Caswell_Well Abandonment_20231101

,
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILLS
Brian James Bellis 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
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'3 (gal.)
I.
WithersRavenel, Inc. FOR WATER SUPPLY WELLS!ONLY:
•
Company Name
7c.Type of disinfectant used: i.
2.Well Construction Permit#: Not Applicable I.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:I :
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement G put I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement t oet ^'iT.-,: q i'LT,Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) I Concrete Grout NOV --El-Drill Cuttings
0 Irrigation 0 Specialty Grout NOV I) 1 2023❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
e Manitoring ['Recovery +c• 7„• J L,,{I:$
Injection Well: 7f.For each material sefeotetl'alioi provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips ) . 38 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
['Aquifer Test ❑StormwaterDrainage Concrete Grout i, 50 lbs
['Experimental Technology ['Subsidence Control t
7g.Provide a brief description of theiabandonment procedure:
['Geothermal(Closed Loop) ['Tracer I!
OGeothermal(Heating/Cooling Return) [Other(explain under 7g) Bentonite chips were poured into well and tamped
until they came up to ;`one foot from top of well.
4.Date well(s)abandoned: August 1, 2023 I�
Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
JKE Properties, LLC 0-0-04433
Facility/Owner Name Facility ID#(if applicable) 8.Certification:_`—
10795 NC Hwy 86 North, Providence 2731.5 10-26-2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Caswell 0047 291
By signing this form, I hereby certifyithat the well(s) was (were) abandoned in 2
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 beren!provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
35.8551471 N -79.572318 You may use the back of this pagelto 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# M W 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 8 (in.) above, also submit one copy of thins form within 30 days of completion of well
abandonment to the following:
6d.Water level.below ground surface 27.00 (ft•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
NA 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 1 health department of the county where
6f.Inner casing/tubing length(if known): (ft.)
abandoned.
i
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016

