McDowell_Well Abandonment_20231113

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis
7a.For Geoprobe/DPT or Closed-..cop 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: I
NC Well Contractor Certification Number 7b.Approximate volume of wateri remaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS O NLY:
Company Name
p 7c.Type of disinfectant used: I' _
2.Well Construction Permit#: 'V/„ - z :c^J : '�•�``
A' '
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
NOV ` }�
3.Well use(check well use): i Z1�.3
Water Supply Well: 7e.Sealing materials used(check ail hata 1 '?,- :;.3.7,1--.o 1.10
0 Agricultural 0 Municipal/Public I Neat Cement Grout I IT'eti'ton'iie,Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry I 0 Other(explain under 7g)
AMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation -15 lbs Bentonite -4 cf Clean Sand
0 Aquifer Storage and Recovery ❑Sal inity Barrier
❑Aquifer Test ❑Stormwater Drainage -25 lbs Cement Grout
❑Experimental Technology ❑Subsidence Control '
7g.Provide a brief description of the abandonment procedure:
0 Geothermal(Closed Loop) 0 Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite pellets were poured into the well and tamped to
top of well casing. Space within 2 ft by 2 ft vault filled with
4.Date well(s)abandoned: 10/4/2023 -4 cubic ft of clean sand and cement grout was used to
5a.Well location: seal the steel vault at the ground surface.
Say-A-Stop 00-0-0000013600 '
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4613 US Hwy 221 North, Marion (/ 11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
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:
35.738389 N -82.049226 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# EW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.1 (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 2 (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: ~6'5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
r .
6e.Outer casing length(if known): Unknown (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 1 health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
I
6g.Screen length(if known): Unknown (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
II
.

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor information: WELL ABANDONMENT DETAILS
Brian James Bellis I
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-�i0lis needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: II
NC Well Contractor Certification Number 7b.Approximate volume of water i remaining in well(s): • (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name i
7c.Type of disinfectant used: I'
2.Well Construction Permit#: N/A
~ .., Li,: JJJ
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known I
7d.Amount of disinfectant used:3.Well use(check well use): NOV
i ' 202-.3
Water Supply Well: 7e.Sealing materials used(check all that`pply):,i-,;, -,;,^ Ul.,
❑Agricultural ❑Municipal/Public I Neat Cement Grout I Berttotiitd'cIiiks,.i r Pellets
•
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
• 0 Irrigation 0 Specialty Grout ❑ 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 -60 lbs Bentonite -4 cf Clean Sand
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage -25 lbs Cement Grout
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite pellets were poured into the well and tamped to
top of well casing. Space within 2 ft by 2 ft vault filled with
4.Date well(s)abandoned: 10/4/2023 -4 cubic ft of clean sand and cement grout was used to
5a.Well location: seal the steel vault at the;,ground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility ID#(if applicable) S.Certification:
4613 US Hwy 221 North, Marion 11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or WWell'Owner Date
McDowell 0793-00-57-1522
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:
35.738389 N -82.049226 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)ifm'ailable.For multiple injection or non-water supply welts
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#: EW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.3 (It) 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: 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: -6.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i.
Unknown 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): (ft.) abandoned.
6g.Screen length(if known): Unknown (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 i
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
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY: .:' - ,, ,_,`)
Company Name Typei �'^.,-�`',• .i ,a ti
A' 7c. of disinfectant used: "'"
2.Well Construction Permit#: 'V/„ , NO V 1 2n23_
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 1.
