Johnston_Well Abandonment_20240301

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WELL ABANDONMENT RECORD
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. For Internal 1.1sd ONLY:.
Thii'formean lie wed for-Single:arm/04k wells • \
1,Weil Ca tractor Iniforntation: . WELL ABANDONMENT DETAILS!
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Brian Ewing . .. . - 7a.Number Of wills being abandencd: P
' worenainaiiitainie or waf,;:,,,,.=ix...:',.sdn'auje„ ing,ttell iin kkr•procry) Far multiple titieetttur, ar 110111ii:dteri uppy 'Welts 'ONLY wish the .Mlle
cotntrucanniithandonmait,put ean submitime.ltirin.
4240-B
71t.AppmrsIntate volume utsiaity'ritnaining in bell(s):
DC Vlrell Contrdclor Ceti ikitiolt Ninnbei
FOR WNIERSTirP1.V WULT.S.019X: ,
SAEDACCO - .
Camay Name' • 7e.TYpe Of disinfectant used!
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2.Well Constnictiou Pernik 0:E , W10501129 1 .
' list 41 vpplkoble wet I pmrits iie-Cuarice,.5'1ieil,d'arleux:e.litlectiolke.t6.}!Atom : ' . .
'At;AtliOttnt of tilsinfeetant'used: ,'
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3.Well use(dtericitell me):
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Water Supply Well: 7e.Sealing materials:used(cheekall that apply);
13Agricultittal 13Munklpal/Publio; 0 Neat Cenient Gtont 121 Ber400ite Chips of Pellets,.
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130cothermal(tleating'CoolingSuppty)' OResiticntial Water Simply(iiinglc) CI Safild:fth,1 Grout , El Dry Clay •
. 0 InthistrialiCommdcial • ; 1311 -itlential Water Supply(shared) 0..Concrete..GleuT '- El Dtillfgatings .
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_Obrigation - • ° . 0 SpecialtyOrout , U Gavel
Non-Water Supply Well:• 0:Bentonite•Slutiy • U Other(explain under 7g)
0Monitoring. 1:Recovery . .
'Injection Welt; • 7f.For each Material sclottetaboye,'provide amount of Materials used:
0Aquifcryreharge: • ' Olcrentiuktater Rinkiiiinion
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rj4glilier MPPOaild.P*0%*. 13Saliniti Barrier
- • • . . Bentonite.:501b ,Etr:gal.
• ._ 0Aiptifer Test CISIciimnaterDiabiagd . °
13twetintetital1IvIntotogr 13Subsideme!. ottitn1 -71ittrride a brief dtscription of the'aliandan;;-...,pregedurtl„,..:; ,, ,,,
OGeolliennatra l(Closed Loop) . Ocers . I' N L V i Lfi t:D•
BENTONITE HYDRAULICLY PUSHED
liGeothennai(Heating/Cooling Return) ElOther(explainuntier 7n) . .
MAR 0 1 2024
4.-Datc isell(sTabandoned: 1-19-24
i' Infor:r..1..1.ir•°1 Prt".",suz:,..4m3 1.):4.-.
5a.Well location: • , DVit'CulOG
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Pantry.#176 • ' ;
Facilityieivoir Nairn • Facility log(ifapOlkable) . 8.Certilka1ion: .. .
208 Main St. Clayton, NC 27520 ' B ria n. Eikting• :, ; 1/24/2024
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-PhysicalAddrdss,City,and Zip 4intellutir:of Ceitifiad Wellnli
Con:gni r u'.:1100ukr Moe
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Johnston fly sIgithig flit s firm,I hereby certii;atat the well(.r)1147S(we)abandoned-In
Comity . . Parcel idaitifi;iitlanNo.(PIN • 'accorded:re oil&ISA ArAe.62e.010.or 2C..0200 Welfaristiliction Skinitary4
mid that a copy of irris fraIrd ita•be0,provided tolhe well owner;
56.liattitudennd longitude in degrecOmioutestseihnds or decimalrdegreem 1; I
(trit.011 nerd,one latilong issitffiric11) 9..Site diagram or additional well details:
. . You.tuak.use the bad:of this page to Provide additional cell site details or well
: , • N . W .abandoinitent details..You may alio ittaelt additional.pages if neeessaty. . .