i ;
•
I '
WELL ABANDONMENT RECORD For Internal Use ONLY: 1 , I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Belles 7a.For Geoprobe/DPT or Closed IL lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GWI-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: 1
7b.Approximate volume of water€;remainin in well(s): 1'45 (gal.)
Well Contractor Certification Number PP I , g (g )
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name I
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:l
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 PI Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ' "�` '+`T ` `Dty Gla�.
❑Industrial/Commercial ❑Residential Water Supply(shared) II Concrete Grout 1t '` �0 DrilliCti'ttings
❑irrigation ❑ Specialty Grout N()V 11 j z���tpravel
Non-Water Supply Well: • 0 Bentonite Slurry ❑ Other(explain under 7g)
U Monitoring ❑Recovery InT3i r. =r^:-1 %'?:, r,; .i'2 '1.�Ty�)
Injection Well: 7f.For each material selectebatsoW p_?mide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips 38 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout �`` 50 lbs
❑Experimental Technology ❑Subsidence Control I
7g.Provide a brief description of then abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite chips were poured into well and tamped
until they came up to -'one foot from top of well.
4.Date well(s)abandoned: August 1, 2023
Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
JKE Properties, LLC 0-0-04433
Facility/Owner Name Facility ID#(if applicable) S.Certification:
10795 NC Hwy 86 North, Providence 27315 10-26-2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Caswell 0047 291
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:
35.8551471 N -79.572318 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 sante construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 2 abandonment to the following:
1!
Division of Water Resources,Information Processing Unit,
6b.Total well depth 35 (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 8 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: IP
26.10 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 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): 20 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
dI
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I: Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis
7a.For Geoprobe/DPT or Close_dJ(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
NCWC 3510-A wells abandoned:
1.4
NC Well Contractor Certification Number 7b.Approximate volume of wate remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS'ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable ;,;
i
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): t
Water Supply Well: 7e.Sealing materials used(check illFthat apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout,._ A Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grtlut,� `i?=- c ; "C..Diy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 1 f--L Drill Cuttings
V
❑Irrigation . ❑ Specialty Grout NU v 1 2023 0 Gravel
Non-Water Supply Well: 0 Bentonite lusty,•^ . 0 Other(explain under 7g)
U Monitoring ❑Recovery 1i'ix..,.,-,-..`,`'•t) t„u
Injection Well: 7f.For each material 'lettedcafe,provtd`ramount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips 1 38 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout 50 lbs
❑Experimental Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer II
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) I Bentonite chips were poured into well and tamped
until they came up to .one foot from top of well.
•
4.Date well(s)abandoned: August 1, 2023
Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout. .
JKE Properties, LLC 0-0-04433 '
8.Certification: 1
Facility/Owner Name Facility ID#(if applicable) G' / �
10795 NC Hwy 86 North, Providence 27315 '' /�` 10-26-2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Caswell 0047 291
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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.8551471 N -79.572318 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 thi 'form within 30 days of completion of well
6a.Well ID#:
MVV-3 abandonment to the following: ii
Division of Water Resources,Information.Processing Unit,
6b.Total well depth 35 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the fonn to the address in 10a
6c.Borehole diameter: 8 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: f
6d.Water level below ground surface: 26.60 (ft.) Division of Water Resources,tnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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 countyi health department of the county where
6f.Inner casing/tubing length(if known): 20 (ft.) abandoned.
I
i
6g.Screen length(if known): 1 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
I .
WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed I iop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW130 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: 1
1
NC Well Contractor Certification Number 7b.Approximate volume of water reinaining in well(s): 1'4 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLSiONLY:
Company Name
7c.Type of disinfectant used: l'
2.Well Construction Permit#: Not Applicable
i
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 ❑Neat Cement Gro t T ! Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout.`:®.Via.,ft' r =.a iii prf Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) I Concrete Grout O"Drill°Cuttings
0 Irrigation ❑ Specialty Grout NOV !) 1208 Gravel
Non-Water Supply Well: 0 Bentonite Slur ❑ Other(explain under 7g)
IMonitoring ORecovery 'y�'"^mot '� •,,'.'•�'-TP 'I-M
Injection Well: 7f.For each material selectd'above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips 1 38 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout I11 . 50 lbs
❑Experimental Technology ❑Subsidence Control f 1
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite chips were poured into well and tamped
until they came up to ;`one foot from top of well.
4.Date well(s)abandoned: August 1, 2023
Remaining space in well and flush mount cover
i.
5a.Well location: filled with concrete grout.
JKE Properties, LLC 0-0-04433
Facility/Owner Name Facility ID#(if applicable) 8.Certification: •=-----31,_e_c ___,LA/ le....ag. •
10795 NC Hwy 86 North, Providence 27315 10-26-2023
Physical Address,City,and Zip Signature of Certified Well Contractor or,Well Owner Date
_Ca_swell 0047 291
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:
35.8551471 N -79.572318 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# MW-4 abandonment to the following: :
Division of Water Resour ces,Information Processing Unit,
6b.Total well depth 35 (ft.) 1617 Mail Service Ce!nter,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 8 (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: 26.40 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
NA 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): 20 (ft.) abandoned. P
6g.Screen length(if known): 15 (ft.) !
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201'6

f
i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1 l
1.Well Contractor information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed IL iop 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
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water)remaining in well(s): 1'7 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS,ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit1I: Not Applicable i
List all applicable well construction permits(i.e.(I/C,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 ❑Neat Cement Grout i • 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 GroutTi , : -1Gl J r Cuttings
a ter''',w3��.s V, ra e❑Irrigation ❑ Specialty Grout ho.,c�yl
Non-Water Supply Well: 0 Bentonite Slurry NO V J 1 Other(explain under 7g)
•Monitoring ❑Recovery Zl'�J
Injection Well: 7f.For each material selected above,provide amount of materials used:
rh,-.er..,:...i1 e'':7^:^7,'a I'.,.e
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips D;? L• °. I Y"' #3'lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑StormwaterDrainage Concrete Grout 50 lbs
❑Experimental Technology ❑Subsidence Control j
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 7g) Bentonite chips were'poured into well and tamped
until they came up to -'one foot from top of well.
4.Date well(s)abandoned: August 1, 2023 Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
JKE Properties, LLC 0-0-04433
Facility/Owner Name Facility ID#(if applicable) 8.Certification:7.
10795 NC Hwy 86 North, Providence 27315 .10-26-2023
Physical Address,City,and Zip Signature of Certified Well Contractor of Well Owner Date
Caswell 0047 291 1
By signing this form, I hereby cergl 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:
35.8551471 N -79.572318 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)ifarailable. 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#: M W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 40.3 (fit) 1617 Mail Service Center,Raleigh,NC 27699-1617
I •
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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 29.80 (fit.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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
6f.Inner casing/tubing length(if known): 25.3 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
r
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcesl,' Revised 2-22-2016
1