3.Well use(check well use): i Gt";ti `'
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public •Neat Cement Grout U Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Thy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑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 -60 lbs Bentonite -'4 cf Clean Sand
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑Aquifer Test ❑StormwaterDrainage -25 lbs Cement Grout
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
Bentonite pellets were poured into the well and tamped to
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
top of well casing. Space within 2 ft by 2 ft vault filled with
4.Date well(s)abandoned: 10/4/2023 -4 cubic ft of clean sand and cement grout was used to
5a.Well location: seal the steel vault at theground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility ID#(if applicable) 8.Certification: _f(
4613 US Hwy 221 North, Marion 11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
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 to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well details:
35.738389 -82.049226 W You may use the back of this page to provide additional well site details or well
N
- 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#: EW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 15.15 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 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 "6.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,;Raleigh,NC 27699-1636
Unknown 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): (ft.) abandoned. i
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

,
•
WELL ABANDONMENT RECORD For intemal Use ONLY:
1.Well Contractor information: WELL ABANDONMENT DETAILS
Brian James Bellis I
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 s needed. indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY: I.T —;
Company Name e:�,, ,:+•._,?' V4a`^t jj
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A NO V T
List all applicable[cell construction permits(i.e.U/C,County,State,Variance,etc.)ifknown l 2023
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 I 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) 0 Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation -60 lbs Bentonite ^'4 cf Clean Sand
❑Aquifer Storage and Recovery ❑Sal inity Barrier
❑Aquifer Test ❑StormwaterDrainage -25 lbs Cement Grout
❑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) Bentonite pellets were poured into the well and tamped to
top of well casing. Space within 2 ft by 2 ft vault filled with
4.Date well(s)abandoned: 10/4/2023 —4 cubic ft of clean sand and cement grout was used to
5a.Well location: seal the steel vault at the;ground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility iD#(if applicable) 8.Certification:
4613 US Hwy 221 North, Marion 11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
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:
35.738389 N -82.049226 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#: EW-5 abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 14.70 (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: 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: -6'S (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (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): Unknown (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
Brian James Bellis I
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 constructi0n/depth,only 1 GW 0 its needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: I I
I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 1IiT '1
2.Well Construction Permit#: N/A
/A List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown I N O 1I 1 2023
7d.Amount of disinfectant used: i �V VLls
3.Well use(check well use): _^
Water Supply Well: 7e.Sealing materials used(check all that apply): far c,:i.t:
❑Agricultural ❑Municipal/Public U Neat Cement Grout U Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) El Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
UMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation ^•60 lbs Bentonite -4 cf Clean Sand
❑Aquifer Storage and Recovery ❑Sal inity Barrier
❑Aquifer Test ❑Stormwater Drainage -25 lbs Cement Grout
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite pellets were poured into the well and tamped to
top of well casing. Space within 2 ft by 2 ft vault filled with
4.Date well(s)abandoned: 10/4/2023 -4 cubic ft of clean sand and cement grout was used to
5a.Well location: seal the steel vault at the ground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
4613 US Hwy 221 North, Marion
11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
By signing this form, I hereby certif,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:
35.738389 N -82.049226 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# EW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 14.15 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In additi n to sending the form to the address in 10a
6c.Borehole diameter: 4 (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: -6.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 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): (ft.) abandoned.
6g.Screen length(if known): Unknown (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
Brian James Bellis 7a.For Gcoprobe/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-ki is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY: is• T'i r;.-,
Company Name I. , k ':,..?y,.-:..r, V g _,)
7c.Type of disinfectant used: 1 fl
2.Well Construction Permit#: N/A ! NOV i 2023
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known i
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 !III Neat Cement Grout • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout El Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout '' ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry El Other(explain under 7g)
IMonitoring ❑Recovery ,
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation -60 lbs Bentonite ! -4 cf Clean Sand
❑Aquifer Storage and Recovery ❑Sal inity Barrier I.
❑Aquifer Test ❑StormwaterDrainage -25 lbs Cement Grout
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of thel abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite pellets were poured into the well and tamped to
top of well casing. Space within 2 ft by 2 ft vault filled with
4.Date well(s)abandoned: 10/4/2023 -4 cubic ft of clean sand and cement grout was used to
5a.Well location: seal the steel vault at thei.ground surface.
Say-A-Stop 00-0-0000013600 I.
•
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4613 US Hwy 221 North, Marion _ %
W' 11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522 I
By signing this form, I hereby certi/5'that the well(s) was (were) abandoned in
County Parcel identification No.(PIN) accordance with 15A NCAC 02C.010o 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:
35.738389 N -82.049226 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)ifat'ailable. For multiples jectionornon-water supply wells
I
ONLY with the same constructiwvabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: EW-7 abandonment to the following: 1
1
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.0 (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 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: -6.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centler;Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (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): (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources ;f , Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor information: WELL ABANDONMENT DETAILS
Brian James Bellis I I
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 J30';is needed. indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water r emaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
f�' /� 7c.Type of disinfectant used:
2.Well Construction Permit#: 'V/~ ! ^'...,,,:-d' ,- i^"!