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cx)NsTitircriON DETAILS OF WE1LLCS)BEINO ABANDONED 151.IIIMITT. AL INSTRUCT TONS
Attach 1.iriteprivr4fleiri ft..i.urde's)if avollefite. Far multiple iMeitlim.or tfriTiFittpr sopply
wellaMl.i.with the.5anie cohstrottionibtiothrtiment.Jou.CIII2 Ofhltill:ClifNfilhi?, Via: For-All Wells: Submit 4his form within 30 days of completion of uicil
6„,,wil iriikxp-3. — xp—.3.7 (odd # Borings) ; . abandountent to the follouina;
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• • Division of WatcrResaurem.,Infornudion;Processing Unit,
6b Totalmell depth
26.25 1617 Mail Set-vice Center,Raleigh',NC 27659-1617
. : (ft.) .. .
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TOIL For•Tn ledlon Wells: In addition to sending the form10 the address In lila
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6e.Borehole dLimeter;2.25 - (111.) . •abore.also'submit one copy of this:form within 30 di of completion of well
abandonntent tn the following:. 11 '
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. ' 'Division of Witter RisourimUttderground Injection contrni Program.
6d.Water level below ground surfacei • (ft.) 1636 Mail Service Cc it Raleigh,NC-27699-1636
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18c.For Water Sunnis'&In lectiMi Wells; In addition to-sending the form to
6e.Outer easing Icn0h(if kmatia): • (t.) the address(es) abo%e.•also submi1l'..one copy of;this form Uithiti 36'days of
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compidiati-of well abandonment to 11'e-county health department of the county .
• where bkaidoned,- .
61.Inner easingitubing length(if known): - (ft.)
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6g.Screen-length(If knoun); , (ht.)
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Pena GMT-0 Nonli Carolina likpaiurrut of Endrouracnt and Natural itcsoinces-Clivision of Water Resources -Revised Angus:2013.
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WELL ABANDONMENT RECORD For internallisd ONLY;
110S foim can lie used for iii,gle or multi&was.
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1.Well Cinitractor InformatiOn:' ‘yILL ABANDONMENT DETAIL'
Brian Ewing 7u.Number Of wills being abandoned: 8 •
Welt Cpuiraet9r Nome(or well ear.t.0 krsOn4ly aitUnianiug ucil an histtici priticro) For undople Infernal or O ismirtioterl ,Supp.1). wells- ONLY with lklit' some linsuctioniabondolonent;pm nut mibuntua e jSmn,
4240-B ff, 1
74,Alipte*haate vulpine of liar&rintuining in ivril(s)t • - (PO
EC Well Contractor C9n Ititioii Tlinnber
•SAEDACCO FOR WAITRSOPPLYWEll,S ONf.Y:
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Company tialuc . •
7 .Type Ofdisinfectant.theta: .
I Well Construction Permit It:, , W10501129
Lin gfi filippotyleiiwt/pe.rardis ei.e.C.Egintv,pail,.Varionie,kirethato,.,e4,if finiolt:
7*Anititint of disinfeetant-tiseth •
3.W,eil usi(citeelpvell nse): I. '..
- - •Water Supply Well: 76,8calitig iitiiOtin :usoti(check all tint apply);
ofticultural • lOiltinieipal/Publie, -- 0 Ncat Cement Grout 'i. 01 Bentonite Chips orPelIcts.
OC:cothcmial Mead neCooling Supply)' : Oltesidential Water-Simply(single) 0 Sand Grout IJ Dry Clay
0 ludostrialiCommercial OlicSidential Water Stipply(siiiircd). Et Clinetete:drout , -0 Drill Cuttings
0 litigation - , 0 Siiecialw Grout. - El Crawl
Non-Water Supply Watt '. 0 Bentonite Slimy . ." . 0 Other(explain under 7g)
0Mo:diming... 011ecovety . . ..
Injection Well; . . • 7f.For-loath material selettettabove,•provide antountof.liniterials tiled:
. - OAquifer Recharge: CIGniundwater Rentedianon • .
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dAtinderSOiligeMidOklivesY Ogalinity Barrier •.
