Davidson_Well Abandonment_20240212

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. . WELL ABANDONME r'RECORD:
For liteirel Use ONLY;
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1.'Well Contractor Information :WELL ABANDONMENT DETAILS ' . .
David-.Hardy 7a.For: robe/DOT or Closed-
I 'i
• Loop,Geothermal Wells hiving the same
Well Contractor Name(or well ownerpe:sonally.®bandomng Well on hisTheepmpeity)'• wellconstriction/depth.only l GR►-30 fs needed. lndicate.TOTAL NUMBER of. •
• 2906:A • Wells abandoned: . c . - _ .
'NC Well Contractor Certification Number • 7b..Approsimato'volume of Water remaining Inwell(s)t . • • p' (gal.)
Aqua.Drill,, Inc. .. .. .: .: . • FOR WATER SUPPLY WELLS ONLY:"• •
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CompanyNamc
. - . 7e.lype.of disinfectant used: . "
2.•Well Const ruction Permit di . . - • '
•List all applicable sell can npcjmiti l.e W.C.Coumj:'Staie 'arlmue.eh.)(lbio,n+• '.
'. 7d.Auro®t of disinfectant trade' -.
3.Well use(cheek well use) .
Water Supply Well: Ye.Sealing materials used(check all that apply) • -
. OAgricultural• ❑Monicipal/Pobile ❑.Neat Cement Grout" - -0 Benbonite Chips or Pellets
. :• :• :❑Geothermal(Heatiog/Coolingdimply)• .'.❑Residential Water Supply(single) •• ❑Sand Cement Grout ❑
Dry Clay
• , . ❑lndustriaY.Commerclal• . , OResidential Water Supply(shared) rg Coaciete Grout i ' . p"Drill Cuttings':
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❑irrigation. . . .• . • .•CI Specialty Grout: "O Gravel . ..
. . Non-Water Supply Well: O.Behtonite Slurry❑IVlonitaring p . CI-Other(explain under 7g)
Infection Welle . • • '7L For each"materW selected above,provide amount of materials used:
:❑Aquifer Recharge :0Gmundwater Remediadon - /
❑Aquifer:Storageand Recovery: Osalieity Barrier • k l6 s'..
. ::❑Aquifer Test. :Ostonnwater•Drainage• - - I "
❑Experimental:Technology . . DSubsidenceControl .
7g:,Provide obrlef de cription o he abandonmfe n Procedure::
• • ,.❑Geothermal(Closed Loop) .:0ltaccr: : " e41d : �OGeo9erml-(H eadng%CoolingRetam) .. OOther(explainander 73)• �.' "P / " . • f���t� ;f' •
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4.Date ieell(s).abandonedi •• ',/-. .
mil. e tr kei r// 1.c, . 4. / .4.:
Si."Well location: : �fi�. . .
Facillisr/OwnerNeae .. . ..F. FeoilityllH#(rfepplicable) eriti .
�; 41 . .f � : : :Pry "" ' / • • e: r /i" •Addres;City.and zr �
p :�/�. , .�.?. goatvieof .,��,.�[���....���, �,e11U r: Date,: :�
/Ill Orielldeatfficetio. ... By.algidng t it jbm.I heieby.certii that the wel(s.)was(were)abandotred.tn,
(i'1N) •accordance With Oil,I lathy.
02C'.0100 or 2C.0200 Well.Construction Standards-
- .Sb.Latitude and longitude•in degreeslmfnutes/secouds or dedmal degrees: and that a copy:oflhLv recon3Jias been prtivided to thi.well awger.. •
(ifwell ficld,one Wong is sufficient) 9.
•' diagram or addition:dwell detailse
. i, : N.ff :eff • •Yoa'may use.the•back of this page to'provide additional well site details Orwell
`� W -abandonmeatdetails.You m so had Eon ages if necessary. '
CONSTRUCTION-DETAIL&O)r W.ELI:(S1 BEING ABANDONED 1. .
