Moore_Well Abandonment_20240301

'1
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIIJS
T. Benford Graham, Jr. 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-36 is needed. Indicate TOTAL NUMBER of
NCWC 2373-A wells abandoned: I 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0'00 (gal.)
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name Clorine
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown - FEMA Project
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 0 Neat Cement Grout ' I NI 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 ; j 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:
❑Aquifer Recharge ❑GroundwaterRemediation 35- 50 lb bags "' "' —°' r-"
,* t...- is it;
❑Aquifer Storage and Recovery ❑Salinity Barrier I.:
❑Aquifer Test ❑StormwaterDrainage =vAR 2624
❑Experimental Technology ❑Subsidence Control f '
7g.Provide a brief description of the abandonment 4rocedure:
❑Geothermal(Closed Loop) ❑Tracer Removed old equipment. ttgbecWI a;`WQi tu4 j
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) "a44r-
. area to standards.Cutpipe.Filled with Enviroplug
4.Date well(s)abandoned: 02/02/2024 Bentonite-Medium. Poured cement slab.Cover &
5a.Well location: smoothed area. Sowed;grass seed as needed
Moore County, NC 1
Facility/Owner Name Facility ID#(if applicable) 8.Certi : -
114 Creek View Dr. Vass, NC 28394 �/ , , .C. z,/
Physical Address,City,and Zip signature of Certi r or Wel Owner Date
Moore
By sign : ereby 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:
35.176483 N -79145817 `4, 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#: Unknown abandonment to the following: '
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14' 4" (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: 24 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1 ,
r 0" 1' I
6d.Water level below ground surface: 7 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I, I
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
Unknown abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if(mown): 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 I
T. Benford Graham, Jr. 7a.For Geoprobe/DPT or Closed-L lop(Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 isl needed. Indicate TOTAL NUMBER of
NCWC 2373-A wells abandoned:
r '' 0.00
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name Clorine
7c.Type of disinfectant used:
2.Well ConstructionPermit#: Unknown - FEMA Project i ;
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: '.
3.Well use(check well use): i '
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) uResidential Water Supply(single) 0 Sand Cement Grout- i'"'' " ' psDrt. lay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout �'"� CI-Daui,uttings
❑Irrigation 0 Specialty Grout MAR 0 1 ,204 Gravel
Non-Water Supply Well: 0 Bentonite Slurry Other(explain under 7g)
❑Monitoring ❑Recovery itllrOiii',S;iF.it?r^:-.;osi !ip 11.z
Injection Well: 7E For each material selectattter:s,Arde alMUnt of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 6 - 50 lb bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
I ,
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Removed old equipment. Used excavator to dig
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
area to standards.Cut;pipe.Filled with Enviroplug
4.Datewell(s)abandoned: 02/2/2024 . Bentonite-Medium. Poured cement slab.Cover&
5a.Well location: smoothed area. Sowed grass seed as needed
Moore County, NC
Facility/Owner Name Facility ID#(if applicable) . ertifrcatio � 1
120 Riverview Dr. Vass, NC 28394Ad p.„„._�r , A _cfir [L
Physical Address,City,and Zip • Signature of• ed Well •ntra•or'r We • .. _Y1 " Dat= f
Moore ii
By :.'r c this o i e sy cert0 that the well(s)i as(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:
(ifwell Seld one lat/long is sutlicient) 9.Site diagram or additional well details:
35.19087 N -79.18251 W You may use the back of this page tol,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#:
Unknown abandonment to the following: .: '
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 37' 3" (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
24" 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
1 'in I
8 3 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): Unknown (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): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcesf , Revised 2-22-2016

. f
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS'+
T. Benford Graham, Jr. 7a.For Geoprobe/DPT or Closed-L lop 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 2373-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.00 (gal.)
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Clgrine
2.Well Construction Permit#: Unknown - FEMA Project
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout , , M 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 ° : C( rr}� t gs
❑Irrigation - 0 Specialty Grout �` id GATE
Non-Water Supply Well: ❑Bentonite Slurry Mot 0 1 E I r(explain under 7g)
❑Monitoring ❑Recovery ; I
Injection Well: 7f.For each material seel�f: ed, b Vp yid arpo t Gmaterials used:
❑Aquifer Recharge ❑GroundwaterRemediation 96 - 50 lb bags Difa'Gi3OG
❑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 Removed old equipment..Used excavator to dig
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
area to standards.Cut pipe.Filled with Enviroplug
4.Date well(s)abandoned: 02/07/2024 Bentonite-Medium. Poured cement slab.Cover 8
5a.Well location: smoothe area Sc grass seed as needed
Moore County, NC
Facility/Owner Name Facility ID#(if applicable) .Certification: I' ,
125 Creek View Dr. Vass, NC 28394 �,; eil , ;, , I 5 — (f
Physical Address,City,and Zip '' Signature of Certifi : n1' r• • • • owner Date
Moore By '+.in: this orm •, .y certifi,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
i.
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:
35.17484 79.14668 You may use the back of this page;to!provide additional well site details or well
N �'l' abandonment details. You may also!attach additional pages if necessary.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS j
Attach well construction records)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 m#: Unknown abandonment to the following: ', 1
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 56' 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: 24 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: i.
8r 11�� 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): Unknown (ft) lOc.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): Unknown (ft.) abandoned.
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

