Guilford_Well Abandonment_20231024

WELL ABANDONMENT RECORD For lntemal Use ONLY:
1.Well Contractor Informatio_n_: _ _ WELL ABANDONMENT DETAIL'S j
Gary 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
29446, __. ._..._ wells abandoned:(; }...�__ -- -
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):4 ''(gal.)
;$&ME-Ind. - " . i FOR WATER SUPPLY WELLS ONLY:
Company Name f d of eta t- - 7c.Type o isi e n used.
2.Well Construction Permit#:
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:. =
i
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ■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
1:31ni ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 8Q,IbS `,; •';. t
[]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) Filled well casing wlth bentonite chips and
,then-h drated
9/28/2023
Y f k
4.Date well(s)abandoned..
5a.Well location: I �- -
Eddies-Texaco
Facility/Owner Name FacilityID#(if applicable) 8.Certification:
j103 West Main Street, Gibsonville,_NC, ' 9/28/2023 .
Physical Address,City,and Zip_ _ _ .___ _ _ Signature of Certified Well Contractor 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:
(ifwell field,one lat/long is sufficient)
9.Site diagram or additional well details:
36 06'20.92" 79 32'.32.28��• You may use the back of this page I:to,provide additional well site details or well
N ' 'W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auach Well construction record(s)ifavallable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
r - 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#•wW 1 abandonment to the following: I.
Division of Water Resources,Information Processing Unit,
6b.Total well depth:50.9 '(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
101b.For Injection 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:24:22 (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 Sunuly&Iniecti In 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
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
r
Forth GW-30 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016
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WELL ABANDONMENT-RECORD For Internal Use-ONLY:__ _. ____.- {{ -- _•__ —__._
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Ga SiMcox-
ry. !: 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-3 nee 0 is needed. Indicate TOTAL NUMBER of
- r;l wells abandoned!�` - C
2944B .__ . f f1,0
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal J
S&ME, InC: = FOR WATER SUPPLY WELLS ONLY:
Company Name - -- - ------ --- - r i(_ y
lc.Type of disinfectant used:I.
2.Well Construction Permit#:r i I ,- ----- --
List all applicable well construction permits 6.e.UIC,County,State,Variance,etc.)ifknown
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 ■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)
■Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 50.-Ibs
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage I
❑Experimental Technology ❑Subsidence Control I
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracerr — — —— - -- -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled well:casing with,bentonite chips and j
then.hydrated F:
4.Date well(s)abandoned:9/28/2023
5a.Well location:
Eddie's.-Texaco "
Facility/Owner Name _ Facility ID#(if applicable) S.Certification: I• [y.� J
103 West Main Street, Gibsonville, NG~ �' 9/28/2023
Physical Address,City,rand Zip _ Signature of Certified Well Contractor or,Well Owner Date
,Guilford_: I
' 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 Iatgong is sufficient) — 9.Site diagram,or additional well'details:
36 06:20 87" N i79 32' 32.18' .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-watersupply wells
ONLY with the same construction/aandonment,you can submit oneform. I
I-.----------------- --- 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:MW=1 J abandonment to the following: j
t Division of Water Resources,Information Processing Unit,
6b.Total well depth: '
29 6 1617 Mail Service Center,Raleigh,NC 27699-1617
-.. -�{ft.)
I'
10b.For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter:" (in.) abandonment to the following:
6d.Water level below ground surface:24'06. (fit) Division of Water Resources,biderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):i (ft.) 10c.For Water Supply&Iniecti In Wells: In addition to sending the form to the
address(es)above,also submit onelcopy 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):I (ft.) abandoned.
6g.Screen length(if known):!
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For1riternal1JseONLX: _ -
1.Well Contractor Information: WELL ABANDONMENT DETAILS
GSIIIICOX_.L _ _..---___-- -- I
I ry 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 i§needed. Indicate TOTAL NUMBER of
r --_� wells abandoned:(..: -
2944B ; _ I i r 0 — -�
NC Well Conhactor Certification Number
7b.Approximate volume of water remaining in well(s):t�1'Q
S&M E, Inc. "._. ;. = FOR WATER SUPPLY WELLS ONLY:
Company Name --- - {' - -
IfI ,--- --— 7c.Type of disinfectant used:F'-" --- J
2.Well Construction Permit#:i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1;.
