Pender_Well Abandonment_20230113

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) ror multiple injection or non-water supply wells ONLY with the same
construction/abandonnhent,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:
2.Well Construction Permit#:
List all applicable well consstruction permits(i.e.County,State,Variance,etc.)tfknown
7d.Amount of disinfectant used: -
�_e r
t
3.Well use(check well use): ;;;,,_ ' 11023
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonife'ditpso`le& ts:�it ,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑ Sand.Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: O Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑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: 1 0/24/22
Sa.Well location:
WOODCOCK OIL COMPANY
Certification:
Facility/Owner Name Facility IDft(if applicable) 8.
700 EAST CHURCH STREET ATKINSON 28421 C-��G)� 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER By signing this form, /hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0f00 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:
340 31' 54.23" 780 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
Asach well construction record(.)if available. For multiple h jection or non-water supply
wells ONLY with the.same consn-mctioniabandoth»hen4 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,
Gb.Total well depth:
17.5 1617 Mail Service Center,Raleigh,NC 27699-1617
(ft.)
10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2'0 (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: (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunnly.& 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):
6g.Screen length(if known): (ft.)
I
Form G W-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-umler supply wells ONLY with the saute
construction/abandomnew,you can submit one form.
A - 4475
7b.Approximate volume of water remaining in wcll(s): 0'5_(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:_ •-
2.Well Construction Permit#:
l/� -S
List all applicable well construction permits t.e.County,State,Variatncc,etc.)ifknown JA/V • r•� "
pn P r Y �
7d.Amount of disinfectant used:• _.
J
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): !i 5
El Cement Grout ❑ Bentonite Chips or Pe let's
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 21 Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑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 El 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 I D#(if applicable) 8.Certification: .col �> _
700 EAST CHURCH STREET ATKINSON 28421
11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Dale
PENDER By signing this form, 1 hereby certify that the ivell(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 io the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34° 31' S4.23" 780 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 arailable. Far multiple hyuction or non-water supply
wells ONLY with the same covstruction/abandotnnte»!,you can submit one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-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 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:
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&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 or
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):
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-crater supply wells ONLY %slat 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:
2.Well Construction Permit#: JAIV
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 2n2 9
7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealingmaterials used(check all that apply): `"'° '' ' J t
Water Supply Well: PP Y) ".0-,�
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
El Monitoring ❑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
0 Aquifer Test ❑Stonnwater 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
8.Certification:
Facility/Owner Name Facility 1D#(if applicable) i•'
700 EAST CHURCH STREET ATKINSON 28421 C.- 7' 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 1SA 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 tat/long is sufficient) 9.Site diagram or additional well details:
34° 31' 54.23" N 78° 09' 49.18" 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(%)if available. For multiple injection or non-water supply
%yells ONLY with the same construction/abandonment,you can submit one Orin. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
MW-15 abandonment to the following:
Division of Water Quality,Information Processing Unit,
15.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
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
6c.Borehole diameter: (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&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
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-wafer 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: h;
Company Name 7c.Type of disinfectant used: `
• `%
2.Well Construction Permit#: 1U n jn
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known �,-�_. .} C 112)
7d.Amount of disinfectant used: �,.
3.Well use(check well use): r'
7e.Sealingmaterials used(check all that apply): • "•'",`•
Water Supply Well: PP Y)� .._�, �• t' =/
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
lMonitoring ❑Recovery
Injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.5 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 Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location:
WOODCOCK OIL COMPANY
8.Certification:
Facility/Owner Name Facility IDS(if applicable)
�>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 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" N 78° 09' 49.18" 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(%)if available. For multiple injection or non-water supply
wells.ONLY with the same construction/abandonment,you can submit one form. IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
MW-14 abandonment to the following:
Division of Water Quality,Information Processing Unit,
15.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth:' (ft.)
lOb. For injection Wells: In addition to sending the form to the address in I Oa
20 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 Sunni),& 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
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 frith 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: I •••
Company Name 7c.Type of disinfectant used:_ /n
2.Well Construction Permit#: Jq/V - I }�
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used:_ - 2°2 3
ln:• rL
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
O Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
RI Monitoring ❑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 ❑Stonnwater 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
8.Certification:
Facility/Owner Name Facility IDII(if applicable)700 EAST CHURCH STREET ATKINSON 28421 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER 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.
