__20230113 (2)

,
•
WELL ABANDONMENT RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells l
,
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER I 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-water I supply wells ONLY with the same
construction/abandonment,you can submit one form.
A -4475
7b.Approximate volume of water remaining in well(s): . (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: /r -
2.Well Construction Permit#: ty"`' -,.. `', -*
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known - '✓ii°°' ITS
7d.Amount of disinfectant used: I���h r :,, 1 ti
- � 7 �rf
3.Well use(check well use): {r,���,�,. L L 023
Water Supply Well: 7e.Sealing materials used(check all that apply): " ?t)p't- t
ri,❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite'CIiips�Q`4ie'(ets,-J i
.J ( N
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand.Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
EMonitoring ['Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 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) OTracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ['Other(explain under 7g)
•
4.Date well(s)abandoned: 10/24/22
5a.Well location: I I
WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID#(if applicable)
8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 �GG7'� 11/04/22
Physical Address,City,and Zip . Signature of Certified Well Contractor or Well Owner Date
. FENDER By signing this form, /hereby certi&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.
Sb.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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
Attach well construction record(s)if arailable. For multiple injection or non-crater supply
wells ONLY with the sane 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-8 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 17.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• lOb. For infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 •(in.) � abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I •
10c. For Water Supply.&Infection 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
ll
t ,

