Davidson_Well Abandonment_20230626 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeffrey Grant 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
4328-8 wells abandoned: ode--
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '1 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: W M0401453
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 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
INMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑AquiferTest ❑StormwaterDrainage Concrete Grout 50 pounds
❑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) Fill the entire length of the borehole with
concrete grout.
4.Date well(s)abandoned: 6-15-23 t r-- •-•
5a.Well location: )U N J ; 2023
Facility/Owner Name Facility ID#(if applicable i 8.Certification: Ink,Pl1=;a:1en ?r: biAeirg Ur/.
664 Old Hargrave Road, Lexington, 27295 w , elQi3OG 6-16-23
Physical Address,City,and Zip Sign. 'e"'Me."'ell ntractor or Well Owner Date
Davidson
By signing this form, 1 hereby certe 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:
35.788295 N 80.311819 �, 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 construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 16 (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: (in.)
(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: 12.5 (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 Suoaly&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): 12 (ft.) abandoned.
6g.Screen length(if known): 4, (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
Jeffrey Grant 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
4328-B wells abandoned:Two
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '1 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: W M 0401453
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 0 Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial 0 Residential Water Supply(shared) ! Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
!Monitoring 0 Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑AquiferTest ❑StormwaterDrainage Concrete Grout 50 pounds
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Fill the entire length of the borehole with
concrete grout.
4.Date well(s)abandoned: 6-15-23
iU1N 3 2023
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.(crli cation: C,f��3y�3
664 Old Hargrave Road, Lexington, 27295 6-16-23
Physical Address,City,and Zip Signal a of Certified ell ontractor or Well Owner Date
Davidson
By signing this form, I hereby certify 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
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.788295 80.311819 �, 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#: TW-2 & TW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (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: (in.)(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: 12.12 (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&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): 11 (ft.) abandoned.
6g.Screen length(if known): 4 (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
Jeffrey Grant 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:Two
4328-B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): .1 (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLI:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: W M0401453
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 ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) !Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 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 ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑AquiferTest OStormwater Drainage Concrete Grout 50 pounds
❑Experimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer 72.Pro ide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Fill the entire length of the borehole with
concrete grout.6-15-23 O
�! G _M: .
4.Date well(s)abandoned: �
Sa.Well location: Jt,1v 263 r
?rD BOG" Utz
4�
Facility/Owner Name Facility ID 8.Certification: Itir«#(if applicable) p.1
664 Old Hargrave Road, Lexington, 27295 /•, 6-16-23
Physical Address,City,and Zip Signal r of e tfied 'ell ntractor or Well Owner Date
Davidson
By signing this form, I hereby certifr 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:
35.788295 . 80.311819 M, 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.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-3 & TW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.l oral well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: (in.)
(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 6.56 (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 SUDDIV&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): 16 (ft.) abandoned.
6g.Screen length(if known): 4 (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
Jeffrey Grant 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:Two
4328-B
1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
JG Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: WMO4O1453
List all applicable well construction permits(i.e.UIC,Cowi( .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 ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
DAquifer Storage and Recovery OSalinity Barrier --
❑AquiferTest ❑StormwaterDrainage Concrete Grout 50 pounds
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Fill the entire length of the borehole with
concrete grout.
4.Date well(s)abandoned: 6-15-23 :..— i !,.•'
5a.Well location: JUN 2 r) 2023
IntsrrrsiCn Pr;rasoW Unit
Facility/Owner Name Facility ID#(if applicable) 8.Certification: DWO Cl
664 Old Hargrave Road, Lexington, 27295 /�, , 6-16-23
Physical Address,City,and Zip Signature `' e ied Wel/ont ct6 for or Well Owner Date
Davidson
By signing this form, I hereby certifr 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:
(if well field,one Jut/long is sufficient) 9.Site diagram or additional well details:
35.788295 N 80.311819 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#• TW-4 & TW-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Iniection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: (in.)
(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: 14.03 (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 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
6f.Inner casing/tubing length(if known): 14 (ft.) abandoned.
6g.Screen length(if known): 4 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016