Forsyth_Well Abandonment_20240301

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VVELLABANDoNMENTRECoRD. ,. • • :frorkiteroawse Olk11.*:. , '. - - •.
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1.Well Con*ictorInformiSon:
. WELL ABANDONMENT DETAILS • •
•David Hardy . . . . . . .
.•72. • .-. •• - -• . • - 1 1 - - . • •
• ,. . For GeoprobeiDPT.or Cloied-Loop Geotheinital Wills having the same • -
- Well CoatractorNeme(or well ow persenelly abandoning well on higher property)' • .well constructicinfdepth,only-I GW=,39 is needed. Indicate TOTAL*UNDER of
2906-A . wella ebandened: • - - . I' ' • . . - .' . . . -
NC Well Coatreetor Ctiitigiatioa Nomber•-• . ' .76..Approaimate volume of water lienudnieginivell(s); -. ..1.e. ..a.). •, .
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.Aqua.Drill';.Inc . . ': . : - -. . -- . . -.. - . - FOR W.ATEREUPPLY WELLS ONLY ." • ' - •.. . . .
CompanyNteno
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• 7c. need
TyPe of dialefeetant :. - 1 . , . - • . 0 • . . . • .. .: . . :
•• .2:Weil Conitrar1jonPerin110: • -. . '. , . • • . • . . 1::31c
WC co i ,.. . .
- . Ltire/Icespfteabte wet/cossfinthecapiontrege.• rui01 ,Fari: aace,etc/Pim 7d.Amo Old of •. . t • .:. . . : le e :„- . . ..-... • •.
.. . . .3:Well use(cheekviell nee): . . . . . • • . . • • . .
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' • • •. Water Supply Well:• ' • • - .: .. '. .. -7e.Beiges materials used(Cheek all that apply):. , •• • : . . ' •
pAgiiiultdmi • ; • - ..'• * EiMrmieipal/Fablio . • • : -... D bleat .eirrint drout: " : :•0 Bentonite:dips or Pellets •.6Deethennal(fleating(C.00 ling Supply)..-OResidendel Water Supply(single) • *.Cl.Send Cement Grout • : . '13.Thy Clay • ' ' • _
..• tlInduetrlai/Cornmerclal- '- • - - • .thResidential Water Supply(shared), S./Concrete.Grout : • . • . •• CI Drill Cuttings: .-• • . .
. • thirrigation•• :- ' . : • ".'• .: -- - ' : .• . '•• : :D Specialty Gro' uf • - . • -1 . • 13 GmVel• • ' . • - - - .. .
Non-Water Supply Well:- . • - - • • .0-Bentonite Sheri:- i
•D.0.ther(eXplalduldei 7g)
.. : • . : .OMenitaring .. ' . • • '0RecoVery- .. - . , . ; ' ' . • ,
. . Injection Well: • - - •
. n For each materiel selected above,provide anitadtiotinaliffeCnied:m.
O4ciuifer Rechatge.• _ •.Eldiernidwiiter Remediatimi 2- . . } r-‘$"-Gt•-:1VtD.
- --;...., . „-......t. .-- . -
• • 6Aqueer Stine'aid Recovery' • :OSalin' ityterrier.•
• .y - 0-11 . .
DAeirifer Teat:. •DStonnwater Drainage. . •
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. . olktperimentallechnelegt- . •DSobsidence Control-' . . . • -
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: 7gBroVide a hrief description Of the abendhtfielip'.;.blelliirniCp00:09
. : .DGeethenind(CloSed Leap). - '• •011ecar,• . . .
ClCinotliermal(Heating/Cooling Return). . '00tirer(explainunder 76. - -• .:J.•.;;S71-4,1/Ars,•'7 .7.; /6' ,-.' ,4,4. 1.1f.C114.!:,1.; -)..1;(41-
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. 4.Dile w.ei).aliandoindt--4,..'%/:.2:i..?' ...7--4/'• : - ' - . • 1,y01y.. ./...t:' :7CD: . >C0'/O•Ri1.1:*/./1.'?'d - - . •
• .So.Well location; - .•• • .• . 1. '. ZA /.. ..... . • .. 1' -. . . ..: -. . . .
„ • . cittio/.9,:t.-.:. • . . . .
p. i . •
.. -facil~Narne, . . •.Facility 1Dii(ifeptilivable). . -8. . te1207.,.., .. :. •. .., . •. . .. . . ,
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. • - 27510::94:..1. •, ,.1-)1,:" .1,././:*...;.(b--,..44 7' . . :. --.. -- ..2..-. . , . . ...- --x-/4-04.c/.'
nwa.lcal Ad*-- CiiY.!Ild?Ai) . • ' ivz: .2 0,:>4 90:. ,Signatute.ofCertl.fledWelICo • 1 ell OWeer • . Date: •.
