Surry_Well Abandonment_20240301

. II
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1 ;
1.Well Contractor Information: WELL ABANDONMENT DETA1I S'
HENRY NEMARGUT 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-watersupply wells ONLY with the same
construction/abandonment,you can submit one form.
3426-A ,• 1
NC Well Contractor Certification Number 7b.Approximate'volume of water remaining in well(s):•
1 gal • (gal.) •
HENRY NEMARGUT ENGINEERING SERVICES FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: '
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State, Variance,Injection,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 ❑Neat Cemen,Groat_•'" ;•�, , 14��,"' entonite Chips or Pellets
0 Sand CementGrout0,- Li L.I�" Clay
(Heating/Cooling Supply) ❑Residential Water Supply(single) I ,; Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout MAR 0 1 2024 0 Drill Cuttings
❑Irrigation 0 Specialty Grout I 0 Gravel
Non-Water Supply Well: • ❑Bentonitelg1u9nq'reailk;1?f;. 3Q•Sv?2(1) ft)ther(explain under 7g)
El Monitoring ❑Recovery IV+eci000 '
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.0 bags of bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
1
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothemral(Closed Loop) ❑Tracer 1
Bentonite pellets were poured into the well to top of casing,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
. saturated with H2O then capped with cement.
4.Date well(s)abandoned: 1/15/24
5a.Well location:
Intex Print Plant N/A
Facility/Owner Name Facility IDb(if applicable) 8.Certification:
523 South Stephens Street, Pilot Mountain, NC 27041 Henry Nemargutt ;� — '-- 2/15/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Wiell Owner Date
Surry 596619608713601 By signing this form, I hereby cer10 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 I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: .
36.38082 -80.47146 You may use the back of this page Ito�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 construclimt record(.r)if available. For multiple injection or non-water supply
wells ONLY with the same conslruclion'obandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well MThMW-1 abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 52 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
2" above,also submit one copy of this'form within 30 days of completion of well
tic.Borehole diameter: (in.) abandonment to the following: I ,
I
36.51 Division of Water Resources,,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 .
} I;
0 lOc. For Water Sunnly&IniectionlWells: In addition to sending the form to
. 6e.Outer casing length(if known): (ft.) the address(es) above, also submit',one copy of this fonn within 30 days of
completion of well abandonment to the county health department of the county
where abandoned. I
'
6f.Inner casing/tubing length(if known): 37 (ft.) i ,
6g.Screen length(if known): 15 (ft.) '
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resoerces Revised August 2013

' I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
HENRY NEMARGUT 7a.Number of wells being abandoned:
1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water! supply wells ONLY with the same
construction/abandonment,you can submit3one firm.
3426-A
7b.Approximate volume of water remaining in well(s): 1 gal (gal.)
NC Well Contractor Certification Number
HENRY NEMARGUT ENGINEERING SERVICES FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: i
2.Well Construction Permit#: N/A
List all applicable well permits the.County,Slate,Variance,Injection,etc,)iflmown
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 ]t , -+°Bentonite Chips or Pellets
•❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement(C rogtC I)
h �'h]'D, Clay
❑IndustriaUCommercial OResidential Water Supply(shared) 0 Concrete Grout 7 0 Drill Cuttings
•
❑Irrigation 0 Specialty Grout MAK 0 1 2024❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurp D Other(explain under 7g)
OMonitoring ❑Recovery .aw..t 1?.<~ "4 131C
Injection Well: 7E For each material sel Anil• j rovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1.0 bags of bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
Bentonite pellets were poured into the well to top of casing,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
saturated with H2O then;capped with cement.