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: Nt l I/ I V Iron
3.Well use(check well use): «t� t
Water Supply Well: , �'7
PP Y 7e.Sealing materials used(check all that apply):'''`'�'•�°• � .•_. ,,, �irhT.S
❑Agricultural ❑Municipal/Public •Neat Cement Grout • Bentonite Clirps'or Pellets
OGeothermal(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: ❑ 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 -60 lbs Bentonite -4 cf Clean Sand
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage -25 lbs Cement Grout
•
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Bentonite pellets were poured into the well and tamped to
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
top of well casing. Space within 2 ft by 2 ft vault filled with
4.Date well(s)abandoned: 10/4/2023 -4 cubic ft of clean sand and cement grout was used to
5a.Well location: seal the steel vault at the ground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility ID#(if applicable) 8.Certification: - K w
4613 US Hwy 221 North, Marion - 11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
By signing this form, 1 hereby certrfj'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:
35.738389 N -82.049226 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#: EW-8 abandonment to the following:
15.35 Division of Water Resources,Information Processing Unit,
6b.Total well depth (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 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 -6.5 (ft•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): Unknown (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): Unknown (ft.)
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:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis I
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- 0 lis needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Withers Ravenel, Inc. 'FOR WATER SUPPLY WELLS ONLY:
Company Name r..,'I i 0.,a ""i 1 y'>: �^•:
7c.Type of disinfectant used: •r F4 i ....;y.
t�'
2.Well Construction Permit#: 'V/„ NOV y 202'
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.)ifknown !
7d.Amount of disinfectant used: 1
Pli.-:,-:r:,:,..-, a,- -
3.Well use(check well use): i 1.10
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ 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 —60 lbs Bentonite i —4 cf Clean Sand
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage —25 lbs Cement Grout
❑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) Bentonite pellets were poured into the well and tamped to
top of well casing. Space within 2 ft by 2 ft vault filled with
4.Date well(s)abandoned: 10/4/2023 —4 cubic ft of clean sand and cement grout was used to
5a.Well location: seal the steel vault at the'i.ground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility ID#(if applicable) S.Certification: - _ I
4613 US Hwy 221 North, Marion
11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
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:
35.738389 N -82.049226 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 hells
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#: EW-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 15.20 (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 4 (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: —6.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,;Raleigh,NC 27699-1636
I
Unknown I Oc.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): (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
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:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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 1 GW J30I is needed. indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water I remaining in well(s): (gal.)
II
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name • f. d ,
7c.Type of disinfectant used: ' L._:,a ;: ;1 ; "'I
2.Well Construction Permit#: N/A p� n
PP permitsCounty, etc.)if NOV V . 2023
List all applicable well construction (i.e.l.e.UIC, Slate,Variance. ! known 1 .�
7d.Amount of disinfectant used:
3.Well use(check well use): 1t:.. �,, ,-,,_
Water Supply Well: 7e.Sealing materials used(check all that apply): Dt�a O y
❑Agricultural ❑Municipal/Public ['Neat Cement Grout IPJ 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
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water'Supply Well: El 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 '-20Ibs Bentonite
DAquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑StormwaterDrainage —25 lbs Cement Grout
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
DGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite pellets were poured into the well and tamped.
until one ft from top of casing. Remaining space in well
4.Date well(s)abandoned: 10/4/2023 and protective cover was filled with cement grout.
5a.Well location:
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility ID#(if applicable) 8.Certification: •
4613 US Hwy 221 North, Marion 11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
By signing this form, I hereby certify 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
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:
35.738389 N -82.049226 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-14 abandonment to the following: '
Division of Water Resources,Information Processing Unit,
4.5 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 4 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
NA Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 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): (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
II
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis I
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
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY: I ;
n,. .. �.�„ �� 4.,s�_.:
Company Name
7c.Type of disinfectant used: t,
2.Well Construction Permit#: N/A NOV i 2023
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: tn= : sa 1 g(•a
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 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑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 —85 lbs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage —25 lbs Cement Grout
❑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) Bentonite pellets were poured into the well and tamped
until one foot from top of casing. Remaining space in well
4.Date well(s)abandoned: 10/4/2023 and protective cover space was filled with cement grout.