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
CARL CARPENTER 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-water I supply hells ONLY with the same
construction/abandonment,you can submit;one form.
A - 4475
7b.Approximate volume of water remaining in well(s): 0 5 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: c .. 17-'
r
2.Well Construction Permit#:
/I �/ r ,
List all applicable well construction permits(i.e.County,Stale.Variance,etc.)if known 7d.Amount of disinfectant used: Jry l V l �' q023
3.Well use(check well use): ""+ ,,
Water Supply Well: 7e.Sealing materials used(check all that apply): C1;:(-3,,,,,
- -'^
Pr Y ' 0 Neat Cement Grout 0 Bentonite Chips or Pe Iefs�,G .-i ('/r
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
ElMonitoring ID Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 GALLONS
0 Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
•
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothennal(Closed Loop) OTracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location:
WOODCOCK OIL COMPANY
Facility/Owner Name Facility lD#(if applicable) 8.Certification: _
700 EAST CHURCH STREET ATKINSON 28421 C`-�� 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER 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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
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#: MW-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 17.5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in Ina
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
15.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. 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.
6f.Inner casing/tubing length(if known): (ft.) i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 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
CARL CARPENTER 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-Tate supply wells ONLY with the .satire
construction/abandonment,you can submit one form.
A - 4475
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: t <
2.Well Construction Permit#: Jq/b
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known .? 2P2 J�
7d.Amount of disinfectant used: r <
3.Well use(check well use):
7e.Sealingmaterials used(check all that apply): ' '""
Water Supply Well: PP Y)� �'�.)G' 01;:7
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: I I
WOODCOCK OIL COMPANY
8.Certification:
Facility/Owner Name Facility ID#(if applicable)
700 EAST CHURCH STREET ATKINSON 28421 1/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PEN DER By signing this form, I hereby certiA,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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
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
Ga.Well ID#:
MW-15 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 15.0 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb. For Injection Wells: In addition to sending the form to the address in IDa
2 0 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 Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. 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.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 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 I
CARL CARPENTER 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-water supply wells ONLY with the same
construction/abandonment,you can submit'one form.
A - 4475
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: s1.`',;_ -?..---,
Company Name 7c.Type of disinfectant used: "'•S�'' , .i ,.:,
/ `vtii ti t
2.Well Construction Permit#: ��/�4 . qn27
List all applicable well construction permits(i.e.County,Stale,Variance,etc.)if known 7d.Amount of disinfectant used: i'l t:.. _.. '- 2/
3.Well use(check well use): 01,1',''-''^. -�
7e.Sealingmaterials used(check all that apply): y.'"
Water Supply Well: PP Y)� �l� �',I 1_?(;.�
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ 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 ❑ Drill Cuttings
❑Irrigation ❑ Specialty Groui 0 Gravel
Non-Water Supply Well: RI Bentonite Slurry 0 Other(explain under 7g)
IL Monitoring ❑Recovery
Injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: - I
WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 !�'- 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, I hereby certfy 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.
Sb.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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
Attach well construction record(s)if available. For multiple injection or non-water supply
wens ONLY with the same construction/abandonment,you can submit one firm 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: MW-14 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 15.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
•
Gd.Water level below ground surface: (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply& Infection Wells: In addition to sending the form to
Ge.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.
6f.Inner casing/tubing length(if known): (ft.) i
I
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY. ,
This form can be used for single or multiple wells I ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 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 ,sane
construction/abandonment,you can sttbnt f one form.
A -4475
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification NumberIi .
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: I
�.
ti ,--\,
Company Name 7c.Type of disinfectant used: '�'y-N',, `' :1 c,
• / z'.' ,,•,, •,,, a�
2.Well Construction Permit#: J4Iv
1 n
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: /7`-,_ 2023
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): °Q S;) •:9 Li/,,!
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: RI Bentonite Slurry 0 Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.5 GALLONS
❑Aquifer Storage and Recovery 0 Salinity Barrier •
0 Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer ABANDONED'VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: - - - • I
WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID/I(if applicable)
$•Certification: `
700 EAST CHURCH STREET ATKINSON 28421 C_- ,)' 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, 1 hereby Bert,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 Iat/long is sufficient) 9.Site diagram or additional well details:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
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
Ga.Well ID#: MW-1 2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth 15.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Injection Wells: In addition to sending the form to the address in 10a
2 0 above,also submit one copy of this form within 30 days of completion of well
6e.Borehole diameter: (in.) abandonment to the following: ,
I .
6d.Water level below ground surface: (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): -_ (ft.)
Ii
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 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
CARL CARPENTER 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 I supply wells ONLY with the sante
construction/abandonment,you can submit one form.
A - 4475 j,
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: I --,
• �.
Company Name Fv- f
7c.Type of disinfectant used:
2.Well Construction Permit It: JAiV i
List all applicable well construction permits(i.e.County,State,Variance;etc.)if known 9/1
7d.Amount of disinfectant used: In:T— 2029
3.Well use(check well use): Ci:, -;:
Water Supply Well: 7e.Sealing materials used(check all that apply): OLD"r'9 Ciro
El Agricultural ❑Municipal/Public El Neat Cement Grout ❑ 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)
0Monitoring ❑Recovery
Injection Well: ' 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: - - --- -
WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 G-:-� r 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, I hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance wilt 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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the saute construction/abandonment,you can submit one jbrm• 1Oa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-1 3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 15.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2.0 (in.) abandonment to the following: I.
6d.Water level below ground surface: (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. 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.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.) 1 •
i
• l
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 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
CARL CARPENTER
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 11w same
construction/abandonment,you can submit one form.
A -4475
7b.Approximate volume of water re I aining in well(s): 45' (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: G' --------
Company Name 7c.Type of disinfectant used: • ` As., ., :",,-.,
2.Well Construction Permit#: J4�f } ; ,; L.
n /� .
List all applicable well construction permits(i.e.County,State,Variance,etc)if known 7d.Amount of disinfectant used: 'n`0; _ 4 923
ti
3.Well use(check well use): ,,,I..:~'...3_,,;
7e.Sealingmaterials used(check all that apply): '''1- �»r."-:?IJ
Water Supply Well: PP Y)� C,: r,;j
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 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 ❑ Gravel
Non-Water Supply Well: P1 Bentonite Slurry 0 Other(explain under 7g)
P1Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 8.0 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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: _
- -- - - --
WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID#(if applicable) 8.Certification: ,,> _
700 EAST CHURCH STREET ATKINSON 28421 G.` 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, 1 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34° 31' 54.91" 78° 09' 49.38" You may use the back of this page to 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
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 1D#: T-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
48.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
20.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. 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. , 1
6f.Inner casing/tubing length(if known): (ft.)
i
6g.Screen length(if known): (ft.)
Form GW-30 • North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
i I
1 i

