Guilford_Well Abandonment_20240419

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS!
Brian James Bellis 7a.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. indicate TOTAL NUMBER of
wells abandoned: l
NCWC 3510-A i ' • 0.44
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
:\ s .,,....
Company Name I \t,ice,C.,.`"
7c.Type of disinfectant used: •< <� !._ ,y
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc.)if known
APR 9
2024
7d.Amount of disinfectant used: 1
3.Well use(check well use): 1 /' I .,-..."cw.--:fi tJR;
Water Supply Well: 7e.Sealing materials used(check all that apply): '
❑Agricultural ❑Municipal/Public I Neat Cement Grout 1 I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 1 ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
•
❑Irrigation ❑ Specialty Grout • ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
(Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
['Aquifer Recharge ❑Groundwater Remediation -35 lbs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier •
['Aquifer Test ❑Stormwater Drainage -25 lbs Grout i
['Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite was placed in.one foot lifts and hydrated
['Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) -
until one foot from top of casing. Remaining space was
4.Date well(s)abandoned: 3/29/2024 capped with grout to surface grade. Flush-mount
5a.Well location: protective manway was filled with grout to surface.
Nan Bro Ceramics Not Applicable
Facility/Owner Name Facility ID#(if applicable) S.Certification: .,
7309 Summerfield Rd, Summerfield 27358 — 4/9/2024
Physical Address,City,and Zip Signature ofCertifi ell Contractor or Well Owner Date
Guilford 7839411827 ''
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.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:
36.197205° N -79.901398° 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)ifarailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-13 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (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 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 22.32 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A 1Oc.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 15 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS,
Brian James Bellis f
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number
l 7b.Approximate volume of water remaining in well(s): 0.43 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
I .
Company Name 7c.Type of disinfectant used: P't;"iT _. k, la,4 a -'
2.Well Construction Permit#: N/A .1.1...
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known APR 1 9 202
7d.Amount of disinfectant used: Y
3.Well use(check well use): : initur.:rw rD 'r-::, rt,,.m UStk
Water Supply Well: 7e.Sealing materials used(check all that apply): C13V i: OG
❑Agricultural ❑MunicipaUPublic I Neat Cement Grout IR Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout j ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ' ❑ Gravel
Non-Water Supply Well! - Cl Bentonite Slurry 0 Other(explain under 7g)
(Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation -35 lbs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
1.
❑Aquifer Test ❑Stormwater Drainage -25 lbs Grout
❑Experimental Technology ❑Subsidence Control 1 i
7g.Provide a brief description of the;abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite was placed in one foot lifts and hydrated
until one foot from top of casing. Remaining space was
4.Date well(s)abandoned: 3/29/2024
capped with grout to surface grade. Flush-mount
5a.Well location: protective manway was filled with grout to surface.
Nan Bro Ceramics Not Applicable
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
7309 Summerfield Rd, Summerfield 27358 6-"c j -c-'.e-GE._ 4/9/2024
Physical Address,City,and Zip Signature ofCertifie ler ontractor or Well Owner Date
Guilford 7839411827
By signing this form, I hereby cert5 that the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.196904° N -79.901013° 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.
• 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-12 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 -(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 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface 22.34 (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.) IOc.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): 15 (ft) abandoned. } •
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NCWC 3510-A I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): �'85 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A =z< o,-C•'C.j. l �•- ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: APR I f, ZOZ4
•
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that 0 y):-1 '£a Pr �Fsk• F UM❑Agricultural ❑Municipal/Public I Neat Cement Grout 1 II Bentonrttti tripsIiNellets
❑Geotheral(Heating/Cooling Supply) ❑Residential Water Supply(single) Sand Cement Grout m CI Thy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) CI Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout 1 ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
IMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation —35 lbs Bentonite 1
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage —25 lbs Grout
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Bentonite was placed in one foot lifts and hydrated
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
until one foot from top of casing. Remaining space was
4.Date well(s)abandoned: 3/29/2024
capped with grout to surface grade. Flush-mount
5a.Well location: protective manway was filled with grout to surface.
Nan Bro Ceramics Not Applicable
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
7309 Summerfield Rd, Summerfield 27358 �-•-4/9/2024
Physical Address,City,and Zip Signature of Certifi I Contractor or Well Owner Date
Guilford 7839411827
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.O100 or 1C.0200 Well Construction Standards
and that a copy of this record has ben 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:
36.197186° N -79.900997° 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)ifarailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW 6 abandonment to the following: ;
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 28 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in IOa
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
6d.Water level below ground surface: 22.79 (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&Iniecti on Wells: In addition to sending the form to the
address(es)above,also submit oneicopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 18 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

1
i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-LI 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 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water re maining in well(s): 1.24 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name I •-- -"
7c.Type of disinfectant used: 1- • 3 i,•"'••-,
2.Well Construction Permit#:
N/A .� . ..�•L. tV ii.-d:.
List all applicable well construction permits(i.e.UJC,County,State,Variance,etc.)iflmown t 7d.Amount of disinfectant used: ' APR *d ?O��
3.Well use(check well use): ,
Water Supply Well: 7e.Sealing materials used(check all that apply): GWQ1204:0" a
❑Agricultural ❑Municipal/Public a Neat Cement Grout i IP 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: ID Bentonite Slurry 0 Other(explain under 7g)
uMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation -35 lbs Bentonite I ,
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage -25 lbs Grout
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite was placed in one foot lifts and hydrated
until one foot from top of casing. Remaining space was
4.Date well(s)abandoned: 3/29/2024
capped with grout to surface grade. Flush-mount
5a.Well location: protective manway was filled with grout to surface.
Nan Bro Ceramics Not Applicable ,
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
7309 Summerfield Rd, Summerfield 27358 _ a a--..L �f ��}/9/2024
Physical Address,City,and Zip Signature of Certifie ontractor or Well Owner Date
Guilford 7839411827
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.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 lat/long is sufficient) 9.Site diagram or additional well:details:
36.197289° N -79.901016° W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the 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-1 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 27.3 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:
6d.Water level below ground surface: 19'70 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 12'3 (ft) abandoned. I '
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY: '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
1
Brian James Bellis 7a.For Geoprobe/DPT or Closed-Troop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining1 in well(s): '15
(gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name I.
7c.Type of disinfectant used: : I.t._E, ,•4, i .1 t .J
2.Well Construction Permit#: N/A 9
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known APR PR I 2024
7d.Amount of disinfectant used:
3.Well use(check well use): :-c.,..
.-, o..;:ma's Uali
Water Supply Well: 7e.Sealing materials used(check all that apply): DW
❑Agricultural ❑Municipal/Public I Neat Cement Grout i I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ 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 0 Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑Groundwater Remediation -35 lbs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier ,
❑Aquifer Test ❑StormwaterDrainage -25 lbs Grout
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite was placed in one foot lifts and hydrated
until one foot from top of casing. Remaining space was
4.Date well(s)abandoned: 3/29/2024 capped with grout to surface grade. Flush-mount
5a.Well location: protective manway was filled with grout to surface.
Nan Bro Ceramics Not Applicable
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
7309 Summerfield Rd, Summerfield 27358 ,F, e-%4/9/2024
Physical Address,City,and Zip Signature of Certifi W Contractor or Well Owner Date
Guilford 7839411827 By signing form, hereby fy well(s)
si nin this I certi that the 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 welldetails:
36.197070° N -79.900743° W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the 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-14 abandonment to the following: '
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 28 (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 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 20.92 (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&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): 13 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016