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-crater 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#: M W-12 abandonment to the following:
Division of Water Quality,Information Processing Unit,
15.0 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 IOa
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:
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
6c.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

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-hirer 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: w �-
Company Name ,7c.Type of disinfectant used:
2.Well Construction Permit 0: Jq 1 y 1 r )/�
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used:, .'h`' G(I2
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): `; "-1I_!P;l
❑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
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: O 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 Reinediation 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) 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
8.Certification:
Facility/Owner Name Facility ID#(if applicable) / -
700 EAST CHURCH STREET ATKINSON 28421 C- •�' 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor of Well Owner Date
FENDER By signing this form, 1 hereby certify that the we/l(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 INSTRUCTION S
Attach well construction record(%)if available. For multiple injection or not-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#: MW-13 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:
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&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.)
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.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 same
construction/abandonment,you can submit one form.
A - 4475 4.5
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
4,
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: J.
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used:_ rr'% . _ e 091
3.Well use(check well use):
7e.Sealing materials used(check all that apply):
Water Supply Well:
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ 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 ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ['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
❑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 _ 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PEN DER 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.
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° N 78° 09' 49.38" 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
Aaaclr well construction record(s)if available. For multiple injection or non-water supply
we/Ls 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#: 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 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
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
CARL CARPENTER 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For maniple injection or non-water supply wells ONLY trill, the same
construction/abandonment,you can submit one form.
A - 4475
7b.Approximate volume of water remaining in well(s): 5.0
(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: •
/n
tj
2.Well Construction Permit#: JAA i 1
List all applicable hell construction permits(i.e.County,State,Variance,'etc)if known 7d.Amount of disinfectant used: .r.'_. zn. �
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): ,Ls •-J i_fi:
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: RI Bentonite Slurry ❑ Other(explain under 7g)
El Monitoring ❑Recovery
Injection Well: 71.For each material selected above,provide amount of materials used:
El 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: 10/24/22
5a.Well location:
WOODCOCK OIL COMPANY
8.Certification:
Facility/Owner Name Facility ID#(if applicable) .�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 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' 54.21" N 78° 09' 49.18" 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)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. I Oa. 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,
50.0 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 l0a
20 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
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
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

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-Crater supply wells ONLY with the saute
construction/abandonment,you can submit 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:
2.Well Construction Permit#: n
List all applicable well construction permits(i.e.County,State,(Variance,etc.)if known J�i Al ~
7d.Amount of disinfectant used: 1
3.Well use(check well use): t`)
Water Supply Well: 7e.Scaling materials used(check all that apply): L t •
-.
❑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 0 Drill Cuttings
0 Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: P Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑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
❑Aqui ter 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 C` a 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER • By signing this form, I hereby cent fy 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 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#: M W-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 l0a
6c.Borehole diameter: 2'0 (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: 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.)
Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Match 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 the same
construction/abandonment,you can submit 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: r.
1
Company Name 7c.Type of disinfectant used:_ '�-:'
2.Well Construction Permit#: �/v
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used: g
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): N' ' ,.v' •: r!',l
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water.Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: RI Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑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
ID 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: j] ;
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, 1 hereby certify that the well(s)was (were) abandoned ut
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)iif available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one Jorm. 1Oa. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: MW-9 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 20.0 (it,) 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:
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& 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

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 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:_ :'
2.Well Construction Permit#: - -
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known IA ill 7d.Amount of disinfectant used: J' r
3.Well use(check well use): 'n:;: ,';:;.,.. c((,5
'Water Supply Well:
7e.Sealing materials used(check all that apply): ''-':-'--_
, : .-'' •'�� -.