Bentohite.:501b ,Wtr:gal. !;
EtAlprifet Test fiStonnwater.Dralage
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Otxperintentalli:chnotogy. 13SubsidetreConnul 7g,Provides hriefllescriptionnf the aharidimment procedure:
riCteelketin4i(Closed Loop) ElTracer . 1
BENTONITE HYDRAULICLY PUSHED • .
OGeethennai(Hotino/Cooling Return)- 'NOther(explain under 7.10
r--_. ..,---,;7 .,1 17"7•'-il
ii, !••••4
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4.Dare inks)'abandoned: 1-19-24
MAR 4. I 2024
• Sa:WilltueadOn: •
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Pantry #176 • • - ' . ; ittrOtir.atit".Ft iJr l/
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8.Certittentioin
I. WICV30(3
• FactlitilChillarTkutte FacilitylD0(irepOScAle) . . .. ,. , - - .
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208 Main St.. Clayton, NC 27520 Brian. Ewing': ' 1/24/2024
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PInsicatAddic'ss..City..airid Zip . - • : Siam*:or Centered Wen ContrOctiu*vs1:4.110w*r Date
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Johnston . • By signing ilos fin70,1 hereby certik that the well(s)was(were)abandoned In
Candy . '. ' Parcel TictuirOdult No(PIN) occoillance iiiith 15.4 AVAd 02d.010:i?r;C".0200 Welt neptistructian tarularels
and that a cop;Of this record hat beeiAPIIIVidedtpthe well Owner;
56.:Jpititude and longitude in degreestatinittesf.secondsor d&knot liegtves: . .
itrWeil(ield,on latiloug'is, 111t1)• 9.Site diagram or addition:tin:ell details:
You may.use the back of thii.page to provide additional Av011 site details or well
- N . - W abandonment details..You ivamay also'Attach iulditional.pages if necess-aty.
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CONSTRitCrioN DETAIL OR NvEtusi BEING ABANDONED sunmITTAt.INSTRUCTIONS
,tifarde t(ell Onanklivin rauriiN,if dwilable. For multiple m(iemien.or iini7tarlr„supply
wells ONO with the 4tone tratstreellotraindati aura Jou min sant:Rote lona. 10a;'Fin-All Writs:. Submit.this faint within 30 days'of reouipletion of well
6aAsien ThilIP-1 - IP-17 (Even # Borings) :0)-04c.insitcal ip the folloWing:
• Di Ion of Water Resources,Informotion•Progis.sing Unit,-
6h Total well dpth: 25 5 (64 .1611 Mail Serviceeeriter,Raleigh,NC 276991,61.7
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lib.Forinlertion Wtlls: In additiOn to sending the fount°the addiesi in Oa
above.also Submit one copy of this,form within-30'daYs of completion of Well
Ge.Borehole diameter:2,25 - CII.) til*icitutecnt to the radon:log; 1.
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Division Of Water R u estiurees, nderground injeetioncontrbt.Pnigram,
Gil.Water tevelberoir-ground surface:. . (ft.) • /636 Mail Service Ccnicr,Raleigh,NO7699-1636
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10c.FirWiter-Stirinly 4:In tertinn Wells: In addition to sending the form to
6e;Outer easing tength(if tolown): (ft.) the,address(es)abolte. also submill,One copy of this form within 30 days of
completion-of well abandonment to tire county health&pertinent of the county
where Atemdpiscd. I :
(If.Inner cluing/tubing length(if known): - (FL)
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6g.Screen-length(if known): (ft.) '
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Form GW-30 TIonh Carolha Depanrocre of Envinnuncre and Nuturat Ecsounes-Division of Wateritesources -Revised August 2013

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 7a.For Geoprobe/DPT or Closed-Limp Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water 4niaining in well(s): 0 (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name 7e Type of disinfectant used: Chlorox pool shock
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 2 oz
3.Well use(check well use): '
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I, 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout i. ' C Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
®Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
[Aquifer Recharge ❑Groundwater Remediation Clay Placed From 8'to 1'Below Land Surface Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier f
Concrete Cap Placed from 1'BLS to Land Surface Poured in top of well
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control I.