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• . ' . • - . •By*wing this.Airm,:i hereby'edit&that-the,Well(s):was(Were).abandpkedin •
. • County / • . ' •Paly!!Ithelificadon No(PIN) : accordance with ISA NCAC 02C.010.0.or 2C:0200 Well constiuction Standards: '
•. -.5b.ialltude saiillongitild In ' •. .mintitesisecondi or decimal degrees•• . t - ' 'anal 1*a.c°-M ornis ivit-ird 17 6601/m4i/11th the well mwien
: , . - •Of ril field,one*norm is suf.ficlon.0 :. • • ' - • . . -, • ' • .. .• .9:Site diagram-or additional wen details - I '' • ' •• 1 •' - .
- . • yic.,./4.."7 7 .. -.N. •re,..7./-7. ;,,9 . , w. ..2,.. :tdetails. You may also attach additional pages if necessary,• •
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CONSTR11411091DETAILS•OF WELUSi•DEING AliANDONlio . . ..famparrAL sntuenoNti .
Amachwellcameruitionnword(s)&witlable,
• pwonnwFWoyrMuicliapnl=eftkW1 onifornwon.7w• egipplwels •• ,. .. . . . - - . • •ONLY with g
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10a:For.A.U.Weise. Submit this kern.within.30 days of'completion-of Well
.6a.Well IDN:.- - - •- . • • • : - '• . • - • •abandomirent Oa the follevrieg: : . I
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•Division of Water Reionrees,Inforinistlen Frocessing Unit,- •6b;Total well ciiptli.;_ / • .. . (ft.):. ' . • • :1617%fell:Service Center;Raleigh,NC 7169.9-1617 • ..
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•1011.For Maguire Weis: •,.,..edgier to sending the Sinn to the address in'10a:
• '• , •Er.:BorehOle diameter: • . . . ._•• ' abOie,also sabmit.one:copy of this.fond.ivithin.30 aof eoineletion of well•
ithandOnment tole:following. 1 I. .
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Divide:sof Ii)aterltesontees,landergiround Neition CoatiolPregram,. '
6d.Water;Wei bele*.groarid Serfaci: :/.2./..7 ' (i)
1636 Mill Serdee Cceiteratrdeigh,NC 27699-1636
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• .10c.For*ate:1;61001V&Inleetion Weller•In additiem to sending the form to the•
de.Outer caeing length(If Imoivn): - • -•'- _ - - (ft.).
address(es)thoye,also.submit one ceitrof this form within:30 days of completion
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. of.wc11-.abandonment An the•Wanly"health.department:of the county Where'
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. • • 6 *t t er casing/tubing length(iflmown):' _ • .(ft.). .abandoned. V
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4 Screed length Of knit**. . - . • -(ft.)-
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.Form 0*-30. • . .. Northtliroibui Department ofEnvirormteinelQuality.;DIVIlinofWeIerResoinces • ' Revised 2-224016.• . ••
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WELL ABANDONMENT RECORD For internal Use ONLY:
I
1.Well Contractor Information: - WELL ABANDONMENT DETAIL
Frank Beecher 7a.For Ceoprobe/DPT or Closed)Loop Geothermal Wells having the same
Well ContractorName(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GV,-30 is needed. indicate TOTAL NUMBER of
3225-A wells abandoned:NI" Q
7b.Approximate volume of water;remainingin well(s): 0.81 al.
NC Well Contractor Certification Number pp I (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A ___
2.Well Construction Permit#: N/A ;
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: N/A
3.Well use(check well use): b.
Water Supply Well: 7e.Sealing materials used(check,all that apply):
❑Agricultural 0 Municipal/Public 0 Neat Cement Grout II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout _ 0 Dry Clay
❑lndustrial/Commerciai ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
uMonitoring 0 Recovery
injection Well: 7f.For each material selected above,provid un of atc4"Is aD
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-80.;lbs E
❑Aquifer Storage and Recovery ❑Salinity Barrier I . MAN 0 1 /112
❑AquiterTest ❑StormwaterDrainage Water-4.0 gallons `t
❑Experimental Technology ❑Subsidence Control I� ltli`t3ri'Pidijc n ar^;_. ;,1a, Uoillt
7g.Provide a brief description ofithe abandonment pAp t$G
OGeothermal(Closed Loop) ❑Tracer �;
Slowly added bentonite chips and ensured there was no bridging
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
taking place. Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 01.19.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113. ,
Former 7-Eleven Store#36069 00-0-0000032363
Facility/Owner Name Facility TM(if applicable) 8.Certification: j.