Attach nsiemvtrueAodreaord(e)IjacatlabieAormgyNpleinJxHonorrtou-wateraupplyaeils �'IN—Ut;TI(1NS •
.ONLYwItithe Have.o"Gruedon/abandonmen youmnsubmitoneforei.
• 10a;For.All Weill •Submit thisfeint ovithln 30 days'of completion.of well"
6a:Well D>►F: abandonmient,to the following: .
J - Division of Water Resources,Information Proceid:1g Urlt,
-.6b.Total well depth:. . if. • _ (ft.): - .1617 Mill. Center,Raleigh,NC 27699-1617 •
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�q 106.'For Infection Wells:'In addition to sending the form to the address-in.10a.
"6c:Borehole diameter: G c,) above,also submit one copy of.thls fain within:30.days of completion of well•. .
abandonment to:the following: I • .
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-6d.Water level below ground snrfaee: - . -(ft.): . Division of Water Resources,Under fond Infection ContirolPrograio,
1636 Mail Service Raleigh-,NC 27699-1636 - 1
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6.e.Outer easing IeagW Of]mown): •" ( ,) . •10c.For WaterSnpaly do 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 depart ont.of the"comity.where"
6L Innir:cesingltubing length(miown):: •({t,) abandoned.• ri r^°' Vi
6g.wren length(if known): - . ' ( ) . FEB 1 2 2074 .
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• Wiiormilie:lt ar ltQ Ua .
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PennGW!-30 '-North Carolina DepaitmontofEnviemimentilOueldy-Diwionof Water Resumes 1 ow01900 •Ravised2222016.

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WELL ABANDONMENT RECORD ForloteivalUseONLY:
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.1.Well Contractor Information: WELL ABANDONMENT DETAILS •
-David_Hardy.• : -• - • . 1 ;
.7a:For•GeoprobelDPTorClneed-LoopiGeothermal Well,having the same '
Well contractor Name(orwellowrterpenaonally abandoning well onhWtierpiopnny) '. • -wellconstruction/depth;onlyI.OW-30lisneeded.,Indicate TOTAL NUMBERof
• 2906-A Wells:abandonedo - ; : . .
NC Well Couhector Cenifcafon Number. . . • . 7b.Approslmate volume tawnier remaining Inwell(a): : (gal.).
A�1ua••Drll '.Inc.: .
"l s FOR WATER SUPPLY.WELLS ONLY:
CompanyNorn
7c:Type of disinfectant used:.
2:Welt Conlfrnctton Permit a: - . • •. _ .
Lint dU applicable tveliconsovcttoa permits(Le UIC,Corue[y,Stag I'ar/a+ro4 eta)ittbmr.141
7d.Mao of dtsinfeetantused:'
' •3:Wel use(check Weil use) . . . • •- • .
' Water Supply Well:. le.Sealing materluls used(thedc all that apply):
DAgncultural ClMusicipal/Publio: Cl:Neat Cement Grout • Cl• ' :Bentonite Chips or Pellets •
OGeotherrital(Heating/Cooling Supply) .: ;OResideritlal Water Supply(single): . ..13 Sand Cement Grout. - ' I Cl Dry Clay
O• lndastrial/Commercial. • _ OResidential Water Suppiy.(shared): ('Concrete OrOut : - Cl:Drill Cuttings.
N• onW ter Supply.WeRe . . .•
.• :O Specialty Grout• : • 17 Gravel
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O Bentonite Shiny: O Ottier(explain under 7g).
OMonitaring pRecovery
.• Injection•Well: . . • 7i For each material selected above,.i
provide amount of materials used
- • ' :0AquiferRecharge.• . '.DGroundwaterRemediation • '
CAguifer Storage and Recovery, , • OSalinityBamer... •
Q�/./S'
DAgaifer Test. OStomrwaterDmuiage.
