Randolph_Well Abandonment_20241022

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILSI
Trevor Mizelle 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-30 is needed. Indicate TOTAL NUMBER of
4629-C wells abandoned:
0.7378
NC Well Contractor Certification Number "� '•"" ,_ " ;' ' ;7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers & Scientists �� Ay' FOR WATER SUPPLY WELLS ONLY:
Company Name p r T ,�, LG�4
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U1C,Cot}n'ty;State,'Na1iagce eta)mown
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 PI Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑irrigation ❑ Specialty Grout l ❑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 ❑Groundwater Remediation Bentonite • 50 lbs
❑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
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 7g) Removed well shield and pad from ground.
Cut off well below surface level.
4.Date well(s)abandoned: 9/17/2024 Filled well with bentonite.
5a.Well location: Topped hole with dirt and leveled area.
Glenola
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5275 Glenola Industrial Dr, High Point, NC 27263 10/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph 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 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:
35.86969967248319 N -79.90839552968707 `,1, 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)ifavailable.For multiple injection or non-watersupply 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# EW-3 abandonment to the following:
•
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 23 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
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 5.64 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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. •
Unknown
6g.Screen length(if known): (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'
Trevor Mizelle 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-I0 is needed. Indicate TOTAL NUMBER of
4629-C wells abandoned:
7b.Approximate volume of water remainingin wells: 0.62815 (gal.)
Well Contractor Certification Number pp O• (g )
CATLIN Engineers & Scientists --, FOR WATER SUPPLY WELLS ONLY:
Company Name
to _ 7c.Type of disinfectant used:
2.Well Construction Permit#: (�` [ 9 42 2024
List all applicable well construction permits(i.e.UIC,Coun�,$tdte,•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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: _ ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery '
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 25 lbs
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed well shield and pad from ground.
Cut off well below surface level.
4.Date well(s)abandoned: 9/17/2024 Filled well with bentonite.
5a.Well location: Topped hole with dirt and leveled area.
Glenola
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5275 Glenola Industrial Dr, High Point, NC 27263 10/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph Bysigning thisform, I herebycertify that the wells was(were) abandoned in
s s Iv (1
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:
35.86969967248319 N -79.90839552968707 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 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
6a.Well ID#: Ew-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 26.5 (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:
11.72 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): NA (ft.) 10c.For Water Supply& 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

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS:
Trevor Mizelle
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
4629-C wells abandoned: I
7b.Approximate volume of water remainingin well(s): 0'309825 a1
NC Well Contractor Certification Number PPI (gal.)
CATLIN Engineers & Scientists 't' ",4..r `" 4" °^-FOR WATER SUPPLY WELLS ONLY:
Company Name
OCT 2 2 2024 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Counry,•,$(ale,Variance;ire)ifldfowiiJ
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 a Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) El Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout I 0 Gravel -
Non-Water Supply Well: 0 Bentonite Slurry I 0 Other(explain under 7g) __
•
(Monitoring ❑Recovery •
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 25 lbs
❑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
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) Removed well shield and pad from ground.
Cut off well below surface level.
4.Date well(s)abandoned: 9/17/2024 Filled well with bentonite.
5a.Well location: Topped hole with dirt and leveled area.
Glenola
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5275 Glenola Industrial Dr, High Point, NC 27263 10/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 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 IaUlong is sufficient) 9.Site diagram or additional well details:
35.86969967248319 N -79.90839552968707 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 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
6a.Well ID#: EW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (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 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: 12.71 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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.)
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
Trevor Mizelle 7a.For Geoprobe/DPT or Closed-IJoop 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
4629-C wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water r'maining in well(s): 22.14 (gal.)
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ! _
2.Well Construction Permit#: y _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known t:
7d.Amount of disinfectant used: 77_
3.Well use(check well use): r N cif
Water Supply Well: 7e.Sealing materials used(check all that apply):IG=J: .r
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I Bentonite Chip,s•or PelletsY,:" 'L sc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) El Concrete Grout ❑Drill Cuttings
Olrrigation ❑ Specialty Grout 1 ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g) _
❑Monitoring (Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 400 lbs
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed well vault box from ground.
Cut off well below surface level.
4.Date well(s)abandoned: 9/30/2024 Filled well with bentonite.
5a.Well location: •
Topped hole with dirt and leveled area.
Glenola
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5275 Glenola Industrial Dr, High Point, NC 27263 10/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph •
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 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:
35.86969967248319 N -79.90839552968707 �, 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 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
6a.Well ID# RW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 33 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 ,
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 5 (in.) above, also submit one copy of this iform within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 11.29 (It) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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
6f.Inner casing/tubing length(if known): Unknown (ft.) abandoned.