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Trace' 2 oz of chlorox pool shock poured in well followed by filling
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1
Bentonite Clay Filled From 8' BLS To
4.Date well(s)abandoned: 2-2-24 1' BLS. Concrete Filled From 1' BLS
5a.Well location: To Land S u rface ti' L i'fir tZ j(J
McLambs LP Gas s na MAR 0 A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1 2024
3469 NC 242 South Benson 27504 h,for"rsti!e t Prc, g u, 2-6-24
1194;Physical Address,City,and Zip Signature of Certified Well Contractor or ch 1d"wncr Date
Johnston 154700-33-3574
By signing this form, I hereby cart)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: k
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35 19' 33.88" N -78 31' 1 1.88" �, 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
M W-9Aabandonmentthefollowing:
6a.Well 1D#: to
l
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 8 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in-10a
6c.Borehole diameter: 6 (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: { 1
6d.Water level below ground surface: 3 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): N/A (ft) 10c.For Water Supply&Iniection:Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county'health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned.
N/A
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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'WELL ABANDONMENT RECORD For Internal Use ONLY:
is
I
1.Well Contract�orr7Information: WELL ABANDONMENT DETAILS
ThomaWill
s il l 7a.For Geoprobe/DPT or Closed-L000p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned: 1 1
I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLSL+ONLY: •
Company Name 7c.Type of disinfectant used: Chlorox pool shock
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 2 oz
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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout II 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)
!Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Clay Placed From 10'to 1'Below Land Surface Poured in top of well
❑Aquifer Storage and Recovery 0 Salinity Barrier
Concrete Cap Placed from 1'BLS to Land Surface Poured in top of well
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ,.
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer 2 oz of chlorox pool shock poured in well followed by filling
❑Geothermal(Heating/Cooling Retum) DOther(explain under 7g)
Bentonite Clay Filled From 10' BLS To
4.Date well(s)abandoned: 2-2-24 1' BLS. Concrete Filled From 1' BLS
5a.Well location: To Land Surface _J r�,,, ��
McLambs LP Gas na .�`ice.. i V CO
Facility/Owner Name Facility ID#(if applicable) S.Certifica' •
3469 NC 242 South Benson 27504 MAR 20242-6-24
Physical Address,City,and Zip Signaturro Certified Well ContractortVOL ,elF0(V ifbd cPrr..; ,;;;
Johnston ciln65-3 -.3 7 1 DWQ;3OG
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 1at/long is sufficient) 9.Site diagram or additional well details:
35 19' 33.88 N -78 31'
11.8811 W You may use the back of this page,to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supplywells
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 8A abandonment to the following:
• Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
106.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I 1
6d.Water level below ground surface: 3 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ci nter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i '
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAII!S
Thomas Will 7a.For Geoprobe/DPT or Closed-Lloop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):0 (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name ChloroX pool shock
7c.Type of disinfectant used:
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if/mown
7d.Amount of disinfectant used: ? oz
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
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout IR Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout I 0 Gravel
Non-Water Supply Well: - 0 Bentonite Slurry 0 Other(explain under 7g)
IJMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Clay Placed From 33'to 1'Below Land Surface'ce' Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier t
Concrete Cap Placed from 1'BLS to Land Surface Poured in top of well
❑Aquifer Test ❑Stormwater Drainage I,
❑Experimental Technology ❑Subsidence Control i '
7g.Provide a brief description of the'abandonment procedure:
❑Geothermal(Closed Loop) OTracer 2 oz of chlorox pool shock poured in well followed by filling
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Bentonite Clay Filled From 33' BLS To
4.Date well(s)abandoned: 2-2-24 1' BLS. Concrete Filled From 1' BLS
5a.Welllocation: To Land Surface '
McLambs LP Gas na _ "" . ► ;-
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3469 NC 242 South Benson 27504 I MAN 0 1 20242-6-24
i.
Physical Address,City,and Zip Signature of Certified Well Contractor a lJiUw(ivr� .7rr, Ila
bmit
Johnston 154700-33-3574 ;' g' '�` 'gip,- ' `
By signing this form, I hereby cerl that the x'2�li?seas(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: 1
(if well field,one lat/long is sufficient) I '
t� 9.Site diagram or additional well details:
35 19' 33.88"
N -78 31' 11.88 W You may use the back of this pageto 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
lVl W-6
6a.Well 1D#: abandonment to the following: ,
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 33 (ft.)