I
I
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells ! I
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER ' 1
7a.Number of wells being abando ed:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wine) supply wells ONLY with the same
construction/abandonment,you can submit one form.
A - 4475
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): 5' _(gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: C.-' -
Company Name 7c.Type of disinfectant used: 1 t1,-j.%`'-' v`':.
2.Well Construction Permit#: Jq/`f ti~�
r'
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: }rs,-..' Z`'C J'
3.Well use(check well use): ',,
Water Supply Well: 7e.Sealing materials used(check all that apply): '£u�r L� /T/r./
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 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) ❑Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry 0 Other(explain under 7g)
0Monitoring 0 Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 8.0 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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 1 0/24/22
5a.Well location: -
WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID#(if applicable) 8•Certilication: '
�
700 EAST CHURCH STREET ATKINSON 28421 .„- ,' 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, I hereby certfy 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.
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:
34° 31' 54.21" 78° 09' 49.18" You may use the back of this page to 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
Attach well construction record(s)if available. For multiple injection or non-water supply
we/Ls ONLY with the sante constructions/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: T-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth 50.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb. For Injection Wells: In addition to sending the form to the address in 10a
2.0 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: 20.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10e. 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.
6f.Inner casing/tubing length(if known): (ft.)
1
6g.Screen length(if known): . -_ - - (ft.) I
11
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
i

1
WELL ABANDONMENT RECORD For Internal Use ONLY: .
This form can be used for single or multiple wells
t 1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER
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-water supply sells ONLY with the same
construction/abandonment,you can submit,one form.
A - 4475
7b.Approximate volume of water remaining in well(s): 1'� (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: •t`'i' -
2.Well Construction Permit#: - ` 5
List all applicable sell construction permits(i.e.County,State,Variance,etc.)if known � .� '`.-, yf
7d.Amount of disinfectant used:
;n-_- — //Pel
3.Well use(check well use): +^,7 -, C.,)
7e.Sealing materials used(check all that apply): ,42!, . r-'
Water Supply Well: k-ti' -' g t r .
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pella§ • ,/.,,, .
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.25 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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location:
WOODCOCK OIL COMPANY •
Facility/Owner Name Facility IN(if applicable) 8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 G"-�-" --- 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, I hereby certfy 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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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,
Attach well construction record(s)if available. For multiple injection or non-water supply
sells 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 abandonment to the following:
Division of Water Quality,Information Processing Unit,
20.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2.0 (in.) abandonment to the following:
•
6d.Water level below ground surface: 1 5.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
IOc. For Water Supply&Infection 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.
6f.Inner casing/tubing length(if known): (ft.) '
i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

