)4k'0 7 49c-/%h jV/.4 ed ,7 % j -
4.Date well(s)abandoned: i//j l7 r��� � � '"�`�' l �p/®� �E?� �! d•d�f
5a.Well location:
Wed
Facility/OtvnerName, Facili ID#(ifappligbtc) S.C Catio
IF U Physiyyy I Address,City,and Zip 'ry tier: © /
/ ��� e S afore of Certified true or Well Owner Date ee
By signing this forte,I hereby cent that the well(s)was(were)abandoned in
County
Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if w ll field,one lat/long is sufficient)
9.Site diagram or additional well details:
t 7 J •, 6 ri
p ,/ N 71' 9er*-910 4? 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
Attach well construction record(s)ifavailable.For mtdtiple injection or,tort-rratersupply wells SUBMITTAL INSTRUCTIONS
ONLY with the same conslntction/abandonment,you can submit onefornt,
10a. For MI Wells: Submit this form within 30 days of completion of well 6a.Well ID#: ' abandonment to the following:
Z if Division of Water Resources,Information Processing Unit,
6b.Total well depth: 421a-0 (f() 1617 Mail Service Center,Raleigh,NC 27699-1617
B9 10b.For!flied-ion Wells: In addition to sending'the form to the address in 10a
6c.Borehole diameter: al t'/ (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
IOe.For Water Supply&Infection Wells: In addition to sending the form to the
be.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): (ft.)
FormGW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH .
Division of Environmental Health; Water Quality Unit
400\V.Market St.,Suite 300, Greensboro,NC 27401
C®M.1 ®R Cor sit riv Qo Elvers, OF Abandonment doer scat of i Wen
bet( i
Address of Well: .1m ti/1 Ie// 6tericrioya '�AT1TUDF 3 e e<7 ht
Well Permit Number: 17 Jre
Well Contractor Company: /9 ti/ ' / Completion Date: 641i /2.3
i if
Total Well Depth: V i.,ft. Well Yield: gpm Static Water Level: ft.
Outer Casing - Material:45714dd( de Formation Log
Casing Diameter: 7e7 in. Casing Depth: ft. Depth Description
From: ft.To: ft. •
Inner Casing - Material: From: ft.To: .ft.
Casing Diameter: in. Casing Depth: ft. From: ft. To: ' ft.
From: _ft. �i o: _ft.
Grout From: ft.To: ft.
Depth Material Method From: ft. To: ft.
From: ft.To: ft. From: ft. To: ft.
From: ft.To: ft.
From: ft.To: ft.
From: ft.To: ft. From: ft. To: ft.
Water Production Zones,
Depth: ft. ft. ft, ft. ft. ft.
Yield: gpni g m pm Pi. .
gpm gpm gpm gpm
Method of Repair:
it
Method of Abandoninent: /0'"LJ r-,ft Cd l0 i f -7,
.__i
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Well
Rules in effect on ' date d that a copy o; this record has been provided to the well owner.
Well Contractor: ., l r State Number:Iliad Dated ,
Rccovd of Pump ,, pis alilla fior .
Pump Installation Company:_ Completion Date:
Pump Depth: ft. Static Water Level: R.
Pump Brand: Pump Size and Rating: hp___ gpin
a
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner.
Well Contractor: �__ State Number: Date:

WELL ABANDONMENT T RECORD
Far Internal Use ONLY:
_ 1.Well Contractor Information: i
WELL ABANDONMENT DETAILS
David Hardy
7a.For Well Contractor Name(or well owner personallyabandoningwell on his/her roc well construction/depth,DPT or Closed-Loop Geothermal Wells having the same
property)rty) only 1 GW 30 is needed. Indicate TOTAL NUMBER of
2906 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): al.