1013.For Injection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: f
4
6d.Water level below ground surface: 3 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 7a.For Geoprobe/DPT or Closed-IJoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned:
[ I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0
m (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorox pool shock -
7c.Type of disinfectant used:
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if;mown
7d.Amount of disinfectant used: ? oz
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipalPublic 0 Neat Cement Grout I; 0 Bentonite Chips or Pellets
1.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout i. S Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑Groundwater Remediation Clay Placed From 15'to 1'Below Land Surface Poured in top of well
DAquifer Storage and Recovery ❑Salinity Barrier I.
Concrete Cap Placed from 1'BLS to Land Surface Poured in top of well
DAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer 2 oz of chlorox pool shock poured in well followed by filling
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) i,
Bentonite Clay Fille:d From 15' BLS To
4.Date well(s)abandoned: 2-2-24 1' BLS. Concrete Filled From 1' BLS
5a.Well location: To Land S Surface —e ;• ��,/FZ D
McLambs LP Gas na
Facility/Owner Name Facility DM(if applicable) 8.Certification: ;MAN 0 1 2074
3469 NC 242 South Benson 27504 2-6-24
mforp-a:ie n Prn, ,ytg 4;vg
Physical Address,City,and Zip Signature of Certified Well Contractor or Well-AM-BOG G Date
Johnston 154700-33-3574
By signing this form,I hereby certO that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well(details:
35 19' 33.88" N -78 31' 11.88" 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
NIW-5
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• lOb.For Injection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter: 6 (�,) above,also submit one copy of this font within 30 days of completion of well
abandonment to the following: I 1
6d.Water level below ground surface: 3 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft,) 10c.For Water Sunnlv&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the cotinty health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS{
Thomas Will 7a.For Geoprobe/DPT or Closed-Lo p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW40 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned: 1 1
NC Well Contractor Certification Number 7b.Approximate volume of water Iernaining in well(s): 0 (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Cllorox pool shock
7c.Type of disinfectant used:
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)((known
7d.Amount of disinfectant used: 2 oz
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout j, 0 Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout II Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout b 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
IJMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Clay Placed From 20'to 1'Below Land Surface Poured in top of well
DAquifer Storage and Recovery 0 Salinity Barrier j,
Concrete Cap Placed from 1'BLS to Land Surface Poured in topof well
❑Aquifer Test ❑Stormwater Drainage I' .
❑Experimental Technology ❑Subsidence Control I:
7g.Provide a brief description of the abandonment procedure:
• ❑Geothermal(Closed Loop) ❑Tracer 2 oz of chlorox pool shock poured in well followed by filling
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Bentonite Clay Filled From 20' BLS To
4.Date well(s)abandoned: 2-2-24 1' BLS. Concrete Filled From 1' BLS
5a.Well location: To Land Surface -_ ,, t
<-i pc--7-1
McLambs LP Gas na p7.`- .i LZ;. V b 1 ,
Facility/Owner Name Facility ID#(if applicable) 8.Certification: i:MAR 0 1 2024
3469 NC 242 South Benson 27504I _ 2-6-24
Physical Address,City,and Zip Signature of Certified Well Contmdtdi oi;Mr-'�,'� .., ... '1fa[e
Johnston 154700-33-3574 30G
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 beenlprovided 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 I details: •
35 19' 33.88" N -78 31' 11.88" W You may use the back of this page ito.provide additional well site details or well
abandonment details. You may also'attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
IVIW-4
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service C nter,Raleigh,NC 27699-1617
6b.Total well depth: 20 (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter 6 On.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
3
l
6d.Water level below ground surface: (R) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): N/A (ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 7a.For Geoprobe/DPT or Closed-logp Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned:
II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorox pool shock
7c.Type of disinfectant used:
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: , oz
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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout I ; NI 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)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Clay Placed From 20'to 1'Below Land Surface Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete Cap Placed from 1'BLS to Land Surface Poured in top of well
❑Aquifer Test ❑Stormwater Drainage 1,
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the,abandonment procedure:
❑Geothermal(Closed Loop) OTracer 2 oz of chlorox pool shock poured in well followed by filling
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Bentonite Clay Filled From 20' BLS To
4.Date well(s)abandoned: 2-2-24 1' BLS. Concrete Filled From 1' BLS
5a.Well location: To Land Surface rr- ---t,.. �.,.�')
McLambs LP Gas na
Facility/Owner Name Facility ID#(if applicable) 8.Certification: .' MAN0 1 2024
3469 NC 242 South Benson 27504 I ?- -24
lnforir ;ic n?rr,; :.
