Person_Well Abandonment_20230825 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary S i meox 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
2944—B _ °it Dwells abandoned:
NC Well Contractor Certification Number �, 7b.Approximate volume of water remaining in well(s): '20 (gal.)
S&ME, Inc. AUG 2 5 2023 FOR WATER SUPPLY WELLS ONLY:
P y
Corn an Name lrt,`orr'.ati,—n ?MC*1*M UM 7c.Type of disinfectant used:
2.Well Construction Permit M DV°V'21G
11
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):
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout i! S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 30 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier i
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control I`
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Backfilled well casing w/ bentonite chips.
i
4.Date well(s)abandoned: 8/1 7/23
5a.Well location: I,
Huffman Oil Company
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3620 Chub Lake Rd., Roxboro, NC 27574
8/21/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Person By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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]at/long is sufficient) 9.Site diagram or additional well details:
360 26' 36.29" N 780 59' 30.29" 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.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formultiple injection ornon-watersupplywells
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#: V Vtt,—6 abandonment to the following:
Division of Water Resourcesi Information Processing Unit,
6b.Total well depth: 17 (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:
i
6d.Water level below ground surface' 15.97 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service CenIter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Sunnlv&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 casing/tubing length(if known): (ft,) abandoned.
i
6g.Screen length(if known): (ft.)
i
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 DETAILS
GaryGary 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-36,is needed. Indicate TOTAL NUMBER of
2944—B wells abandoned:
NC Well Contractor Certification Number DECEIVED 76.Approximate volume of water t emaining in well(s): 0 (gal.)
SW E, Inc. AUG 2 5'20?2 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: lnforic.-W.-n Pr.naa-aSPrq UN4
List all applicable well construction permits(i.e.UIC,County,State, ariance,eta)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 ❑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 35 lbs.
I'
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storntwater Drainage
❑Experimental Technology ❑Subsidence Control I'
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Backfilled well casi ng w/ bentonite chips.
4.Date well(s)abandoned: 8/17/23
i
5a.Well location:
Huffman Oil Company
Facility/Owner Name Facility ID#(if applicable) S.Certification:
3620 Chub Lake Rd., Roxboro, NC 27574 8/21/23
Physical Address,City,and Zip Signature of Certified Well Contractor or}Nell Owner Date
Person B signing this form,I hereby certi Mal the wells was were abandoned in
Y Sr+ 8 f Y fY �� (were)
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: I'
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36° 26' 35.41" N 78° 59' 29.4$" `l, 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 ornon-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#:W-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I`
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 thisyfoim within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: D'71�� (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ce i ter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Suonly m 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. '
i
6g.Screen length(if known): (ft.)
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
1.Well Contractor Information: WELL ABANDONMENT DETAILS
GarySimcox
7a.For Geoprobe/DPT or Closed- lap 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
2944—B wells abandoned:
NC Well Contractor Certification Number �^ _S 7b.Approximate volume of water�remaining in well(s): .2 (gal.)
SW E, Inc. F�� �V E FOR WATER SUPPLY WELLS't)NLY:
Company Name A U G 2 5 2 i
7c.Type of disinfectant used:
2.Well Construction Permit#: e
List all applicable well construction permits(i.e.Uk b y,' e, q eta 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 ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout i ❑Dry Clay
❑Industrial/Commercial EIResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑LTi 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 35 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Backfilled well casing w/ bentonite chips.
i'
4.Date well 8/17/23s)abandoned: i
5a.Well location:
Huffman Oil Company
i
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3620 Chub Lake Rd., Roxboro, NC 27574 8/21/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Person 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
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: I.
(i£well field,one lat/long is sufficient) 9.Site diagram or additional well details:
360 26' 34.43" N 780 59' 31 .96" `,), 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.
a
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form. i
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:W-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
21 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in l0a
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: 19.78 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cent er,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016