- Aqua Drill, Inc. (g )
FOR WATER SUPPLY WELLS ONLY:
Company Name ��
a 3 oce� Up`kle 7c.Type of disinfectant used: r
2.Well Construction Permit#: j
List all applicable well construction permits(r e.UIC,Cowry,State,Variance,etc.)if blown e
7d.Amount of disinfectant used: C
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):❑Agricultural ❑Munici al/Public ❑Neat Cement Grout 0 B
en tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout
❑industrial/Commercial 0 Dry Cl
❑Residential Water Supply(shared) PkConcrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout
Non-Water Supply Well: ❑Gravel
under 7lain
❑Monitorin 0 Bentonite Slurry 0 Other ex
g ❑Recovery (explain g)
Injection Well: 7f.For each material selected above,provide amount of matg 115.us -. ,
❑Aquifer Recharge ❑Groundwater Remediation l �, ,» ®a � "°' '�d
❑Aquifer Storage and Recovery ❑Salinity Barrier "��t T� f1
❑Aquifer Test ❑Stomnvatcr Drainage L N 3 5 2 0 23
❑Experimental Technology ❑Subsidence Control '
❑Geothermal(Closed Loop) ❑Tracer 7g. lN
Provide a brief dese 'ption of the abandonment proceire s l"n'af"'° ?°a��
1'^
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 /M to 5P tr� 12' 4
D' A,� / ta� 3®�
4.Date well(s)abandoned: it"Y 1/3 /2,3 / /
5a.Well location:
A7o 'eIj �4ss'- 'A d%fd/ex/
iajtif Facility/Owner Name Facility ID#(if applicable) S e ''cation °
i�, 1 -tee 64 � // ,e. ,cle&75 ,® �Z � .
Cr Physical Address,City,and Zip �� l'L s�ti
fad �7 .e- St Lure of Certified Well o ctor ar Well Owner Date
t4 it®-/ By signing this fonn,1 hereby cett that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and Ion nude in d and that a copy of this record has been provided to the well owner.
g egrees/minutes/seconds or decimal degrees:
(if well field,one 1¢Ulong is sufficient) 9.Site diagram or additional well details:
.3‘• '6, ' /#/ N 7' if f P ir-3 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 constructionrecord(s)ifarailable.Fat-multiple inject/on or non-water supply ire/is
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#: abandonment to the following:
bi Division of Water Resources,Information Processing Unit,
6b.Total well depth:p/ tV (ft) 1617 Mall Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a '
6c.Borehole diameter: 1/ (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1
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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) I
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
400 W.Market St.,Suite 300,Greensboro,NC 27401
a e [i oT Col stmet o p Paper, ov Abandonment o a Wen
61,,,rt ',7
Ad re s of ell:Caf_er,E.zu liced‘"-e,ifelei&eetfaitg4,Alf:TIT-UDE .3 X. el 6:- „:,,1274_,Ljtef
Well Permit Number: ,r2,) c t2 tX7I JLP, � IVGirtlM 7 f le zit: 3 i;/
Well Contractor Company: /4 t,'/ j1/, // Completion Date: i/is(2,3
0 t
Total Well Depth: 3 7 // Well Yield: gpm Static Water Level: 30 ft.
Outer tCa�s':1=g Material: / /1 ,n j` J Formation Lo
Casing Diameter: 4 in. Casing Depth: it. Depth g
p Description
From: ft.To: 'ft.
Inner Casing - Material: From: ft.To: ft.
•
Casing Diameter: in. Casing Depth: ft. From: ft.To: ft —"
From: ft.To: • _ft.
Grout
From: ft.To: ft.
Depth Material Method From: ft. To: it.
From: ft.To: ft. Frorn: ft.To: ft. •
From: ft.To: ft.
From: ft. To: ft.
From: ft.To: ft.
From: ft. To: ft.
Water F=oonction Zones
Depth: ft. ft. .ft. ft.Yield: gpm ft. ft.
ft.
gpm gpm _gpm gpm gpm gpm
Method of Repair: e
274:71
Method of Abando ent: G A I l
3 L�'N�'rR �i foie'. 6� . l
, _____—
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Well
Rules in effect on date nd that a copy.. f this record has been provided to the well owner.