f1
• I
WELL ABANDONMENT RECORD For internal Use ONLY: i
This form can be used for single or multiple wells 1
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
CARL CARPENTER 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-+raieri supply +ret/s ONLY with the same
construction/abandonntent,you can subnti'i one form.
A - 4475
7b.Approximate volume of water remaining in well(s): 1.0
(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: /""
Company Name 7c.Type of disinfectant used: z `�
2.Well Construction Permit#: ✓qj .
ist A
L all applicable well construction permits(i.e.County,State,Variance,etc.)if '_ y -"'
7d.Amount of disinfectant used: /rr-,. f ,0L 91
3.Well use(check well use): 1—.1,,' rj`:',
Water Supply Well: 7e.Sealing materials used(check all that apply): `',0,--)f_ -;�Li
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellet i
❑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
0 Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry 0 Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
0 Experimental Technology ❑Subsidence Control ; 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location:
WOODCOCK OIL COMPANY
8.Certification:
Facility/Owner Name Facility ID#(if applicable) J�700 EAST CHURCH STREET ATKINSON 28421 G`- �� 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER 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
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
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-9 abandonment to the following:
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
6b.Total well depth 20.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the form to the address in IOa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface: 1 5.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.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.
6f.Inner casing/tubing length(if known): _ (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells 1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 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-waier! supply wells ONLY with the same
construction/abandonment,you can submit one form.
A - 4475 1.0
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
' • .s ,
2.Well Construction Permit#: _'k
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used: IAA/ 7 r k_,
1 •7..
3.Well use(check well use): 't?;. -...;.. ` 0/(3
Water Supply Well: 7e.Sealing materials used(check all that apply): '7:'>
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite CNipsoi PeLllets')j_rt.;
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry 0 Other(explain under 7g)
El Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 GALLONS
❑Aquifer Storage and Recovery ['Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: ••
WOODCOCK OIL COMPANY •
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 C 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, 1 hereby certij,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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
Attach well construction record(%)if available. For multiple injection or non-water supply
wells ONLY with the.sane 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-5 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 20.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb. For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface: 15.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
10c.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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.) ,
I
Form GW-30 Nortl,Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 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
CARL CARPENTER ' 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-water j supply wells ONLY with the same
construction/abandonment,you can submition form.
A - 4475
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'� (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: /
PP P (i.e.County, etc.)ifJ4 'i? :
List all applicable well construction permits Stare,Variance, known 7d.Amount of disinfectant used:
Al/1/
r
3.Well use(check well use): '"t'�%. _ C.t�(3n
7e.Sealing materials used(check all that apply): "s'''l '--,
Water Supply Well: ID!!.. ..,�
0 Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chipd or'.P Il`s'•'.9 tr/-`,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.25 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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location:
WOODCOCK OIL COMPANY '
Facility/Owner Name Facility ID//(if applicable) 8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 l:--- -- %7 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, 1 hereby certij)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:
34e 78°31' 54.23" 09' 49.18" You may use the back of this page to provide additional well site details or well
NW 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 sante construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30.days of completion of well
6a.Well ID#: AMW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 20.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb. For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2•0 (in.) abandonment to the following:
6d.Water level below ground surface 1 5.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Infection 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.
6f.Inner casing/tubing length(if known): (ft.) ' • '
6g.Screen length(if known): (ft.)
i
f
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
1

WELL ABANDONMENT RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
i '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 7a.Number of wells being abando led: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For nmltiple injection or non-water' supply wells ONLY with the same
construction/abandonment,you can submit o t e form.
A - 4475
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'O (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: .
/
Company Name 7c.Type of disinfectant used: !'
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Stale,Variance,etc.)if known 7d.Amount of disinfectant used: 'IAA/ - - ":IJ .
s,
'/v i r, ' i,...
3.Well use(check well use): • Mi°Cr,', . Oft
Water Supply Well: 7e.Scaling materials used(check all that apply): '' '''j �_ c/��
CI Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Clifps;orl?ellefs,':., ;
❑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 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry • 0 Other(explain under 7g)
0Monitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 GALLONS
CI Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: - .
WOODCOCK OIL COMPANY
8.Certification:
Facility/Owner Name FacilitylDtl(ifapplicable) �, � -
700 EAST CHURCH STREET ATKINSON 28421 L`-�- --- 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, I hereby ceriify 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:
34o 78°31' 54.23" 09' 49.18" You may use the back of this page to provide additional well site details or well
NW 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 nor-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
Ga.Well ID# AMW-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 20.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
15.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
lOc.For Water Supply&Infection Wells: In addition to sending the font to
6e.Outer casing length(if known): (ft.) the addresses) 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): (ft.)
1
6g.Screen length(if known): (ft.)
I
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