2375 Lewisville Clemmons Road, Clemmons, 27012 J &2 02.16.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth 5893-05-5421.000 l 1
By signing this form, I hereby certifr that the well(s) was(were)abandoned in
County Parcel identification No.(PTN) 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: _
36.037486 N -80.384871 N, 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.
Ica. For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#: MW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
40. (ft.)
0Serv
ice Mail Center,Raleigh,NC 27699-1617
I
lob.For injection Wells: Tn addition to sending the form to the address in l0a
6c.Borehole diameter 2.0 (in.) above, also submit one copy of this form: within 30 days of completion of well
abandonment to the following: l
350 Division of Water Resources,Underground Injection Control Program,
.
6d.Water level below ground surface: (ft.)
1636 Mail Service Cf enter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) l Oc.For Water Supply&injection Wells: in addition to sending the fonts to the
address(es)above,also submit onel'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner easing/tubing length(if known): 10.0 (ft.) abandoned.
,
6g.Screen length(if known): 30.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAII!S
Frank Beecher 7a.For Geoprobe/DPT or Closed1L9 op 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
3225-A wells abandoned:WA
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): 0•43 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS.ONLY:
Company Name 7e.Type of disinfectant used: N/A,,
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:,?N/A
il
3.Well use(check well use): '
Water Supply Well: 7e.Sealing materials used(check fall that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout a 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 i'
Injection Well: - 7f.For each material selected above,provide oulionnt 9,14n JEL)
ksal❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-80Ibs 'E r, 8
❑Aquifer Storage and Recovery 0 Salinity Barrier I
❑AquiterTest ❑StormwaterDrainage Water-4.0 gallons MAK 0 1 207$
❑Experimental Technology ❑Subsidence Control G,
7g.Provide a brief description of the abanimmoknaeatirgtacks4n Uitet
❑Geothermal(Closed Loop) ❑Tracer
❑Geothemtal(Heating/Cooling Return) ❑other(explain under 7g) Slowly added bentonite chips and ensured tf i�bridging
taking place.Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 01.19.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113. Ii .
Former 7-Eleven Store#36069 00-0-0000032363 is
Facility/Owner Name Facility 1Db(if applicable) 8.Certification: 1(7
2375 Lewisville Clemmons Road, Clemmons, 27012 '2'✓ •, 2.16.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth 5893-05-5421.000
By signing this form, I hereby certi. 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:
36.037295 N -80.386880 `,lr 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 constructian'abandonment,you can submit one form. 10a. For All Wells: Submit this,form within 30 days of completion of well
6a.Well m#: MW-14 abandonment to the following: i` '
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35.0 (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: 2.0 (in.) above, also submit one copy of tills form within 30 days of completion of well
abandonment to the following: '
i
6d.Water level below ground surface:
32.35 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft) 10e.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): 20.0 (ft.) abandoned.
6g.Screen length(if known): 15'0 (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: I:
1.Well Contractor Information: WELL ABANDONMENT DETAIIS
Frank Beecher •
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
3225-A wells abandoned:WA I 1
I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0'25 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well construction permits t.e.UIC,County,State,Variance,etc.)([known
7d.Amount of disinfectant used: I
NSA
3.Well use(check well use): f
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural 0 Municipal/Public 0 Neat Cement Grout C Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/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)
MI Monitoring ❑Recovery
injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
Bentonite Chips-70 Ibs 7.7. -•�.�� ��
❑Aquifer Storage and Recovery ❑Salinity Barrier .. p ,,,,(,,r i, i
❑AquiterTest ❑StormwaterDrainage Water-4.0 gallons!.
�� ����
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ,;, ,
kle
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Slowly added bentonite chips and enstlre Fft lt�asshrnoln''elg?t>
g P O-�
taking place.Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 01.19.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113.
Former 7-Eleven Store#36069 00-0-0000032363
Facility/Owner Name Facility iD#(if applicable) 8.Certification: --)
2375 Lewisville Clemmons Road, Clemmons, 27012 J "` 02.16.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Forsyth 5893-05-5421.000 1
By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(Pill) 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 latllong is sufficient) 9.Site diagram or additional well details:
36.037435 N -80.385013 : 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 supplywells
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-12 abandonment to the following: !
I;
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
10b.For Iniection Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (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: 33.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (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 cou{ty health department of the county where
6f Inner casing/tubing length(if known): 25.0 (ft.) abandoned.