• OE:Merimental Technology .OSubaidence Control..'. -
O• GeoUiermal(Closed Loop). p�CC1'. •
= 7g:Provide a biief on of the abando procedure:
:OGeothermel(Iieating/Cooling Kellam) • OOther(explain under 7g)'- • /J MI. is jilt' •t�: '
, 1,c � '' - ,s : 6t'I I:.a�'i,I•. '...• Is.4• t
4.Date well(s)abandoned: • / : • •I r ;. . ,� M ".e
�1� �- T it.p.4•t„'•'. •�r.-of s'i •.�Lc_:X/aa4..
Se.Will location:• I
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Facility/OwnerName. ; 1fr! s
FacilityNO(ifm:iOW)•. .5. r, lion•�� : :Si . .of caned Well or ell Owner. Date:
. :By signing This form,I herrtbycerttfy that.the•wells)was-(were)abandoned Os .CountyI. . : : " . : : Parcel Identification No(PIN)
accordance with"ISA*CAC 02C.0109or 2C.0100 Welt CorutirrcNon Standards
5b:•Latltnde and longitude In degrees/mintiteslseconds•or deehna•l d` .-and that a.copyof this record has bassi provided to the well owner.
(ifwel1 field,one 1et/long is sufficient).: • ' egneest• - - ,
�j j� (�'' • ."9.Site diagram or addition!!well detaiU: •
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:577� 7/J ••. .N /' •D J/ ) . .. . 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 - - ARIMUITAL INSTRUCZZOI%.Attach we/lrnnshucdwincond(s):(/'avatiabie.Aormu:OlelnJectionoramt-watermrpplyweUs: -
ONLY iv:M.0e same conovitigniabaadonmeaR y+outan submit ohaefain . .
10a:For-All Wells:. Submit-thin faint within 30.days of completion Of'well
6m Well kWh . _ •abandonment to the following:
/ . . . Division of Water Re n:rees,Inforniation•Processing Unit;.
- •6b.Total well depths • . . (fL) 1617 Mall Service Center;Raleigh,NC 27699-1617•.
.10b.For Inlectiou Wells: •In addition to sending tile'fonit totheaddress in•10a:
•6e.Borehole diameter: _ .� (In.) • above,also subntit.one copy,of this form within•30 days of completion of well'
sbandonmcat to the following.
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•60.Water level below ground Surface:. Diviiton K Water Resani cam,Un and •
(ff:) . d:rg:v Injection Control Program,.
1636 Mall ServieF Center,Raleigh,NC 27699-1636.
6e.:0uter easing length.(tf>mown)tl . . (}L) � 10e.For11Veter Suoniv&Infection Wells:•In addition sending the form to the
addresr(es)above,also subnut one copy of this faun within30 days of completion:
of.well-abandonment to the•.county'health,department:of the county where
6t.Inner casing/tubinglength(i[Imown)e .• (ft.)• .abandoned.•
6y,.Screen length(if ImoWa): @, ` last
(. ). ,
• • FEB 1 2 2024 .
.FotmOW 30 NorthCamlmaDepadmentofEmrironmentel Quality-Division ofWater i �r' t,l procasoirti u 'Revised2-22:2016
R 0/500
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WELL ABANDONMENT RECORD For Internal Use ONLY:
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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-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: I ,
NC Well Contractor Certification Number 7b.Approximate volume of water relmaining in well(s): 2'81 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: I '
2.Well Construction Permit#: Not Applicable
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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):
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Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout i II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) U Concrete Grout 0 Drill Cuttings
0 Irrigation 0 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 Bentonite Chips -50 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete Grout -25 lbs'
❑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 chips were poured into well and tamped
until they came up to -one foot from top of well.
4.Date well(s)abandoned: January 30, 2024
Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
2495 Hickory Tree Road
Facility/Owner Name Facility ID#(if applicable) S.Certification:
2495 Hickory Tree Road, Winston-Salem, 27127 , ,-; Feb. 2, 2024
Physical Address,City,and Zip Signature of Certifie.W7'" ontractor or Well Owner Date
Davidson 6821-02-97-5925
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: 1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.991061 N -80.252372 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)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can subunit one forum.