I
WELL ABANDONMENT RECORD For Internal Use ONLY: '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
T. Benford Graham, Jr. 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 isl needed. Indicate TOTAL NUMBER of
NCWC 2373-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water reI lining in well(s): 0.00 (gal.)
i
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name C l o rl n e '
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown - FEMA Project
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use): `
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout i P Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) "Residential Water Supply(single) 0 Sand Cement Grout 0 thy Clay
-a,
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout c f-/ irDill Cuttings
�w6�`.+1...if�r'
❑Irrigation ❑Specialty Grout el
Non-Water Supply Well: ❑Bentonite Slurry M�K 1 ,CO�� Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each mat selgc ye,p ovitde a unt of materials used:
tom,����'!�,. ,,�st„�t,$'s�t -
❑AquiferRecharge ❑GroundwaterRemediation 119 - 50 lb bagspvic,;
❑Aquifer Storage and Recovery ❑Salinity Barrier •
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Removed old equipment. Used excavator to dig
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
area to standards.Cut,pipe.Filled with Enviroplug
4.Date well(s)abandoned: 02/08/2024 Bentonite-Medium. Poured cement slab.Cover &
5a.Well location: smoothed area. Sowed grass seed as needed
Moore County, NC
Facility/Owner Name Facility ID#(if applicable) 8. t teat:)i•
133 Creek View Dr. Vass, NC 28394 `-- ,�,_► 1 C(,
Physical Address,City,and Zip �#-F
. .r or ell Owner/� Date `-T
Moore
By st: . , ereby cert fy;that the •ll(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1SA 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:
35.17449 N -79.14678 �, 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 ornon-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 ID#:
Unknown abandonment to the following: 1'
•
Division of Water Resources,Information Processing Unit,
• 49' 1" 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) ' f
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 24 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6 t n
2 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): 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): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Fonn 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 DETAIILS
T. Benford:Graham, Jr. 7a.For Geoprobe/DPT or Closed-Loop 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
NCWC 2373-A wells abandoned: i '
NC Well Contractor Certification Number 7b.Approximate volume of water rein laining in well(s): 0.00 (gal.)
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELL
/-S ONLY:
Company Name
7c.Type of disinfectant used: Clori ne
2.Well Construction Permit#:
Unknown - FEMA Project
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):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout a Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) (Residential Water Supply(single) 0 Sand Cement Gr tP ."i-- .-" y•0-D9rClay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout k 4'"" L i V tr.DLIKuttings
❑Irrigation 0 Specialty Grout MAR 4 ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry V I�OL 0 Other(explain under 7g)
❑Monitoring ❑Recovery infoir.;cten o,,:y-1
Injection Well: If.For each material selec ahoyielt a ai ournt of materials used:
yam.
❑Aquifer Recharge ❑GroundwaterRemediation 59 - 50 lb bags 1
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g) Removed old equipment. Used excavator to dig ent
area to standards.Cut pipe.Filled with Enviroplug
4.Date well(s)abandoned: 02/02/2024 Bentonite-Medium. Poured cement slab.Cover&
5a.Well location: smoothed area. Sowed grass seed as needed
Moore County, NC
Facility/Owner Name Facility ID#(if applicable) '
156 Riverview Dr. Vass, NC 28394 ",, / _ 4
Physical Address,City,and Zip Si- :. e of Certified elMirntr for or We ••• .'1.11 /111 Date
Moore
By signing this orm, !ram certfy that the well(s as(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 1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.1923682 N -79.17771 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 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 ID#: Unknown abandonment to the following:
Division of Water Resources,Information Processing Unit,
31.9 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) i•
10b.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 24 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
5' 2" I; i'
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): Unknown (ft.)
IOc.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 cotutty health department of the county where
6f.Inner casing/tubing length(if known): Unknown (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
1, '