Well Contractor: . t� • �"- f/ •
S
vtate Numb Cr: Date:4 03/Z
Racal of Pump Enstagliatkin
Pump Installation Company:- Completion Date:
Pump Depth: ft. Static Water Level: ft.
Pump Brand: Pump Size and Rating: i hp gpm
I hereby certify that this pump was installed-and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner.
Well Contractor: - - State Number: ____� _ Date: •

WELL ABANDONMENT RECORD
For Internal Use ONLY: I
1.Well Contractor Information:
WELL ABANDONMENT DETAILS
I .
David Hardy7a.For Geoprobe/DPT or ;
the same
Well Contractor Name(or owner personallyabandoningwell on his/herproperty) wellconstruction/depth,only IoGW 30 is eededIndical ate TOTAL ells gNUMBER of
A (
' 2906-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): G' (gal.)
Aqua Drill, Inc. FOR WATER SUPPLY WELLS LYE
Company Name i, 7a '45
2.Well Construction Permit#:
t �(Q c Lc-9t C"Yf t4-0�', ,,Ile..Type of disinfectant used:
List all applicable well construction permits(i.e.UIC.County,State.Variance.etc.)ifknown
7d.Amount of disinfectant used: 1d 0 1.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑A icultural pP y)0
❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) St-Concrete Grout 0 Drill Cuttings
0 Irrigation ❑Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slimy 0 Other(explain u er�g,�7
" 1' � ^7")
❑Monitoring ❑Recove
Injection Well: • 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ��� J 1 I N 2 1 2023
❑Aquifer Storage and Recovery ❑Salinity Barrier �/.4f 5, l�
' ❑Aquifer.Test ❑StormwatcrDrainage / lfiWy-tk2:;1 Pr•^74-4.e4,,3 URx
❑Experimental Technology ❑Subsidence Control Url+tett 3i .:4
❑Geothermal{Closed Loop) ❑Tracer 7g.Provide a brief descriptign of the abandonment procedure: /w
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) AI•
/4/fne�?4 3</®,� ll/,44 / i
,f' /�i,�e,��j/, a/mod
`' it . -,re' ‹,..., Mont'. 7J c
F 4.Date well(s)abandoned:6/9... � � �
(4P t,/ de- ,F07-"// CAA
5a.Well location:
)C/ Facility/Owner Name Facility ID#(if applicable) 8. rifrcatio : '
31.
Physical Address,City,and Zip gam' / { - 1 � rJ�'.
F t alf Signature of Certified We4Co et6ror ell Owner Date
•
Xiii ifei<1. By signing this font:,I h eby cerr'that the well(s)was(were)abandoned in
ounty Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well f cud,one IaViong is sufficient) 9.Site diagram or additional well details:
471.o6$ /9 / N 7q fo 4, 3 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 nwell construction record(s)ifavailable.For multiple infection ornon-watersnpptvwells
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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 7 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
106.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: '2,4 (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: (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) iDe 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.
• i
6g.Screen length(if known): (ft.)
•
Form GW 30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

GUILFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health, Water Quality Unit
400 W.Market St.,Suite 300, Greensboro,NC 27401
C R:-coot of Cons reue on, Revak Off Abandonment of a Oil .
Address of Well: , /,f t Gi/l i. 1 4J -MUM 3 i QeC 5'
Loti
Well Permit Number: t�(P,-��Pr .—p��, 4004LONGITUDE f�' C:
Well Contractor Company: ,4` 4 ir, / j//2
f ` Completion Date 1 J
Total Well Depth:? ft. "Well Field: .
gpm Static Water Level: ft.
Outer Casting Material: ei..#4evele- r��
Casing Diameter: 9.L- in. Casing Depth: ft. Depth e°nano Log
A Description
From: ft.To: ft.
L n fier Casing • Material:
From: ft.To:__
Casing Diameter: in. Casing Depth: ft. From: ft. To:V ft.