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 Resources,Information Processing Unit,
43.6 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
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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:
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26.34 Division of Water Resources Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
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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): 18.6 (ft.) abandoned.
`sL iv ,D
6g.Screen length(if known): 25 (ft.) FEBen q I 1 2 20Z4
Form GW-30 North Carolina Department of Environmental Quality-Division of Water w5 rrp Uffai
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-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I •
NCWC 3510-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.78 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 1 '
7c.Type of disinfectant used: __
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known 1
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 1 II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) II Concrete Grout ❑ Drill Cuttings
❑Irrigation . ❑ Specialty Grout ❑ 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 Bentonite Chips -45 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout I. -25 lbs
❑Experimental Technology ❑Subsidence Control i
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite chips were poured into well and tamped
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
until they came up to -one foot from top of well.
4.Date well(s)abandoned: January 30, 2024
Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
2495 Hickory Tree Road
Facility/Owner Name Facility iD#(if applicable) 8.Certification:
2495 Hickory Tree Road, Winston-Salem, 27127 1 s_ tE Feb. 2, 2024
Physical Address,City,and Zip Signature of Certifi Contractor or Well Owner Date
Davidson 6821-02-97-5925 1
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:
35.991061 N -80.252372 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 saute 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-3 abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 38.8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Infection 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: 1
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6d.Water level below ground surface 27.9 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water Supply&Injections 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
13.8 abandoned. �ice' �,'IT op
6f.Inner casing/tubing length(if known): (ft.) E " , �.;..,3�?^ D
ILeif
em
6g.Screen length(if known): 25 (ft.) i EB 1 2 2024
Inlormatien Pri1C30104 UM
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources t ow Revised 2-22-2016 y,�

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1
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-30 is'I 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): 3•18 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.U/C,County,Slate,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I IA Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout f ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
IN Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips —50 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier •
❑Aquifer Test ❑Stormwater Drainage Concrete Grout •
—25 Ibs
❑Experimental Technology ❑Subsidence Control 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.Datewell(s)abandoned: January 30, 2024 Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
2495 Hickory Tree Road
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2495 Hickory Tree Road, Winston-Salem, 27127 . Feb. 2, 2024
Physical Address,City,and Zip Signature of Certi' Contractor or Well Owner Date
Davidson 6821-02-97-5925 I
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel identification No.(PiN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i '
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.991061 N -80.252372 �t 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-2 abandonment to the following:
,
Division of Water Resources,information Processing Unit,
6b.Total well depth: 45.0 (ft.) •1617 Mail Service Center,Raleigh,NC 27699-1617
I
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 this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface 25.46 (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): 20 (ft.)
abandoned.
F., ,---,i W t .�-..
6g.Screen length(if known): 25 (ft.) ` t if ."
. FE,B } 2 2024
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Ressoggr��cess 1, Revised 2-22-2016
DWG/ o

WELL ABANDONMENT RECORD For Internal Use ONLY: 1
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-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water r Imaining in well(s): 2.76 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(Le.U/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 0 Neat Cement Grout II! Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) II Concrete Grout 0 Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RIMonitoring ❑Recovery
Injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips 50 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete Grout , 25 lbs
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(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: January 30, 2024 Remaining space in well and flush mount cover
5a.Well location: filled with concrete grout.
2495 Hickory Tree Road
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2495 Hickory Tree Road, Winston-Salem, 27127 �,,,2� Feb. 2, 2024
Physical Address,City,and Zip Signature of CertifielirContractor or Well Owner Date
Davidson 6821-02-97-5925 1 •
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:
35.991061 N -80.252372 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#: M W 1 R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 44.0 (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: 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: 27.05 (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 colt) trealth.,4epar¢ a o,C,t4 county where
6f.Inner casing/tubing length(if known): 19 (ft.) abandoned.
6g.Screen length(if known): 25 (ft.) tIO 2 2 2024
IntorsraKie l?rczasehRi 1,nk
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016