4.Date well(s)abandoned: 1/15/24
•
5a.Well location: •
Intex Print Plant N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
523 South Stephens Street, Pilot Mountain, NC 27041 Henry Nemargut, ,, .; °* 2/15/24
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Surry 596619608713601 By signing this form, I hereby certify'that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with i5A NCAC 02C.0/00 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 ladlon is sufficient)g 9.Site diagram or additional well let ils:
36.38082 N -80.47146 `� 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)if arailable. Nor multiple infection or non-water supply
wells ONLYwilh the same conslruction'ahandonment,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: 27 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 211 (in.) above,also submit one copy of thisi,form within 30 days of completion of well
abandonment to the following: l• I•
6d.Water level below ground surface: 21.87 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Q' 10c. For Water Supply&Irijection Wells: In addition to sending the form to
6e.Outer casing length(if known):' (ft.) the address(es) above, also submit oiie copy of this form within 30 days of
completion of well abandonment to'the county health department of the county
6f.Inner casing/tubing length(if known): 12 (ft.) where abandoned.
6g.Screen length(if known): 15 (ft.)
•
Form GW-30 North Carolina Department of Enviromnent and Natural Resources—Division of Water Resources Revised August 2013

r
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
HENRY NEMARGUT I 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well ou his/her property) For multiple. injection or non-wafer I supply wells ONLY with the same
construction/abandonment,you can submtitione form.
3426-A I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 gal (gal.)
1 ,
HENRY NEMARGUT ENGINEERING SERVICES FOR WATER SUPPLY WELLS ONLY:
Company Name '
7c.Type of disinfectant used: i
2.Well Construction Permit it: N/A
List all applicable well permits(i.e.Connie,Stale, Variance,Injection,etc.)if known I 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
0 Agricultural ❑MunicipaVPublic 0 Neat Cement G1,`t1t "-^ :•. .._•. i 1 !❑ Sand Cement Groat L e 41 Bentonite Chips or Pellets
" : '
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ✓L t V. t&Cla Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout MA U 0rin. 0 Drill Cuttings
❑Irigation ❑ Specialty Grout IVI '1 4U440 Gravel
Non-Water Supply Well: ❑ Bentonite Slhr1�J`rTf+o; it or- 0Other(explain under 7g)
Monitoring ❑Recovery DW
Injection Well: 7f.For each material selected abgrovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Retnediation 1.0 bags of bentonite j
❑Aquifer Storage and Recovery ❑Salinity Barrier i ;
❑Aquifer Test • ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite pellets were poured into the well to top of casing,
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
• saturated with H2O then capped with cement:
4.Date well(s)abandoned: 1/15/24
5a.Well location:
Intex Print Plant • N/A
Facility/Owner Name Facility IDh(if applicable) 8.Certification:
523 South Stephens Street, Pilot Mountain, NC 27041 Henry Nemargut.. - 2/15/24
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Surry 596619608713601 By signing this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5h.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:
36.38082 N -80.47146 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-
ilttacIt well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructiomitbandoninent,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:
Division of Water Resources,Information Processing Unit,
27 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
lOb.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2". (in.) above,also submit one copy of this'form within 30 days of completion of well
abandonment to the following: I
i
26.01 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service CeiItCr,Raleigh,NC 27699-1636
lOc. For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned. I
6f.IInnereasing/tubing length(if known): 12 (ft.) Yi
I
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resourr es Revised August 2013

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells l
I.Well Contractor Information: WELL ABANDONMENT DETAILS '
HENRY NEMARGUT
7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or tort-wa)er supply we0s ONLY with the same
construction'abandonment,you can submit one_form.
3426-A 11 1 al
7b.Approximate volume of water remaining in well(s): g (gal.)
NC Well Contractor Certification Number
I -
HENRY NEMARGUT ENGINEERING SERVICES FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ! 11
•
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)ifknown
I
7d.Amount of disinfectant used: ; 1
3.Well use(check well use): I
Water Supply Well: 7e.Sealing materials used(check all.that
❑Agricultural ❑Municipal/Public 0 Neat Cement Gt•.•-- :•� ,• 1 if..,PJ<)3entonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) 0 Sand Cement ffrdh$� d,. o Clay
❑Industrial/Commercial ['Residential Water Supply(shared) 0 Concrete Grout AA n o ryA CI Drill Cuttings
❑Irrigation 0 Specialty Grout MP II 0 1 Z�L`t 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slrtriv n p.r;,. 3Ciftlter(explain under 7g)
2Monitoring ['Recovery DVI +AOG
Injection Well: If.For each material selected'above,provide amount of materials used:
❑Aquifer.Recharge ❑GroundwaterRemediation 0.5 bags of bentonite 1.