From: ft.To: _ft.
Grout From:. ft.To: ft.
Depth Material Method From: ft.To: ft.
Frorn: ft.To: ft. From: ft.To:
From: ft.To: --�- - 't.
From: ft.To: From: ft. To: ft.
From: ft.To: ft.
Water Production Zones
Depth: ft. ft. f, ft f
gpm
Yield: ft,gpm gpm gpm gpm gpm gpm
Method of Repair:
Method of Abandonment:
/' ,
I hereby certify that this well was constructed,repaired,or abandoned according to the Guilford County Well
Rules in effect on tl ' date nd that a co y of this record has been provided to the well owner.
Well Contractor: 2/ ��
state Number:7 l®a Date: '2c 3
Recorrerl of Nam ns of Q trlon
Pump Installation Company: Completion Date:
Pump Depth: ft. Static Water Level:_
- Pump Brand: Pump Size and Rating: ' hp gpm .
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner.
,
Well Contractor: _ State Number:_ , i Date:

WELL ABANDONMENT RECO jI)
I For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy
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 islneeded. Indicate TOTAL NUMBER of
2906-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): al.
Aqua Drill, Inc. (g )
FOR WATER SUPPLY WELLS ONLY:
Company Name (� n _ 7
2.Well Construction Permit#: 04`c cop T c`` Do I as. 7c.Type of disinfectant used: Z 9 i
List all applicable well construction permits(i.e.UIC Count};State,Varfauce,etc.)iflmoun o
7d.Amount of disinfectant used: ie a a--
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munici al/Public0 ye
p 0Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout
❑Industrial/Commercial 0 Dry Cl
❑Residential Water Supply(sharcri) Jaroncrotc Grout 0 Drill y
Cuttingsti
0 Irrigation 0 Specialty Grout
Non-Water Supply Well: ❑Gravel
❑Monitorin ❑Bentonite Slurry ❑Other(explain under 7
g OR
( P g)
Injection Well: 7f.For each m .�
saeraselected above,provide amount o ateraluusrd t -..,..❑AquiferRechaaa ❑GroundwaterRemediation / ^�tom,. :o a
�
❑Aguifer Storage and Recov�Y ❑SalinityBatrier J �{oP ---....r
❑AquifcrTest ❑StormwaterDrainage JUN 2 i2023
❑Experimental Technology ❑Subsidence Control lnf 11
OGeothermal(Closed Loop) ❑Tracer 7g.y Provide a brief description� of the abandonment prrocedu f` .'. (tr.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Phi i el ec r dt Isiel/ e.4,„/),f' Ile ` 7,4
4.Date well(s)abandoned: T
"69 u re L / ex,
5a.Well location: ,
facilrty/OOw`nneer/Name / Facility 1D#(if applicable)/,` 8.Ce ' tion:
W4I
al
e<oittytekel
ikt, Ph cal Address,City,and Zip G �� v eA/S/2s�
7_74°7 Si ture of Certified Well Contractor wner
4!) 5 // Date
County /b C� By signing this form,I hereby certi&that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
5(if wcl'Geld,one IaUlong is sufficient) 9.Site diagram or additional well details:
O a 0 6( '7 , / N 779 Q- - 1 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
Attach well constntclion record(s)ifavailable.Fornutltiple it jection or non-uutersapply wells SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
if® Division of Water Resources,Information Processing Unit,
6b.Total well depth: l'f (ft 1617 Mail Service Center,Raleigh,NC 27699-1617
,� / 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6�Borehole diameter: d-�r (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,,Raleigh,NC 27699-1636
) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
be.Outer casing length(if known): W.)
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
•
fig.Screen length(if known): (ft.)
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

r
i
GUEFORD COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit!