7d.Amount of disinfectant used:i h
r
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout IN Bentonite Chips or Pellets
I
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑bri ation ❑ Specialty Grout ' ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
wlonitoring ❑Recovery
Injection Well: 7E For each_material selected above_,provide amount of materials used:
❑A uifer Recharge ❑Groundwater Remediation
q35Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage I
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of tine abandonment procedure: _
❑Geothermal(Closed Loop) ❑Tracer -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Filled well:casing with;beritonite chips and . R
then`hydrated
9/28/202$ `
^�
4.Date well(s)abandoned:
t � -rn !
5a.Well location: �;. - �l'2
Eddwe-'s Texaco" �rT f 3
8.Certification:
Facility/Owner Name Facility ID#(if applicable)- _
11.03 West Main Street, Gibsonville,.NG _ 9/28/2023
Physical Address,City,and Zip Signature of Certified Well Contractor orVell 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 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: i
(if well field,one latQong is,sufficient)
_ 9.Site diagram or additional well details:
36 06' 20.93" !N !79 32' 31.78 I``, 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 coRtructionlabandonment,you can submit one form. !'
r-- - --. 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:22.2 (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:! �fin.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: r
6d.Water level below ground surface::21.68 (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&Iniecti�n Wells: In addition to sending the form to the
address(es)above,also submit one'copy of this form within 30 days of completion
fof well abandonment to the cotinty health department of the county where
6E Inner casing/tubing length(if known):` I(ft.) abandoned.
6g.Screen length(if known):!
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016
I
I

9 i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary:Simcox :-
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner person well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
F'-_- _,-._.__ -_.,_. ____�ally abandoning well on his/her property) wells abandoned: �_.._.._._.. - _
2944B , J r
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):�' (gal.)
S&ME,.Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ': �.
2.Well Construction Permit#:1- - .• - ------ - _ --- -_
-
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)ijknown I P Y �
7d.Amount of disinfectant used:I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ail that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ; ■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 i' ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry j ❑Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above_,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 35Ibs r -
❑Aquifer Storage and Recovery ❑Salinity Barrier III :
❑Aquifer Test ❑Stormwater Drainage t - =j'
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedures
r -
❑Geothermal(Closed Loop) ❑Tracer -,; ---- -•- __
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Filled Well casing wlthibentonite chips and
theh,hydrated _
9/28/2023
4.Date well(s)abandoned:> 1 „_
5a.Well location it
Eddie's-Texaco - --
Facility/Owner Name _ _ Facility ID_#(ifapplicable) 8.Certification:
103 West Main Street, Gibsonville, NC. 9%28/2023
Physical Address,City,and Zip _ _ _ ___--_.__ __ _ Signature of Certified Well Contractor 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.-
(ifwell fie s sufficient)
field,one lat/long iffici
i--_ - - - -- - --- - - - 9.Site diagram or additional well details:
36 06':21 26" ;N �79 32' 32.847 `1, 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.Formulh'ple injection or non-water supply wells
ONLY with the same construction/abandorun 1,y_ou can submit one form.
-------------- 10a. For All Wells: Submit this form within 30 days of completion of well
MW-3 1 abandonment to the following:
6a.Well ID#: - ? g'
-- -- Division of Water Resources,Information Processing Unit,
21.2 .• 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: :(ft.)
i
t -- 10b.For Injection 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:Pry (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
_ I
10c.For Water Su ulv&In ecti n Wells: n addition o sending the form to the
6e.Outer casing length(if known):! - • - (ftJ P l I t g
address(es)above,also submit one copy of this form within 30 days of completion
- of well abandonment to the co I ty health department of the county where
6L Inner casing/tubing length(if known):f (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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