Guilford_Well Abandonment_20241014 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
Il
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lewis Lefever I
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 j30 is needed. Indicate TOTAL NUMBER of
2480A wells abandoned:-' I
NC Well Contractor Certification Number 7b.Approximate volume of water Ire j aining in well(s): 2.21 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: '
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)(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 N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ 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 ❑GroundwaterRemediation 4 Gallons
❑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 routed with Bentonite chips'and FMC filled with concrete mix
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) -- --
4.Date well(s)abandoned: 9-1 8-24
OCT 1 4 W4
5a.Well location:
Fowler M M Inc BP 444 -
(s'J CIO
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
4839 West Wendover Avenue, Jamestown 27282 /6 T
Physical Address,City,and Zip Sin tore of Certified Well Co cui or Well Owner Date
Guilford 7823666874
By signing this form, !hereby certify that the well(q) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constniction 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 field,one IaUlong is sufficient) 9.Site diagram or additional well details:
36.045694 N -79.924305 �, 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.ror multiple injection or non-water supply wells
ONLY with the same constructioroabandonment,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,
6b.Total well depth: 25 (ft.) 1617 Mail Service Center;Raleigh,NC 27699-1617
10b.For Infection Wells: In additiot 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:
6d.Water level below ground surface: 11.17 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
•6e.Outer casing length(if known): (ft.) 10c.For Water Supply&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.
l �
6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
i
WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lewis Lefever
7a.For Geoprobe/DPT or Closed- oop 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
2480A wells abandoned:-'
NC Well Contractor Certification Number 7b.Approximate volume of water Ire i aining in well(s): 1.94 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC Comity,State,Variance,etc.)iiftnown
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 19 Bentonite Chips or Pellets
❑Geothermal(Heating/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 Slurry i ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
I'
❑Aquifer Recharge ❑GroundwaterRemediation 4 Gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of We abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) routed with Bentonite chips;and FMC_fllled with concrete mix
4.Date well(s)abandoned: 9-18-24 O r T 1 2024
5a.Well location:
Fowler M M Inc BP 444
Facility/Owner Name Facility ID#(ifapplicable) 8.Cc r'nation:
4839 West Wendover Avenue, Jamestown 27282
Physical Address,City,and Zip
Si a o Certified Well Contracto r Well caner Date
Guilford 7823666874
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.0100 or 2C.0200 Well Constniction 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: j
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.045678 N -79.924759 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the sane constructionlabandonmemt,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: 25 (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: 6 (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: 12.87 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
1; I
i
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county I,health department of the county where
fill Inner casing/tubing length(if known): 10 (ft.) abandoned.
6g.Screen length(if known): 15 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20 t 6

I� I
WELL ABANDONMENT RECORD
For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lewis Lefever
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 J30 is needed. Indicate TOTAL NUMBER of
2480A wells abandoned:-' I II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2' 5 (gal.)
Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
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 ❑Neat Cement Grout R Bentonite Chips or Pellets
❑Geothermal(Heating/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 Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4 Gallons
❑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
❑ routed with Bentonite chips,and FMC filled with concrete mix
Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 9-18-24
O C T 1 7074
5a.Well location:
Fowler M M Inc BP 444
Gab+.�.•�t�,�
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
4839 West Wendover Avenue, Jamestown 27282
Physical Address,City,and Zip 14ature of Certified Well Contrac r or W Owner Date
Guilford 7823666874
By signing this form, /hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with/5A NCAC 02C.0/00 or 2C.0200 Girell Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
i
(ifwell field,one latllong is sufficient) 9.Site diagram or additional well details:
36.04592 N -79.92463 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 shells
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-7 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 Iniection 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:
6d.Water level below ground surface: 11.55 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&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 dalth department of the county where
6E Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

,1
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lewis Lefever 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 I GW 130 is needed. Indicate TOTAL NUMBER of
2480A wells abandoned:-'
NC Well Contractor Certification Number 7b.Approximate volume of water�remaining in well(s): 137.29 (gal.)
ii Parratt-Wolff, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: _
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown u
7d.Amount of disinfectant used: .
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/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 Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 7.42 Gallons
❑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 routed with Bentonite chips and FMC filled with concrete mix
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: I M4 '
(:T� I G 11
5a.Well location:
Fowler M M Inc BP 444
Diet.G�l„`J
Facility/Owner Name Facility IDIi(if applicable) 8.Cer'tcation:
4839 West Wendover Avenue, Jamestown 27282
Physical Address,City,and Zip Signature o Certified Well Contractor r We Owner Date
Guilford 7823666874
By signing this form, 1 hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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]at/long is sufficient) 9.Site diagram or additional well details:
36.045820 N -79.924461 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 WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atiach well constriction records)ifavailable.Formulriple injection ornon-watersupply wells
ONLY with the same consirnction/ahandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-8D abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45.5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
Lob. For Iniection Wells: In addition;to sending the form to the address in IOa
6c.Borehole diameter: 14 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6
11.85 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Cent,�Ir,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 30 (ft) 10c.For Water Suaaly&Iniection Well's: 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
611 Inner casing/tubing length(if known): 40 (ft.) abandoned. {
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016