WI0501123_GW-1, GW-30, and drilling log_20240516

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10501123
Were any wells abandoned during this injection
1. Permit Information event?
x❑ Yes ❑ No
Geological Resources,Inc.
Permittee If yes,please provide the following information:
J Mart Number of Monitoring Wells
Facility Name
Number of Injection Wells 19
5654 NC Highway 87 S,Sanford,Lee County
Facility Address(include County) Please include a copy of the GW-30 for each well
abandoned
2. Injection Contractor Information
4. Injectant Information
DeepEarth Technologies,Inc.
Injection Contractor/Company Name Coolox®
Injectant(s) Type (can use separate additional sheets
Street Address 12635 South Kroll Drive if necessary
Alsip IL 60803 Concentration
City State Zip Code
If the injectant is diluted please indicate the source
70( 8 ) 396-0100 dilution fluid.
Area code—Phone number
Total Volume Injected(gal) 2,486
3. Well Information
Volume Injected per well (gal) 130.84
Number of wells used for injection 19
5. Injection History
Well IDs IP-1 through IP-19
Injection date(s) 04/16/2024
Were any new wells installed during this injection
event? Injection number(e.g. 3 of 5) 1 of 1
X1 Yes ❑ No
Is this the last injection at this site?
If yes,please provide the following information: ❑ Yes ❑ No
Number of Monitoring Wells
I DO HEREBY CERTIFY THAT ALL THE
Number of Injection Wells 19 INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
Type of Well Installed(Check applicable type): INJECTION WAS PERFORMED WITHIN THE
❑ Bored ❑ Drilled ❑x Direct-Push STANDARDS LAID OUT IN THE PERMIT.
❑ Hand-Augured ❑ Other(specify) G�s� /%�1 05/16/2024
SIGNATURE OF INJECTION CONTRACTOR DATE
Please include a copy of the GW-1 form for each
well installed. William Regenthal,P.G.
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection. Form UIC-IER
Attn:UIC Program, 1636 Mail Service Center,Raleigh,NC 27699-1636,Phone No.919-807-6464 Rev.3-1-2016

40
Geological Resources,Inc.
SITE INFORMATION
Site Name: J Mart Date: 04/17/2024
Project Number: 4238 Log Completed By: L.Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. Drill Type: Direct Push
Driller: Matt Steele License Number: 4548
BORING INFORMATION
Boring ID: IP-1 thru IP-8 Depth (ft):40
Diameter: 1.5" OD Completion Details:Abandoned with native soil
Depth (ft) PID Lab Lithology
From To (ppm) Sample Description Color Moisture Odor
0 0.5 Asphalt
0.5 5 Silty clay red/brown
5 40 DPT;no recovery
i
Photo 1: Preclearing Photo 2: Completion

40
Geological Resources, Inc.
SITE INFORMATION
Site Name:J Mart Date: 04/17/2024
Project Number:4238 Log Completed By: L.Weathersby
DRILLING INFORMATION
Company:Geological Resources, Inc. Drill Type: Direct Push
Driller: Matt Steele License Number: 4548
WELL CONSTRUCTION INFORMATION
Boring ID: IP-1 thru IP-8 Top of Casing:
Diameter: 1.5" OD Depth to Water(ft):
Sand Outer Casing
From (ft) I To (ft) From (ft) To (ft) Diameter (in)
N/A 40
Bentonite Inner Casing
From (ft) To (ft) From (ft) To (ft) Diameter (in)
N/A N/A N/A
Grout Screen
From (ft) To (ft) From (ft) To (ft) Diameter (in)
N/A N/A 40
DIAGRAM - MONITORING WELL
Grout
Casing
Bentonite
N/A
N/A
Sand
Screen
40 40

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft' 40 ft.
4548
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. rt. ft. in.
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft' N/A ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public N/A ft' 40 ft• in. in.
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) f. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation N/A ft.
Non-Water Supply Well:
ft-
❑Monitoring ❑Recovery rt N/A
Injection Well:
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier N/A rt. 40 rt.
❑Aquifer Test ❑StormwaterDrainage rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed LOOP) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 It- 0.5 ft. Asphalt
4.Date Well(s)Completed: Well ID#
04/17/2024 IP-1 thru IP-8 0•5 It- 5 ft. Silty clay
5 ft- 40 ft. DPT; no recovery
5a.Well Location:
J Mart 00-0-0000024866
Facility/Owner Name Facility ID#(if applicable) rt ft.
5654 NC Highway 87 South, Sanford, NC
Physical Address,City,and Zip
21.REMARKS
Lee 9660-5343-3200
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ZL.Cer�'is
(if well field,one lat/long is sufficient)
35.407950 N 79.115805 W 04/17/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 8 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:40 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Direct Push 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

