Guilford_Well Abandonment_20240610

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Wel ontractor lnfor 'on: WELL ABAN)ONMENT DETAILS
A. `xn► 7a.Number of wells being abandoned:
Well Contractor ame(or well owner personally abandoning well on his/bet property) For multiple injection or non-warer supply wells ONLY with file tome
3 3 3 9 entvrruction'abandonnrenr,you can submit one form.
7b.Approximate volume of water remaining in well(s):_ a(
NC WellJ-q
tsaCe fiction Number (g )
M yin ,G t�SS VG• FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit N:
Listal/applicable wel/permits(i.e.Cmmy,State,Variance.Injection,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check aft that ap lyj:
DAgricultural ❑Mur»cipal/Public XNat Cement Grout Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) O Sand Cement?Grout� e + OL Clay
OLnelustrial/Commercial DResidential Water Supply(shared) O Concrete Grout t" v t--6 Drill Cuttings
01rTigation ❑Specialty Grout 1 U �.1 1 O Gravel
Non-Water Supply Well: O Bentonite Slurry ❑Other(explain under 7g)
onitoring ORecovery I[1bDtR'W;plt 7,�.r
]n action Wtll: 711 For each material ea r prBvaeYmount of materials used:
OAquifer Recharge OGroundwater Remediation �j J be ,,T t s 10 aIS-, ja tt P.r
OAquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test OStormwater Drainage ��H ��
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the aband men(procedure:
OGeothermal(Closed Loop) OTrocerJj, b / /r
OGeothermal(Heatin Coolin Return) OOther(explain under 7 ) a 4Vn, Gies Q S /Ottt
.� 1s1 7� 4o �f o� �. (�Jsur u. "J 4.bate well(s)abandoned: 5wAa. ovard hCiLCe4n Qw,
52.Well location, n t f Q
Qa�'cK Snag's �-AkVA/ nd sur e ftc
Facility/OwnPe-vouAl/
Facility IDN(if applicable) g•Ctrlif (ion:
37 5"0 4-V f-. �91P,e►lSZcr�i lie L p N
Physi Address try and Zip a Sign urc of reified I Contractor or Well Owner Due
91 I . Y'd By signing this form, 1 hereby certh,that the weil(s) was(were)abandoned in
County Parcel identification No.(PM) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Conrtruetion 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 luiflong is sufficient) 9.Site diagram or additional well details:
6a O t�e ! i/Z N O p d�r' L;'�q W You may use the back of this page to provide additional well site details or well
ty 1 T J 7 ( abandonment details. You may also attach additional pages ifaecessary,
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multtple ttyeerion or non-warer supply
wells ONLY with the samec oon�stpr�aetion/abondonrnent you can can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6e.Well ID#: /''•— abandonment to the following:
f Division of Water Resources,Informalion Processing Unit,
6b.Total well depth: I 1 (ft•) 1617 Mail Service Center,Raleigh,NC 27699.1617
SIt 10b.For lniection Wells: In addition to sending the form to the address in l0a
O 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: (ft.) Division of Water Resources,Underground Injec(ionControl Program,
1636 Mail Service Center,Raleigh,NC 2'699.1636
1
10c, For Water Supply& Infection Wells: In addition tosending 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 depauent of the county
6f.Inner rasing/tubing length(if known): (ft.)
where abandoned.
/�l
6g.Screen length(if known): V I (ft.)
Form G W-30 Nonh Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ADFk1'N 0%JPl1V1Llr 1 i(L'L U" I For Internal Use ONLY I
I.t%ell Contractor Information: NMENT DETAILS
Timothy D Leatherman Its.For Geoprobe/DPTor Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hisiher property) well construction/depth,only I GW-30 is needed Indicate TOTAL NUMBER of
2888A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remainin:;in well(s):
Pyramid Environmental & Engineering. P.C. FOR"'ATER SUPPLVAVELLS ONLI:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits it e. UIC.('aunty.Slate. I'irtante etc)it kinm it
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Nell: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public S Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement G r—' ;< is Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout �"+ LQ 1 Cuttings
❑Irri ation ❑ Specialty Grout Jt1N 1 0 Z4240 Gravel
Non-Water Supply Well: ❑ Bentonite Slurr� ❑ Other(explain under 7g)
SVIonrtonng ❑Recovery ICtt©rx-av rfl r�•�C ittaW g tjts
Injection Well: 71'. I ur each material selDY40W pro de aliount of materials uwd:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 2 pounds
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Portland Cement 1 pound
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure
❑Geothermal(Closed Loop) ❑Tracer
Slow pour bentonite and porltand cement.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(%)abandoned: June 04, 2024
5a.%N ell location:
Former Patches Body Shop IHSB ID NONCD0002880
Facile, t i—m Name Facility ID-of applicable) 8.t'ertificaliun:
1903 E. Green Drive. High Point, NC 06/04/2024
Physical Address.Cit. and/q, Signature of C ified ell Contractor or ell Owner Date
Guilford 7800838423
By signing this form. 1 hereby certify,that the wells) 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.
Sb.Latitude and longitude in degreeshninutesheconds or decimal degrees:
(ifwell field,one latlong is sufficient) 9.Site diagram or additional well details:
36.953429 -79.401985 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 OFNN'ELI.(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.4nachnellcore.rtrtrcaonrecord(c)tjavndahle 1',unmhtplein/ecnonarnon-uatersupplyNelLc
O:V/.Y with the.name construction abundanmam,you can suhmn one firm.
109. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-1 abandonment to the following
Division of NN ater Resources,Information Processing Unit,
6b. I otal well depth: 16 (ft.) 1617 Mail Service('enter,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.5 (1 in dia.)(11e) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following
6d.NN ater level below ground surface: 4.73 (ff.) Division of NN'ater Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 (ft.) 10c.For Water Smutty Infection Wells:Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 6 (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