6g.Screen length(if known): 10'0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources': ; Revised 2-22-2016

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'WELL A ANDONM r"N.T RECORD D Far Internal ONLY;
IUisfonncaulie used tb'rsitgia'ornttiltipterszlls ��
•
1.WellContractor Information: \� WELL ABANDONMENT DETAILS
Scott aunt 7a.Number dwells being abandoned 1 •
Welt6)L10ctorNosne(Of yrilewc pcagnally atiam(nnhi t aU On?dallier propcn5) Far w-gtaph h fectar or- non-trarcv l sup)* wells ONLY i. h the same
constnrerimiabrurdanmen,,lawn can s honition,.j6rur.
4561•
NCWcu ContmdorCcnlficolioti Nitittcr 7h.Appro hnate turbine of vvatvY I n*�ainirog in well(r)N/A'1 {a[.)
1 .
SAEDACCO FOR WATER.SUPPLY WELLS ONLY:
Company Name 7c.Type rif,disinfectant used:
2.WeltConstruction Permit N:,' ,
;1st pH uppltitild well perinlis ti.'.Carrara-Slrrre,Yarlarre,bvertium.etc}If buten 7d Atlantat of dliinfecfsiul used:
3.Well usr(ehecicWell use): I, . .
Water Supply-Well:- .7c.Scaling materials used(clieek all that apply_):
17Agrieulturat • bMunicip liPublic. Oil NeatCcmcnt.Gtiaut ❑•BentoniteChipsorPellets
DGrothcnnat(Hcating/Conling'Snppty)' ❑Residential Water Sitppty(single) ❑Saud-Cement'Gtnut 9 Dry Clay
❑Irtdu50111 omntcrcial ❑ResidcotialWaterSnpply`(shared). ❑CoucteleGrout. •❑DrillCulliitgs
❑inigation U Specialty Grout 1 Li Gravel
Non-Water Supply Well: ❑Bentouice Slurry Ci Other(explain tinder 7g)
•
pMonitortng ❑Recovery
injection-Weil• • . `-- 7G For each maternal selertcd'abovr,provide amount of-Materials used:
❑Aquifer Recharge ❑GrgundnaterRemedl:iliol. Neat Cem.:941b ,Wtr:6ga1. ii Sand Cem.:lb ,Wtr:gal.
I7AquiferStotvge att:t Recovery bSalinity Battier I
DAn:lifer Test ❑Stonmv'ater Drlinage .
❑everintenlal Technology CISubsidettce Control 7g.Pmv'ide a brief description Of thc!abandonmcnt procedure:
❑Geolherfnal(Closed Loop) ©Tracer 11 ' .
Pulled PVC well from the ground. Grouted borehole from the
❑Geothemtat(Heating/Cooling Return) OOther(evplain under 7g)-_, _ ;1
bottom up via tremie. I.;--:• .!•T,;9' . .,� V ��+M �
4.Dafcnclt(s).abandonctL 2/16/24 II:, 'ti— ./L.1
i,
5a WeDtucat[on: '� 'MAN 0 1 2024 '
8.Cert[lieatiton: iThv, rirsti2: PrC i''g LMt
Fmeilit}lanncrName FacilityIDb(ifapplicable) : C /at
407.Randol h St. WinstonSal 27360 1„,,,,iL-1,197 ,_ I 2/13/2024 4
• Ph}sical'Addtcs,City.and Zip ^y,'i a t i ed Well Cnntr.iei ror Wf11 O•�sti:r .Di
Forsyth - -. - By signing lhfs fora; t hereby ceriffidthat the well(s)was(were)aba ndoned_irt •
Calmly Puicelfdaiiiricatinn No.(PINT arxardairceWithbJA'CACO2e.olo0or3C:02001Vell`CmaatiatetiunStankm(s
• - and that a copy of his record has been+provided to(ire well owner.
56.Latitude and longitude in debmceslmiuntes/seconds or dccintalAegrees ,,
(iftsell Fi`td,one pardons is atirltifict ) 9.Site diagram or additional Well details: -
You may use the back of this.page to,provu[e additional Well site details.or well
N - W .abandonment derails..You may also allacl►additiotralpages ifttecessa►y.
CONSTRIUCTiON DETAILS OF WELL(S)BEING ABANDONED SUBRT1TTAT.INSTRUCTIONS I.
Attach tall cnristrrdteo retvrrl(n if available. -For amrluple is Tertian or rion.wai 'supply " 1
lr trite ONLY uitthesvaneewtao lmvrtion'ouloyment_.wu con sulonnt one frnie' IOa: For All Wells: Submit-this form uititiu 30 days of completion of well
60.Well IDgeTW-i • '
abandonment to'the following: i
Die'ision of WatcrResources.information-Prucesting Unit,
Gb.Total.n'cll depth: 18 • (D,)
I617 Mail Service Carter,Raleigh,NC:27699-1617
10b.Fnr infection Wells: In addition to sending the fonu to the address In Wa
6c.Borehole diameter:2" Cn,). - ?bore,also subsoil one copy of this forth within 30 days of completion of well
abandonment padre following_ I.