400 W.Market St.,Suite 300, Greensboro,NC 27401 -
Accord ©f C is nstru tt0©k Repair/ or Alba.d©l< rat of a WeIA
Address of well: 769` 116//ems J I6 - ax,e�' TI
Well Permit Number: c C( tA?p4IZ.. C:t7 I 7 4 -
c LrruDE
Well Contractor Company:ñ9ifi ,41/ Completion Date: /e,.37/? 3
Total Well Depth: i'f ��
t ft. Well Yield: gpm Static Water Level: ft.
Outer Casing Material: imeirele %:/e
Formation Log
Casing Diameter: if in. Casing Depth: ft. Depth Description
From: ft.To: ' ft.
)inner Casing Material: . From: ft.To: ft.
Casing Diameter: in. Casing Depth: ft. From: ft.To: - ft.
From: ft.To: ft.
Grout From: ft.To: ' .ft.
Depth . Material Method - From: ft.To: ft.
From: .ft.To: ft. From: ft.To: ft.
From: ft.To: ft. From: ft.To: ft.
From: ft.To: ft. • From:. ft.To: ft.
Water Production Zones
Depth: . ft. ft. ft. ft. ft: ft.
' Yield: m _ ft.
gpm gpm gpm ,gpm gpm gpm
Method of Repair:
Method f bandonment ftf, t&) Y(, e7 �3ef< (A loi,',� // �D o 160 -o ./�C'I
Z r P'1 Gee i! e% Pour eI ! tA
yaf-
• I hereby certify that this weII was constructed,repaired,or abandoned according to the Guilford County Well.
Rules ill effect on this dat and that a copy of thi/4/4s record has.been provided to the well owner.
47
Well Contractor. �d Certification •� �� o
#. f'� Date:Ill /aJ
Record ©? Putit9 EnstaOktdon
Pump Installation Company: Completion Date:
Pump Depth: • ft._ Static Water Level: ft.
Pump Brand: Pump Size and Rating: hp gprn
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner. .
Y Well Contractor: Certification#: 1 - Date:
Revised:January 1,2009

WELL ABANDONMENT RECO 1 R iI'
For internal Use ONLY:
I.Well Contractor Information: I
WELL ABANDONMENT DETAILS
David Hardy
ells having the same
Well Contractor Name(or well owner personallyabandoningwell on his/her ro a well 7a. constru r tion/d construction/depth, 1 or 0GW 30 I s needed.rIndicmal ate TOTAL NUMBER of
P P rtY)
2906-A wells abandoned: I /�, /'
NC Well ContractorCertificatian Number 7b.Approximate volume of water remaining in well(s): "/u al.
Aqua Drill, Inc. (gal.)
Company Name FOR WATER SUPPLY WELLS ONLY:
O �(�'- ice..CO/ 7c.Type of disinfectant used: /�� �
2-Well Construction Permit#
List all applicable well construction permits(i.e.UIC County,State.Variance,etc.)ifknoun
7d.Amount of disinfectant used: /ie -
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that
apply):
aP 1Y)❑Agricultural ni "a leia ublic 0 Neat Cement Grout 0 Ben
tonite Chips or Pellets I'''''I I�1174
❑Geothermal eatin blingSapplyystdential Water Supply(single) 0 Sand Cement Grout
❑htdustriaUCommercial „ ❑Dry Clay
ential Water Supply(shared) Concrete Grout
J U aV J L L PP Y CI Drill Cuttings
❑Inigation 0 Specialty Grout
Non-Water Supply Well: nram-:- OVA
0 Gravel
❑Monitoring lntci r=54'C'I ' .. ❑Bentonite Slurry 0 Other
n.AajC I+I31zzcovery (explain under 7g)
Injection Well: 7f.For each material selected above, rovide amount of materials used:
❑Aquifer Recharge QGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier I fry.