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ❑ Bentonitetliips ot.Pel(ets', Li...;,
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial DResidential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
0 Monitoring ❑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 ❑Stonnwater 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
❑Geothennal(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 MI/(if applicable) 8.Certification: `> .e_ ' -
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 certf that the tine//(s) spas (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/tong 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
trel/s 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-5 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 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
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
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 same
construction/abandonment,you can submit 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:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used: Jq 111 -
3.Well use(check well use): ' i J;; 4( •,5t
Water Supply Well: 7e.Sealing materials used(check all that apply): . '}/•
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips br',Pellet$ %r„`
❑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: 0 Bentonite Slurry ❑ Other(explain under 7g)
0Monitoring ❑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 IDO(if applicable) 8.Certification:
700 EAST CHURCH STREET ATKINSON 28421 C-�� "7` 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PEN DER By signing this form, /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'veil construction record(s)if available. For multiple injection or non-[rater supply
wells 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
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
10b. 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:
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.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Match 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 hells 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
P Y 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known
7d.Amount of disinfectant used:_ /L),)t -
•
i n
3.Well use(check well use): '%%:`. - 2020
7e.Sealing materials used(check all that apply): .. n�J
Water Supply Well: • 1� -
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Re1,lefs`... ,
❑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: RI Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7E 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) DOther(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)
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 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 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#: 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 I0a
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.)
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 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 submit 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:
.r Company Name 7c.Type of disinfectant used:_ s
2.Well Construction Permit#: J44 "
List all applicable well construction permits(i.e.County,Stale,Variance,etc.)if known r.
7d.Amount of disinfectant used: ! 1
c 7
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
PMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquiter 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 he 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 lD#(if applicable)
�7 700 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 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/tong is sufficient) 9.Site diagram or additional well details:
34° 31' 54.23" N 78° 09' 49.18" 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)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#: 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 Injection Wells: In addition to sending the form to the address in IOa
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:
13.0 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.)
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 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 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:
2.Well Construction Permit#: /
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 1 f'
7d.Amount of disinfectant used:
cli,7
3.Well use(check well use):
7e.Sealingmaterials used(check all that apply): `' ;-
Water Supply Well: PP Y) Q.
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry 0 Other(explain under 7g)
OMonitoring ❑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 ❑Stonnwater 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
8.Certification:
Facility/Owner Name Facility ID#(if applicable) ��
700 EAST CHURCH STREET ATKINSON 28421 G`�G7 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 we/l(s)was (here) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0/00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
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
6a.Well ID#: AMW-3 R abandonment to the following:
Division of Water Quality,Information Processing Unit,
19.0 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 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: 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.)
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 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: •
2.Well Construction Permit#: +/,4l
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used !.-..- V
3.Well use(check well use):
7e.Sealingmaterials used(check all that apply): `
Water Supply Well: PP Y)� `°
['Agricultural ❑Municipal/Public ❑ Neat Cement Grout El Bentonite Chips or Pellets''''-
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout Cl Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
['Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 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 3.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage['Experimental Technology 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
8.Certification:
Facility/Owner Name Facility TIN(if applicable)
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 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 record(s)if available. For multiple injection or non-crater supply
wells ONLY with the same construction/abandonment,you con submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-11 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 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:
Division of Water Quality,Underground Injection Control Program,
Gd.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.) •
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 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 some
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:
2.Well Construction Permit#: 1,4.1/1i _
List all applicable well construction permits(i.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used: V
(�/�
3.Well use(check well use): v
Water Supply Well: 7e.Sealing materials used(check all that apply): t-'
❑Agricultural ❑Municipal/Public
❑Neat Cement Grout ❑ 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 0 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 ❑Groundwater Remediation 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: - - _
WOODCOCK OIL COMPANY
8.Certification:
Facility/Owner Name Facility ID#(if applicable)
700 EAST CHURCH STREET ATKINSON 28421 C`� I'w 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
FENDER By signing this form, 1 hereby cerafy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
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 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-10 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
IOb. 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
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 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