5a.Well location: •
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility ID/I(if applicable) 8.Certification: � _
4613 US Hwy 221 North, Marion CJ 11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
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:
35.738389 N -82.049226 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.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# MW-15 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20.0 (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: 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 —6.54 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 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 thealth department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
•
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 Closed-.00p 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 its needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name ay
7c.Type of disinfectant used: a'- •,
2.Well Construction Permit#: N/A N �
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)if known �V A I f t t/ 1 2023
7d.Amount of disinfectant used: I J V - It
3.Well use(check well use):
fir":^_.7,7.
Water Supply Well: 7e.Sealing materials used(check all that apply): Dt C ::'O/
❑Agricultural ❑Municipal/Public •Neat Cement Grout • 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) 0 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:
❑A Aquifer Recharge ❑Groundwater Remediation
q g -30 lbs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage -25 lbs Cement Grout
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Bentonite pellets were poured into the well and tamped to
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
one ft from top of well casing. Remaining space within well
4.Date well(s)abandoned: 10/4/2023
and flush mount protective cover was capped with cement
5a.Well location: grout to form seal at the ground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
4613 US Hwy 221 North, Marion -
11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
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
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.738389 N -82.049226 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 sell 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# EM-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 27.90 (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: 2 (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 -6.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 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): (ft.) abandoned.
Unknown
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-20I6

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
I I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis I
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 130 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLY WELLS ONLY: 17 ;--;s.,. --
Company Name ' -"" °,.? .=.i' ;.i' i`' `
q 7c.Type of disinfectant used: <n;�
2.Well Construction Permit#: 'V/„
1�' NOV
/►qq
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown �� 2ltL..,r,
7d.Amount of disinfectant used:
3.Well use(check well use): _ .,,•-�
Water Supply Well: 'a
PP Y 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 1 ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation ^•15 lbs Bentonite I
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage —25 lbs Cement Grout
❑Experimental Technology ❑Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) Bentonite pellets were poured into the well and tamped to
one ft from top of well casing. Remaining space within well
4.Date well(s)abandoned: 10/4/2023 and flush mount protective..cover was cap
ped pped with cement
5a.Well location: grout to form seal at the ground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility ID#(if applicable) S.Certification: i /�—�yl/l
4613 US Hwy 221 North, Marion 1/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
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 lat/long is sufficient) 9.Site diagram or additional well details:
35.738389 N -82.049226 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[yells
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# Unknown ID #1 abandonment to the following:
14.25 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (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: 2 (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: —6.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (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): (ft.) abandoned.
6g.Screen length(if known): Unknown (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 l
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis '
7a.For Geoprobc/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 GWL 30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
I •
NC Well Contractor Certification Number 7b.Approximate volume of wateriremaining in well(s): (gal.)
Withers Ravenel, Inc. FOR WATER SUPPLYWELLSIONLY:
Company Name .t• �
A' /• 7c.Type of disinfectant used: @' ; u.i' i"•; i
2.Well Construction Permit#: N/~ NO V 1 i 202 x J List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known - `3
7d.Amount of disinfectant used:
3.Well use(check well use): '^ -.....
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural ❑Municipal/Public a Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
U Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ^•10 lbs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage -25 lbs Cement Grout
❑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) Bentonite pellets were poured into the well and tamped to
one ft from top of well casing. Remaining space within well
4.Date well(s)abandoned: 10/4/2023 and flush mount protective cover was capped with cement
5a.Well location: grout to form seal at the ground surface.
Say-A-Stop 00-0-0000013600
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4613 US Hwy 221 North, Marion
11/3/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
McDowell 0793-00-57-1522
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:
35.738389 N -82.049226 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 constriction 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# Unknown ID #2 abandonment to the following:
10.00 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: 2 (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 -6.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 10c.For Water Supply&Iniection 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): (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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