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed IL lop 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
NCWC 3510-A wells abandoned: 1 I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'1 - (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS'ONLY:
Company Name
7c.Type of disinfectant used: I.
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown I
7d.Amount of disinfectant used:i
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check'allIthat apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 1 MI Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ❑ Sand Cement Gaut ,".A`-:, ,.LLDry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ` jt"-r.. ar' Jj rily)Cuttings
_❑Irrigation ❑ Specialty Grout NOV V l 1 2O2 Gravel
Non-Water Supply Well: ID Slurry l' Other(explain under 7g)
CMonitoring ❑Recovery Ip;C;,-r,14.,` >,,,_",^r., t M
Injection Well: 7f.For each material selected•above"li ovhl-amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips 37 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout 50 lbs'
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I
Bentonite chips were poured into well and tamped
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
until they came up to ;one foot from top of well.
4.Date well(s)abandoned: August 1, 2023 Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
JKE Properties, LLC 0-0-04433 ,
Facility/Owner Name Facility ID#(if applicable) 8.Certification: i
10795 NC Hwy 86 North, Providence 27315 10-26-2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Caswell 0047 291
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: I
(ifwell field one latllong is sufficient) 9.Site diagram or additional well{details:
35.8551471 N -79.572318 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 records)ifarailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one fonn.
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 Reso Irces,Information Processing Unit,
6b.Total well depth 34.8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
8 r
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
I
abandonment to the following:
6d.Water level below ground surface: 27.85 (ft.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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): 19.$ (ft.) abandoned.
6g.Screen length(if known): 15 (ft.) I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016

.
WELL ABANDONMENT RECORD For Intemal Use ONLY:
i
I
1.Well Contractor Information: WELL ABANDONMENT DETAIILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed1Loop 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
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wate remaining in well(s): 1'3 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS:ONLY:
Company Name
7c.Type of disinfectant used: 1
2.Well Construction Permit#: Not Applicable
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 ❑Neat Cement Grout j Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Thy Clay
❑Industrial/Commercial [Residential Water Supply(shared) a Concrete Grout ,-", ,.Dri)I Cuttings
❑Irri ationt k,.`'i---;I r ;
g 0Specialty Grout �^n W�q�(1`r;ayet
Non-Water Supply Well: 0 Bentonite Slurry NO V ) f 202j Other(explain under 7g)
CMonitoring ❑Recovery 11
Injection Well: 7f.For each matgrialaeleeted above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips uc..,. `11 v_y 1�l''3tlbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete Grout ( •
50 lbs
❑Experimental Technology ❑Subsidence Control I
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite chips were poured into well and tamped
until they came up to ;one foot from top of well.
4.Date well(s)abandoned: August 1, 2023 Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
JKE Properties, LLC 0-0-04433
Facility/Owner Name Facility ID#(if applicable) 8.Certification: •
10795 NC Hwy 86 North, Providence 27315 G ( 10-26-2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Caswell 0047 291
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 ladlong is sufficient) 9.Site diagram or additional well details:
35.8551471 N -79.572318 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# MW-7 abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 39.8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
10b.For Injection Wells: In addition to sending the fonn to the address in 10a
6c.Borehole diameter: 8 (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: 32.1 5 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 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): 24'$ (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1
t