❑Aquifer Storage and Recovery ❑Salinity Barrier
['Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of th'e abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite pellets were poured into the well to top of casing,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
saturated with H2O then!capped with cement.
4.Date well(s)abandoned: 1/15/24
5a.Well location: `
Intex Print Plant N/A
8.Certification:
Facility/Owner Name Facility IDb(if applicable) ••
523 South Stephens Street,,Pilot Mountain, NC 27041 Henry NemargutPF�` "e" ..ru= 2/15/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner ' Date
I.
• Surry 596619608713601 By signing this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0I00 or 2C.0200 Well Construction Standards
and that a copy of this record has begin provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
36.38082 N -80.47146 �� 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)if available. 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
MW-4. 'abandonment to the following: , i
6a.Well ID#: -!
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 10 (ft,) 1617 Mail Service Ce]ter,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition]to sending the form to the address in 10a
2" above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: I,
Division of Water Resources,Underground erground Injection Control Program,
6d.Water level below ground surface: 9.01 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
lOc.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this fonn within 30 days of
completion of well abandonment to the county health department of the county
where abandoned. 11
6f.Inner casing/tubing length(if known): 5 (ft.)
;i
6g.Screen length(if known): 5 (ft.) 4 ;
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: I ,.
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
HENRY NEMARGUT 7a.Number of wells being abandoned:
Well 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-uulerl supply wells ONLY with the same
construction/abandonment,you can on subtnii e form.
3426-A
7b.Approximate volume of water rm eaining in well(s): 1 gal (gal.)
NC Well Contractor Certification Number
HENRY NEMARGUT ENGINEERING SERVICES FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit ii: N/A
List all applicable well permits 0.e.County,State, Variance,Injection,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 f .1 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Ceme St nrou 'r.•'"':1,� Q Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ~' 1....t v 1Dtill Cuttings
❑Irrigation 0 Specialty GroutMAR 0 I 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 2024 ❑ Other(explain under 7g)
0Monitoring ❑Recovery triforii'134i-en?r'>^.ry1;,Si;=, (jam�
Injection Well: 7f.For each material�G ,tret)rlme,povtde'amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.0 bags of bentonite
❑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) ❑Tracer Bentonite pellets were poured into the well to top of casing,
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
saturated with H2O then capped with cement.
4.Date well(s)abandoned: 1/1 5/24 j,
5a.Well location:
Intex Print Plant N/A ..
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
523 South Stephens Street, Pilot Mountain, NC 27041 Henry Nemargutt 7. =; ;.... 2/15/24
Physical Address.City,and Zip Signature of Certified Well Contractor or‘Well Owner Date
Surry 596619608713601 By signing this form, I hereby cerlfh that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.010,0 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:
36.38082 N -80.47146 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.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or nor-water supple
wells ONLY with tl,e 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-4D abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 35 (ft.)
10b.For Injection Wells: In addition to sending the fonn to the address in 10a
2" 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: 10.83 (ft.) Division of Water Resources,;Underground Injection Control Program,
i.
1636 Mail Service Center,Raleigh,NC 27699-1636
15Sl0c. For Water Supply Iniection
. 'Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
6E Inner casing/tubing length(if known): 20 (ft.)
,
6g.Screen length(if known): 15 (ft.) i
i .1
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

.
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
HENRY NEMARGUT I 1 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-waiter supply wells ONLY with the same
construction•abandomnent,you can submit due form.
3426-A
7b.Approximate volume of water rem:' ' gin well(s): 1 gal (gal.)