•
Division of Witter Resources;Underground iiiject(ou Conrrvl Program,
6d.Water level below ground surface: (ft.) 163E Kai'Service rentier.Raleigh,NC 27699-1636
Ge Outer casing length(if Imown): 5' -- (IL) 10c.Fri-Watcr.fimnly& form infection Welty: In addition to sending the to
the addresses) above, also submit One;copy of tills form within 30.days of
completion-of well abandonment to lhie county health department of the county
6f.Inner casing/tubing length(if brawn): (ft.)
where abandoned.-
.
6g.Screen length([f IOtowu):13 (ft.) .
Font GW.30 Nonli Carolina Dcpanntcm of Bnvironutent atti Natural Resoir3Lcs—Dlvls[on of Water Resources -Revised August 2013

iI
WELL ABANDONMENT RECORD For Internal Use ONLY: t
I'
1.Well Contractor Information: WELL ABANDONMENT DETAILS
TerryWhite
7a.For Geoprobe/DPT or Closed iLoop 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
3287-A wells abandoned:one
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 100 (gal.)
I ET FOR WATER SUPPLY WELLS'ONLY:
Company Name 70% Hypochlorite
7c.Type of disinfectant used:
2.Well Construction Permit#: I 1
i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:'6oz
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public IN Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) UResidential Water Supply(single) ❑Sand Cement Grout 0 Dry Clay
DIndustrial/Com nercial '❑Residential Water Supply(shared) O Concrete Grout 0 Drill Cuttings -
❑Irrigation ❑Specialty Grout •Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring El Recovery I.
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1 Cubic yard of Gravel:
❑Aquifer Storage and Recovery OSalinity Barrier i
❑Aquifer Test ❑Stormwater Drainage 15 47LB bags of Portland Mixed.
❑Experimental Technology El Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Graveled from 205'up to 50'. Portland cement from 50'to 1'.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
• Concrete 1'to surface. Capped with soil.
4.Date well(s)abandoned: 2/9/2024
r',P ('I ;0-D
5a.Well location: MAR I� I
Residence(Sunshine Cleaners and Club Haven Cleaners) Mr`R 0 1 2024
Facility/Owner Name Facility IDh(if applicable) 8.Certification:
Informatien
5198 Oxford Drive Winston-Salem, 27104 r.,.. rg
G{l� I WCW3oG 2/12/2024
Physical Address,City,and Zip Signature of Ce ed Well Contractor or Well Owner Date
Forsyth i'
By signing this form,I hereby certifythat 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:
36 05 17 -- _ _ 80-21 10__ - - __ You may use the back of this page to provide,additional well site details or well
N W _ abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i'
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells i'
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 MN: NA abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 205 (it)
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
60 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the countyi health department of the county where
6f.Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): (ft)
.
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016

p I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Terry White 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
3287-A wells abandoned:we I•
NC Well Contractor Certification Number 7b.Approximate volume of wate I r Imaining in well(s): 30 (gal.)
I ET FOR WATER SUPPLY WELLS ONLY:
Company Name 70% Hypochlorite
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 61 pZ
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 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Re_sidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
ehrigation ❑ Specialty Grout a 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:
❑Aquifer Recharge ❑GroundwaterRemediation 1/4Yard of Gravel 80LB Portland Mixed
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 80Lb bag of concrete Mixed
❑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) Graveled to 3'. Tore out pad.
Portland and Concrete to surface. • o I-I �r
4.Date well(s)abandoned: 2/9/2024 Capped with soil. MAR 0 1 2024
5a.Well location: Ith`dr ra:ie Pr: g Ufa
Residence(Sunshine Cleaners and Club Haven Cleaners)
Facility/Owner Name Facility ID#(if applicable) 8.C lion:
5198 Oxford Drive, Winston-Salem,27104 2/12/2024
fi
Physical Address,City,and Zip Signatureertified Well Contractor o ell i Owner Date
Forsyth signing thisform,I herebycerti that the well(s)was were abandoned in
By fJ'
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.
Sb.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:
--— 36 0517 - - - N 80 21-.10 - -- - - 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)tfavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one fonn. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: NA abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 10 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
12 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
6d.Water level below ground surface: 5 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water 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 Of known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I i Revised 2-22-2016