♦VJEAUL t1l)t11\11V1\1y1L`1\ 1 AL'l.V1W IFor Intemal Use ONLY
I.N%ell(ont actor Information: N'ELL ABANDONMENT DETAILS
Timothy D Leatherman 79.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
R-ell Contractor Name(or well owner personally abandoning well on hisiher property) well construction/depth,only I GW-30 is needed Indicate TOTAL NUMBER of
2888A wells abandoned.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
Pyramid Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: NA
etvi all applicable rre//construcirron permits(t.e. t%/C,(•nunrv.State. Variance.etc.)cJ knomw
7d.Amount of disinfectant used:
3.Well use(check well use):
N ater Supply Nell: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: D Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recover\
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑AquiferRedtarge ❑GroundwaterRemediation Bentonite 2 pounds
❑Aquifer Storage and Recovery ❑Salmity Barrier
❑Aquifer Test ❑StormwaterDrainage Portland Cement 1 pound
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Slow pour bentonite and porltand cement.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) VP
3.Date well(s)abandoned: June 04, 2024
5a.Well location:
Former Patches Body Shop IHSB ID: NONCD0002880
Facility Owner Name Facility ID-1(ifapplicable)
8.Certification: DWQ"
1903 E. Green Drive, High Point, NC
06/04/2024
Physical:\ddic;s.tit, and Lip Signature ofCe�rt Fred ell Contractor Fr Well Owner Date
Guilford 7800838423
By signing this form, /hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No (PIN) accordance with 1 SA NCAC 01C.0100 or 1C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degree,/minutes/seconds or decimal degrees:
(ifwell field,one lat long is sufficient) 9.Site diagram or additional well details:
36.953478 N -79.983782 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
.antic%wellc•onrirudtcntrec•ord(.r)ifaratluble. Furmuluple injection ornon-waterstippl)N-ells
0.N/Y avuh the same construction abandonment,you can submit one.fitrm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.N'ell ID#: TW-2 abandonment to the following
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.5 (1 in dia )lit ) 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: 5.5 (ft.) Division of Water Resources,t'nderground Injection Control Program,
1636 Slail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 (ft.) loc.For Water Sunnly&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 5 (ft.) abandoned
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Em ironmental Quality-Division of Water Resources Revised 2-22-2016

VV IL 1,1. E1DL-111111V1\1VI lr 1 1U'Ll Vl(il I For Internal Use ONLY I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Timothy D. Leatherman 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name for well owner personally abandoning well on hisiher property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2888A wells abandoned
NC Well Contractor Certification Number 7b.Approximate volume ofwater remainim-,in welds): (gal.)
Pyramid Environmental & Engineering, P.C. FOR HATER SUPPLI NN ELLS ONLI
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit h: NA
I is all applicable well con.ctrucnan pennac o e I'IC.r•ounir.State, Variance.el,)if kinmit
7d.Amount of disinfectant used:
3.1%'ell use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public S Neat Cement Grout @ Bentonite Chips or Pellets
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slum ❑ Other(explain under 7g)
@Monitoring ❑Recovery
Injection Well: 71. I ur each nialerial selected:ibot c,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 2.5 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑AquiferTest ❑StormwaterDrainage Portland Cement 1 pound
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Slow pour bentonite and porltand cement.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date Aell(s)abandoned: June 04. 2024
u
Sa.N ell location: IN 1 024
Former Patches Body Shop IHSB ID NONCD0002880
Faalm Uwner Name Facility IDa(dapplicable) 8.Certification: E)WdSC4
1903 E. Green Drive, High Point, NC 06/04/2024
Physical Address.City,and Zip Signature ofCe.jfi.3 Well Contractor or Well Owner Date
Guilford 7800838423
By signing this form. 1 hereby certify that the well(s) was (Were) abandoned in
County Parcel Identification No (PIN) accordance with 15A NCAC'02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat long is sufficient) 9.Site diagram or additional well details:
36.953384 N -79.983742 W You may use the back of this page to provide additional well site details or µell
abandonment details You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF"'ELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well c on.vtritt-tian ret ord(r)!fat-aihihle. l•br nndtiple inlection or non-e,ater.rupply w ells
0M V with the same construction abandonment,you can.submit one form
_ IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TIN-3 abandonment to the billowing
Division of Water Resources,Information Processing Unit,
6b.Total well depth- 20 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.5 (1 in dla.)(in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.1%'ater level below ground surface: 6.6 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 flail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 (ft.) 10c.For Water Sunoly&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 5 (ft.) abandoned
6,.Screen length(if Lniiw it): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016