Unknown
6g.Screen length(if known): (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,
Trevor MlZelle 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Namc(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4629-C wells abandoned:
7b.Approximate volume of water remainingin wells 54.66 (gal.)
Well Contractor Certification Number PP O� (g )
CATLIN Engineers & Scientists 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,Slate,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): r r " !..,
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout !Bentonite Chips or}te�l}etf -3CO24
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay I
OIndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cutting6i-C,:": t •
❑Irrigation ❑ Specialty Grout 0 Gravel •
Non-Water Supply Well: • _❑ Bentonite S lurry ❑Other(explain under 7g)
❑Monitoring !Recovery I
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 287.5 lbs
❑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 •
❑Geothermal(Heating/Cooling Return) ['Other(explain under 7g) Removed well vault box from ground.
Cut off well below surface level.
4.Date well(s)abandoned: 9/30/2024 Filled well with bentonite.
5a.Well location: Topped hole with dirt and leveled area.
Glenola
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5275 Glenola Industrial Dr, High Point, NC 27263 Igeoe Gam?% 10/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph Bysigning thisform, I herebycerti that the wells was were abandoned in
g g h� () (were)
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:
35.86969967248319 N -79.90839552968707 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 won-walersupply wells
ONLY with the same construction/abandoment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# RW-5 abandonment to the following:
• Division of Water Resources,Information Processing Unit,
6b.Total well depth: 23.5 (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 5 (in.) above, also submit one copy of this:form within 30 days of completion of well
abandonment to the following:
5.64 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): NA (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.)
1 �
I ,
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD Forintemal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle
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-30 is needed. Indicate TOTAL NUMBER of
4629-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 13.45 (gal.)
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: •
2.Well Construction Permit#: •
r ;
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use): U 1:T 2 to 2024
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips orPellets. ._
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout El Gravel .
_ Non-Water Supply Well: ❑Bentonite_Slurry ❑ Other(explainunder7g)
❑Monitoring ®Recovery I ,
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 287.5 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑Stormwater Drainage
❑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) Removed well vault box from ground.
Cut off well below surface level.
4.Date well(s)abandoned: 9/30/2024 Filled well with bentonite.
5a.Well location: Topped hole with dirt and leveled area.
Glenola
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5275 Glenola Industrial Dr, High Point, NC 27263 10/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph Bysigning thisform, I hereby certi that the wells was were abandoned in
S 8 1 .�' () (Were)
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:
35.86969967248319 N -79.90839552968707 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# RW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter 5 (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 6.81 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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
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 i Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY: ,
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Trevor Mizelle 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
4629-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water iemaining in well(s): �'81 (gal.)
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: f
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,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): 0[T 2 2 2024
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout IP 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 0 Drill Cuttings
❑ `Irrigation ❑ Specialty Grout I ❑ Gravel
-_,_ Non-Water Supply Well: _ 0 Bentonite S_lurry El Other(explain under 7g)
lMonitoring ❑Recovery i
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Benseal 12.5 lbs
❑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
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) Removed well vault box from ground.
Cut off well below surface level.
4.Date well(s)abandoned: 9/30/2024 Filled well with bentonite.
5a.Well location: •
Topped hole with dirt and leveled area.
Glenola
Facility/Owner Name • Facility ID#(if applicable) 8.Certification:
5275 Glenola Industrial Dr, High Point, NC 27263 � 10/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
•
Randolph 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 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:
35.86969967248319 N -79.90839552968707 �, 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 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
6a.Well ID#: SW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24.58 (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: 1 (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 4.77 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (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.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Usc ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILI S'
Trevor Mizelle 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
4629-C wells abandoned:
7b.Approximate volume of water reniainin in well(s): 65.75 al
NC Well Contractor Certification Number PP g (gal.)
CATLIN Engineers & Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine Powder
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1.9725 ounces
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 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout p ❑Gravel
__ Non_Water Supply Well: - - ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery - - - --
`Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑GroundwaterRemediation Bentonite 710 lbs
❑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 __
❑Geothermal(Heating/Cooling Return) [Other(explain under 7g) Removed well vault box from ground. -
Cut off well below surface level.
4.Date well(s)abandoned: 9/30/2024 Filled well with bentonite. O C i 2024
5a.Well location: Topped hole with dirt and leveled
Glenola r '
Facility/Owner Name Facility lD#(if applicable) 8.Certification: /i �'�`
5275 Glenola Industrial Dr, High Point, NC 27263 10/3/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph 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 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:
35.86969967248319 N -79.90839552968707 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#: DVV 7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 112 (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: 4 (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: 11.28 (ft.) Division of Water Resources,Underground Injection Control Program,
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.)
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016