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
T. Benford Graham, Jr. 7a.For Geoprobe/DPT or Closed-L lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 2373-A wells abandoned: I .
11
7b.Approximate volume of water remaining in well(s): 0.00 (gal.)
NC Well Contractor Certification Number
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name Clorine
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown - FEMA Project
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: ' '
•
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout . ; II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) 0 Sand Cement Griuta .'• ^• } ;iB-Dzy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout i"� '1 Cuttings
❑Irrigation 0 Specialty Grout MAR 0 1, 2U2 Gravel
Non-Water Supply Well: 0 Bentonite Slurry CTo Other(explain under 7g)
❑Monitoring ❑Recovery tnfo•,Tt egieD ?rr%-i. , 1+�
Injection Well: 7f.For each material sele to kbo3loii&eSindunt of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 6 - 50 lb bags I.
❑Aquifer Storage and Recovery ❑Salinity Barrier
II
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Removed old equipment. Used excavator to dig
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
area to standards.Cut pipe.Fiiled with Enviroplug
4.Date well(s)abandoned: 02/5/2024 Bentonite-Medium. Poured cement slab.Cover&
5a.Well location: smoothed area. Sowed'grass seed as needed
Moore County, NC
Facility/Owner Name Facility ID#(if applicable) 8.Cer 'cation:
208 Circle Dr. Vass, NC 28394 17 � f AC,S 2
Physical Address,City,and Zip Sign.cure o Ce en tra .r r it e� �� Date 1'
Moore By signing this form, ereby cert )
ify 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:
35.200630 N -79170414 W You may use the back of this page.t 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 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 ID#: Unknown abandonment to the following:
3" Division of Water Resources,Information Processing Unit,
37' . 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) , ,
;, I
6" 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: j
6'
2"
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) • 1636 Mail Service Center,Raleigh,NC 27699-1636
I
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): Unknown (ft.) abandoned.
I
Unknown $
6g.Screen length(if known): (ft.) ;;
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
,

1, 1,
.
1,
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
T. Benford Graham, Jr. 7a.For Geoprobe/DPT or Closed-L000p 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 2373-A wells abandoned: 1 ;i
NC Well Contractor Certification Number
7b.Approximate volume of water re 1aining in well(s): 0.00 (gal.)
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Clorine
2.Well Construction Permit#: Unknown - FEMA Project
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ' ' IR Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) 0 Sand Cement Grout i 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout -.. -r,„a to Cuttings
L.kL.. ! ae1
❑Irrigation 0 Specialty Grout i Q ra
Non-Water Supply Well: . ❑Bentonite Slurry Other(explain under 7g)
MAR 0 1 12OL
❑Monitoring ❑Recovery Q•
Injection Well: 7f.For each material selected above,Iprovide amount of materials used:
❑AquiferRechazge ❑GroundwaterRemediation 15 - 50 lb sc
'',1 3rn:SQ24.n2 u1
❑Aquifer Storage and Recovery ❑Salinity Barrier
II I
❑Aquifer Test ❑Stormwater Drainage I.
❑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) Removed old equipment. Used excavator to dig
area to standards.Cut pipe.Filled with Enviroplug
4.Datewell(s)abandoned: 02/05/2024 Bentonite-Medium. Poured cement slab.Cover&
5a.Well location: smoothed area. Sowed grass seed as needed
Moore County, NC
Facility/Owner Name Facility ID#(if applicable) 8 [cation:
250 Cabin Creek#1, Vass, NC 28394 . j
Physical Address,City,and Zip Sign. e of Certifie.jib,rrtt or Well Owner 1 Date
Moore By signing this form, 1 ereby certi&that the well(s) as (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 We 1 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 lot/long is sufficient) 9.Site diagram or additional well details:
35.198638 N -79172227 �, 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.
i !
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#: Unknown abandonment to the following:
Division of Water Resources,Information Processing Unit,
97.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft)
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:
i
9�2"6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if(mown): Unknown (ft) 10c.For Water Suanly&Injection I 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 count health department of the county where
6f.Inner casing/tubing length(if known): Unknown (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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WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
T. Benford Graham, Jr. 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 lis needed. Indicate TOTAL NUMBER of
NCWC 2373-A wells abandoned: I 1
I
7b.Approximate volume of water remaining in well(s): 0'00 (gal.)
NC Well Contractor Certification Number
i,
Graham & Currie Diversified Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name Clorine
7c.Type of disinfectant used: ,
2.Well Construction Permit#: Unknown - FEMA Project
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout, _ ! ;. •Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) 0 Sand Cement Grottil 7�'Co' I, a fy. lay
CZ❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout �' Cuttings
❑Irrigation 0 Specialty Grout MAR 112Q2L] Gravel
Non-Water Supply Well: 0 Bentonite Slurry. ; ' �❑ Other(explain under 7g)
❑Monitoring ❑Recovery tutor; a,ea+ 'r.^.yam•
Injection Well: 7f.For each material sele t 'ilboYI tryoviile aammoount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 9 - 50 lb bags 1. i
❑Aquifer Storage and Recovery ❑Salinity Barrier
6
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Removed old equipment. Used excavator to dig
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
area to standards.Cut jpipe.Filled with Enviroplug
4.Date well(s)abandoned: 02/05/2024 Bentonite-Medium. Poured cement slab. Cover 1
5a.Well location: smoothed area. Sowed grass seed as needed
Moore County, NC
Facility/Owner Name Facility ID#(if applicable) 8 '• tfic; '..•
250 Cabin Creek#2, Vass, NC 28394 i, ��
4
Physical Address,City,and Zip Signature of .•. . •7�� �� •.Milli Date,___
ate 2
Moore ; 1
By signing • ereby certify that the well(s was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 ell 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:
35.198652 N -79.172219 `l, 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.
i' I
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#: Unknown abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 96'9 (ft.)
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:
t87 n
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
f
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): Unknown (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