NC Well Contractor Certification Number
I
HENRY NEMARGUT ENGINEERING SERVICES FOR WATER SUPPLY WELLS ONLY:
I ',
Company Name 7c.Type of disinfectant used: 1
2.Well Construction Permit#: N/A ,
List all applicable well permits(i.e.County,State,Variance,Injection,etc,)if known 7d.Amount of disinfectant used:
3.Well use(check well use): 1, ,
Water Supply Well: 7e.Sealing materials used(check all that apply):
0 Agricultural ❑Municipal/Public 0 Neat Cement Grout 1 I El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement rtytf;"'.r"':^^1}� g Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout X.. U ill Cuttings
❑Irrigation 0 Specialty Grout MAR 1 2024 ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry f10 Other(explain under 7g)
Monitoring ❑Recovery iTt Rf�F £;l fir_ q tt
Injection Well: 7f:For each material se a o e'tiiPtivi 'mount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.0 bags of bentonite ,
❑Aquifer Storage and Recovery ❑Salinity Barrier '
❑Aquifer Test ❑Storm water Drainage
❑Experimental Technology ID Subsidence Control 7g.Provide a brief description of thie abandonment procedure:
❑Geothemtal(Closed Loop) ❑Tracer Bentonite pellets were poured into the well to top of casing,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
saturated with H2O then:capped with cement.
4.Date well(s)abandoned: 1/15/24 ,
5a.Well location:
Intex Print Plant N/A
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
523 South Stephens Street, Pilot Mountain, NC 27041 Henry Nemargut',F . —° 2/15/24
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Surry 596619608713601 By signing this form, I hereby cert f'that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with LSA 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 latllong is sufficient) 9.Site diagram or additional well details:
36.38082 N -80.47146 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)if available. For multiple injection or non-water supple
wells ONLY with the same consiruction'ahandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 30 (ft.)
10b.For Iniection Wells: In addition,to sending the form to the address in 10a
6c.Borehole diameter: 2" above,above,also submit one copy of this;form within 30 days of completion of well
abandonment to the following: I
28.75 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): 0 (ft.) IOe. For Water Supple&Iniectioni 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 abandoned.
6f.Inner casing/tubing length(if known): 15 (ft.) •
6g.Screen length(if known): 15 (ft.) I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
HENRY NEMARGUT • 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wale), supply wells ONLY with the same
construction/abandonment,you can submit one form.
3426-A l
7b.Approximate volume of water rm eaining in well(s): 1 gal (gal.)
NC Well Contractor Certification Number
HENRY NEMARGUT ENGINEERING SERVICES FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit 4: N/A ;' I.
List all applicable well permits(i.e.County,State, Variance,Injection etc.)iflmowrt 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 GroP ;'F','''• l .11�.Bet{tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grouts l ` V p lay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout MAR 0 1 '202❑Drill Cuttings
❑Irrigation 0 Specialty Grout CJ Gravel
Non-Water Supply Well: ❑Bentonite SlurtglIti i'iLo:ieil ?rf.^,Sys-Ii bi fig(explain under 7g)
Monitoring ❑Recovery DWQ/2,26
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.0 bags of bentonite ,
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite pellets were poured into the well to top of casing,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
saturated with H2O then:capped with cement.
4.Date well(s)abandoned: 1/15/24.
5a.Well location: •
Intex Print Plant N/A
Facility/Owner Name Facility 1Db(if applicable) 8.Certification:
523 South Stephens Street, Pilot Mountain, NC 27041 Henry Nemargutr 1 - 2/15/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Surry 596619608713601 By signing this form, 1 hereby cert/'that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I.SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ''
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:i
36.38082 N -80.47146 ,u 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
A/tac/t well construction records)if available. For multiple injection or non-water supply
wells ONLY with the same constructiomahandonnsent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-6 abandonment to the following:
• Division of Water Resources,Information Processing Unit,
• 6b.Total well depth 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• lllb.For Injection Wells: In addition;to sending the form to the address in 10a
2" above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: r
i
21.93 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&Injections 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 abandoned.
6f.Inner casing/tubing length(if known): 15 (ft.)
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6g.Screen length(if known): 15 (ft.)
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Fonts GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013