1.
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1 '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER
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-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
A - 4475
7b.Approximate volume of waterremaining in well(s): 1'0
(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: J,414/ -
List all applicable well construction permits(i.e.County,Slate,Variance,etc.)if known t j
7d.Amount of disinfectant used:
3.Well use(check well use): ;�...• `J
7e.Sealing materials used(check all that apply):
Water Supply Well: ••'.1(,/
0 Agricultural 0 Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
0 Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: O Bentonite Slurry ❑ Other(explain under 7g)
2Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 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) OTracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: _
• WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID//(if applicable) $•Certification: .
700 EAST CHURCH STREET ATKINSON 28421 L-- - 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PEN DER 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.
Sb.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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
Attach well construction records)if available. For multiple injection or non-water supply
wells ONLY with the sane construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AMW-7 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 19.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface: 13.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
IOc.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.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Fonts GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 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;
CARL CARPENTER 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 man-traeri supply wells ONLY with the sonic
construction/abandonment,you can submit one form.
A - 4475 :'
1.0
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: %'-.
_
Company Name 7c.Type of disinfectant used: ,1i;_
2.Well Construction Permit#: J4/1/ ;,.",
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used: 1r• •^� `—.
3.Well use(check well use): -,
r�,. ,ten
7e.Sealingmaterials used(check all that apply): `'
Water Supply Well: PP Y) t• •-, •:- i r,.
ElAgricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or'Pellets L't•.?
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: RI Bentonite Slurry ❑ Other(explain under 7g)
IDMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.25 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) OTracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: .
WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 G .-��45' 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, I hereby cert(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 Iatllong is sufficient) 9.Site diagram or additional well details:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
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. 1Oa. For All Wells: Submit this form within 30 days of completion of well
Ga.We11ID# AMW-3R abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 19.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb. For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface: 15.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
IOc.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.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
iI
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
I
l

f
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
CARL CARPENTER 7a.Numberofwellsbeingabandoned� 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wafer I supply wells ONLY with the same
construction/abandonment,you can submitjone form.
A - 4475
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):. (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: s"t;
2.Well Construction Permit#: J
all/ r:`` •>
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known -I r
7d.Amount of disinfectant used: t...: _. /9 .7�
3.Well use(check well use): 7,y;. {
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout 0 Bentonite Chips or Pellets'"=% ''tt.t
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 71 Bentonite Slurry 0 Other(explain under 7g)
0Monitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 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) OTracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
El Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location: -
— - - - - 1 I - - -
WOODCOCK OIL COMPANY
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 C-:--� � 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
P E N D E R By signing this form, 1 hereby ceri Jj 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.
Sb.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:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the sane construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: M W-1 1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
17.5 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
•
10b.For Infection Wells: In addition to sending the form to the address in IOa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2.0 (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.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.
•
61.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
1

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
V
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER i. i
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-u'ate f supply wells ONLY with the same
construction/abandonment,you can submit one form.
A -4475
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: f-'
ti
Company Name 7c.Type of disinfectant used: t, ; ',-,
2.Well Construction Permit#: /a/� fT r
List all applicable well construction permits(i.e.County,State.Variance,etc.)if known 7d.Amount of disinfectant used: 4'
;. - / )'in
3.Well use(check well use): `Lv
Water Supply Well: 7e.Sealing materials used(check all that apply): C.'.:c`.`!.'
PPY _�-...7it .
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips br(Pellets `-t%.i
❑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 ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
EMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
— -- 5a.Well location:- - --- -—.-- - __ - _
-- - - - t i - - - - -
WOODCOCK OIL COMPANY
8.Certification:
Facility/Owner Name Facility ID#(if applicable) ��� j" ___
700 EAST CHURCH STREET ATKINSON 28421 Gf--' 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PEN DER 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34° 31' 54.23" 78° 09' 49.18" You may use the back of this page to 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
Attach well construction record(%)if available. For multiple injection or non-water supply
welir 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
Ga.Well ID#: M W-1 0 abandonment to the following:
•
Division of Water Quality,Information Processing Unit,
17.5 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: 2'0 (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
IOc. For Water Sunnly&Iniection'Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also subunit 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): (ft.)
•
1 i ,6g.Screen length(if known): (ft.)
I {
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
I
i ,
ii