Physical Address,City,and Zip Signature of Certified Well Contractor or:Well `ea'MOG Date
Johnston 154700-33-3574
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 b'enI provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
�� 9.Site diagram or additional well details:
35 19' 33.88"
N -78 31' 11.88 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
IVI W-3
6a.Well ID#: abandonment to the following:
I,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: j
6d Water level below ground surface: 3 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Clenter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I i

i I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 7a.For Geoprobe/DPT or Closed-lI o I p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW- 0 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water I eritaining in well(s): 0 (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorox pool shock
7c.Type of disinfectant used:
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: 2 oz
• 3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout i ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 1; II Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 1, 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
®Monitoring ❑Recovery '
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Clay Placed From 20'to 1'Below Land Surface Poured in top of well
r
['Aquifer Storage and Recovery 0 Salinity Barrier
Concrete Cap Placed from 1'BLS to Land Surface Poured in topof well
❑Aquifer Test ❑Stormwater Drainage I;
❑Experimental Technology ❑Subsidence Control !
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 2 oz of chiorox pool shock poured in well followed by filling
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Bentonite Clay Filled From 20' BLS To
4.Date well(s)abandoned: 2-2-24 1' BLS. Concrete Filled From 1' BLS
5a.Well location: To Land Surface
[[ ' - ' V`=L'
McLambs LP Gas na
;i lam.to L..i V R�L!'
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3469 NC 242 South Benson 27504 MAR 0 1 2024 2-6-24
Physical Address,City,and Zip t,C:X1,dy.", �y,�
Signature Well]IConhacfgj(Q�ttllrO�rlci'���� �t7dil"
Johnston • 154700-33-3574. i DkIJOIDOG
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 11suf6cient) 9.Site diagram or additional well Idel ails:
35 19 33.88 N -78 31' 11.88" 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
M W-2
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 3 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Sunnily&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): N/A (ft) abandoned.
6g.Screen length(if known): /A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW'30 is needed. Indicate TOTAL NUMBER of
2700b
wells abandoned: III
NC Well Contractor Certification Number 7b.Approximate volume of water+remaining in well(s): 0 (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS;ONLY:
Company Name Chlorox pool shock
7c.Type of disinfectant used:
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.)if known 2 oz
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout i 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout e Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout j; 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑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 Clay Placed From 20'to 1'Below Land Surface Poured in top of well
❑Aquifer Storage and Recovery El Salinity Barrier 1
Concrete Cap Placed from 1'BLS to Land Surface Poured in topof well
❑Aquifer Test ❑Stormwater Drainage r
❑Experimental Technology ❑Subsidence Control f
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 2 oz of chlorox pool shock'poured in well followed by filling
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) b
Bentonite Clay Filled From 20' BLS To
4.Date well(s)abandoned: 2-2-24 1' BLS. Concrete Filled From 1' BLS
5a.Well location: To Land Surface [7. 7 C a r';! D
McLambs LP Gas naII
Facility/Owner Name Facility ID#(if applicable) 8.Certification: MAN 0 1 207A
3469 NC 242 South Benson 27504 L`t
Physical Address,City,and Zip irlfar rnatic^.n Q/ A*sk;3 to
6-24
Signature of Certified Well Contractor oi,Well Ostr coot Date
Johnston 154700-33-3574 I.
By signing this form, I hereby ceifi,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 9.Site diagram or additional wellIde'tails:
35 19 33.88 N -78 31' 11.88"
W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construcron/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: WW1 abandonment to the following: r
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6
6d.Water level below ground surface: 3 (ft.) Division of Water Resources,Underground Injection Control Program,
1636Su Mail Sery ingice Center,Raleigh, 636
I.
6e.Outer casing length(if known): N/A (ft.) lOc.For Water pply&Iniection Wells: In additionNC to27699-1 send the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where '
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned. j
1
6g.Screen length(if known): N/A (ft.) i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016