Guilford_Well Abandonment_20240123

t WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Blair Mitchell 7a.For Geoprobe/DPT or Closed-foop 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 4419-C wells abandoned:e I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Redox Tech, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
W 10400608 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifkmown
7d.Amount of disinfectant used: 1
3.Well use(check well use):
Water Supply Well: - 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 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: ❑Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 19 Groundwater Remediation Granular bentonite 100 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑StormwaterDrainage Asphalt Patch
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 12 lbs. granular bentonite 24' to surface, asphalt patch
❑Geothermal(Heating/Cooling Return) - ❑Other(explain under 7g)
4.Date well JA N s)abandoned: 1/1 O - 1/12/24 V'j
_ 2 v 2024
5a.Well location:
1,�;
TForce Freight
i3v�"�:
t, 5�; .lG
Facility/Owner Name Facility IDS(if applicable) 8.Certification:
4411 Groometown Road Greensboro, NC 27407 ,rjL 1/15/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford County 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/secohds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.995785 N. -79.863324 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 i
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# I P-01 through I P-08 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
1.5 (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: 16 (ft) Division of Water ResourcesJUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft.) 10c.For Water SuPvIv&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): (ft.) abandoned. I
6g.Screen length(if known): - (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
Blair Mitchell 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 4419-C wells abandoned:-' I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Redox Tech, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
W 10400608 7c.Type of disinfectant used: �
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)iflorown
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 a 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
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge e Groundwater Remediation Type II/II Portland Cement —50 lbs.
❑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
Portland cement tremie grouted from pth,to:surface,.-.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
filling well vault
4.Date well(s)abandoned: 1/10/2024 dAN 2i
V
lrliJrst� �•il ., 1AI
5a.Well location:
TForce,Freight
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
4411 Groometown Road Greensboro, NC 27407 1/15/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford County 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: ,
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.995785 �. -79.863324 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 WE BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formultiple 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-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 27 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
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: 16 (ft) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 10 (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: l
r
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Blair Mitchell 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 4419-C wells abandoned:1 1
NC Well Contractor Certification Number 7b.Approximate volume of water I emaining in well(s). 0 (gal)
Redox Tech, LLC FOR WATER SUPPLY WELLS'ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#: W 10400608
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public S 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
[ Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge 19 Groundwater Remediation Type II/II Portland Cement —50 lbs.
❑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) Portland cement tremie grouted from depth to surface
filling well vault { ,;- v a
4.Date well(s)abandoned: 1/10/2024 "" `'' "T^L)
5a.Well location: AN
TForce Freight t;at.r-::� . .... _ •r. lss;
Facility/Owner Name Facility lD#(if applicable) 8.Certitication: DVVQ,-'''-G
4411 Groometown Road Greensboro, NC 27407 ; 1 1/15/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Guilford County
By signing this form, 1 hereby cerlif
y that the wells) was (were) abandoned in
County Parcel Identification No.(PK 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:
35.995785 N -79.863324 �, 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 INSTRUCTIONSI
Attach well construction record(s)ifavailable.Formultiple injection ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one form,
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-02A abandonment to the following: ;
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 36 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter:
4 (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: —16 (ft.) Division of Water Resources,!Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
I
6g.Screen length(if known). 2 (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016