❑Aquifer Test ❑Stormwatcr Drainage ,
0 Experimental Technology ❑Subsidence Control
❑Geotiretmal(CIosed Loop) ❑Tracer 7g.Provide a brief escri tion of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) t � �07 l�® I(. �/� •
4.Date well(s)abandoned:6f U/7 �� r r / �J/��/1 �� f
erd i6p/ei / ` Cie Sa,Well location:
Facility/Owner Name Facility ID (if applicable) 8.C• iiii;'aon: •
Dell 675-644/4714-4-fe IV *•/694;10/0*4'
Physic Address /L
Y /`CityaandvZip® of Signature o Certified WellLrZowner Date ��
0 i/ fry/66ti, Date
County By signing this form,1 hereb cet76 that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well eld,one lat/long is sufficient)
( ' � �/' 9.Site diagram or additional well details:
. �A e,/ N fa Gter,$ 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
Attach well constructionrecord(s)tfavatlable.For multiple ogectionornon-watersupplvwells SUBMITTAL INSTRUCTIONS
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]tD#: abandonment to the following:
•
eft? Division of Water Resources,Information Processing Unit,
6b.Total well depth: (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: (�,) 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/-t (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (R) 10e.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): (ft,)
Form GW-30 North Catalina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

•
GUILFORD•COUNTY DEPARTMENT OF PUBLIC HEALTH
Division of Environmental Health,Water Quality Unit
• 400 W.Market St.,Suite 300, Greensboro,NC 27401 •
4 coll°d of Constrl'ucttoorllia Rc paOrro or Abandoreret of a Wag!!
-. Address ofWell:,57J&// ' 411 !' o/ce sk//Al.ATITUDE di �-'
Well Permit Number: 5-Do-/-0 le-i O c71•c 270116Nari uDE 2 l
Well Contractor Company: /4,Z414 /2-i ®i Completion Date: /13/23
Total WeII Depth: %�6'
p ft. Well Yield: gpm Static Water Level: 4 0 ft.
Outer CasIng laterial: . fil i Formation Log
Casing Diameter: in. Casing Depth: ft. Depth Description
From: ft.To: ft.
Inner Casing Material: From: ft.To: ft.
Casing Diameter: in. Casing Depth: ft. From: ft.To: ft.
. From: ft.To: ft.
Grout . From: ft.To: ft.
Depth Material Method • From: ft.To: ft.
From: ft.To: ft.
From: ft.To: ft.
ft.To: ft.
ft• From: ft.To: ft.
From: ft.To: ft • From: ft.To: ft.
Water Production Zones •
Depth: ft, ft. ft. ft. ft.
Yield: � �m gpm Qpm Ft ft.
gpm gpm gpm
Method of Repair:
Method clf andonment: .,.: CAl�s advir c 7/1 7il del tS P 41 /4
• I hereby certify that this well was constructed,repaired, or abandoned according to the Guilford County Well
Rules iri effect on t - date nd that a copy f th' record has been provided to the well owner.
i�
Well Contractor: -4 _ �‘ 'L Certification .d rtification#: %f �I Date//l0/2 3
Record of Pump Ellutallmtilorni
Pump Installation Company: Completion Date:
Pump Depth: ft. Static Water Level: ft '
Pump Brand: Pump Size and Rating: hp gpm
I hereby certify that this pump was installed and wellhead completed according to the Guilford County Well
Rules in effect on this date and that a copy of this record has been provided to the well owner.
✓WelI Contractor: Certification#: • Date:
Revised:January 1,2009

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Adam Hill 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
wells abandoned: 1 I�u
Adam Hill
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): n/a (gal.)
4061 A FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#: 2 3- 05 -W Ft f U O L 2 3
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)if known Half Pound
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 0 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) I 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 1 yard
❑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 Poured concrete in well
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 5/26/2023 -Y ttf
1„
5a.Well location: JU1V re `6 2013
in10.7t i:kn ;fir.7nz-, Q!,-,rJ una
Facility/Owner Name Facility ID#(if applicable)
8.Certification: DVICii OG
690 Brigham Road 3
Physical Address,City,and Zip hof ern ied Well Contractor or Well Owner Da e
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 lat/long is sufficient) 9.Site diagram or additional well details:
N 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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 105 (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: 60 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (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
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016