40
Geological Resources,Inc.
SITE INFORMATION
Site Name: J Mart Date: 04/18/2024
Project Number: 4238 Log Completed By: L.Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. Drill Type: Direct Push
Driller: Matt Steele License Number: 4548
BORING INFORMATION
Boring ID: IP-9 thru IP-16 Depth (ft):40
Diameter: 1.5" OD Completion Details:Abandoned with native soil
Depth (ft) PID Lab Lithology
From To (ppm) Sample Description Color Moisture Odor
0 0.5 Asphalt
0.5 5 Silty clay red/brown
5 40 DPT;no recovery
i
Photo 1: Preclearing Photo 2: Completion

40
Geological Resources, Inc.
SITE INFORMATION
Site Name:J Mart Date: 04/18/2024
Project Number:4238 Log Completed By: L.Weathersby
DRILLING INFORMATION
Company:Geological Resources, Inc. Drill Type: Direct Push
Driller: Matt Steele License Number: 4548
WELL CONSTRUCTION INFORMATION
Boring ID: IP-9 thru IP-16 Top of Casing:
Diameter: 1.5" OD Depth to Water(ft):
Sand Outer Casing
From (ft) I To (ft) From (ft) To (ft) Diameter (in)
N/A 40
Bentonite Inner Casing
From (ft) To (ft) From (ft) To (ft) Diameter (in)
N/A N/A N/A
Grout Screen
From (ft) To (ft) From (ft) To (ft) Diameter (in)
N/A N/A 40
DIAGRAM - MONITORING WELL
Grout
Casing
Bentonite
N/A
N/A
Sand
Screen
40 40

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft' 40 ft.
4548
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. rt. ft. in.
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft' N/A ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public N/A ft' 40 ft• in. in.
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) f. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation N/A ft.
Non-Water Supply Well:
ft-
❑Monitoring ❑Recovery rt N/A
Injection Well:
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier N/A rt. 40 rt.
❑Aquifer Test ❑StormwaterDrainage rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed LOOP) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 It- 0.5 ft. Asphalt
4.Date Well(s)Completed: Well ID#
04/18/2024 IP-9 thru IP-16 0•5 It- 5 ft. Silty clay
5 ft- 40 ft. DPT; no recovery
5a.Well Location:
J Mart 00-0-0000024866
Facility/Owner Name Facility ID#(if applicable) rt ft.
5654 NC Highway 87 South, Sanford, NC
Physical Address,City,and Zip
21.REMARKS
Lee 9660-5343-3200
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certifi tool
(if well field,one lat/long is sufficient)
35.407950 N 79.115805 W 04/18/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 8 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:40 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Direct Push 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

40
Geological Resources,Inc.
SITE INFORMATION
Site Name: J Mart Date: 04/18/2024
Project Number: 4238 Log Completed By: L.Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. Drill Type: Direct Push
Driller: Matt Steele License Number: 4548
BORING INFORMATION
Boring ID: IP-17 and IP-18 Depth (ft): 28
Diameter: 1.5" OD Completion Details:Abandoned with native soil
Depth (ft) PID Lab Lithology
From To (ppm) Sample Description Color Moisture Odor
0 0.5 Asphalt
0.5 5 Silty clay red/brown
5 28 DPT;no recovery
i
Photo 1: Preclearing Photo 2: Completion

40
Geological Resources, Inc.
SITE INFORMATION
Site Name:J Mart Date: 04/18/2024
Project Number:4238 Log Completed By: L.Weathersby
DRILLING INFORMATION
Company:Geological Resources, Inc. Drill Type: Direct Push
Driller: Matt Steele License Number: 4548
WELL CONSTRUCTION INFORMATION
Boring ID: IP-17 and IP-18 Top of Casing:
Diameter: 1.5" OD Depth to Water(ft):
Sand Outer Casing
From (ft) I To (ft) From (ft) To (ft) Diameter (in)
N/A 28
Bentonite Inner Casing
From (ft) To (ft) From (ft) To (ft) Diameter (in)
N/A N/A N/A
Grout Screen
From (ft) To (ft) From (ft) To (ft) Diameter (in)
N/A N/A 28
DIAGRAM - MONITORING WELL
Grout
Casing
Bentonite
N/A
N/A
Sand
Screen
28 28

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft' 28 rt.
4548
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. rt. rt. in.
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft' N/A ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public N/A ft' 28 ft• in. in.
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) f. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation N/A �
Non-Water Supply Well:
ft-
❑Monitoring ❑Recovery rt N/A
Injection Well:
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier N/A ft. 28 ft.
❑Aquifer Test ❑StormwaterDrainage rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 It- 0.5 ft. Asphalt
4.Date Well(s)Completed: Well ID#
04/18/2024 IP-17 and IP-18 0.5 ft- 5 ft. Silty clay
5 ft- 28 ft. DPT; no recovery
5a.Well Location:
J Mart 00-0-0000024866
Facility/Owner Name Facility ID#(if applicable) rt ft.
5654 NC Highway 87 South, Sanford, NC
Physical Address,City,and Zip
21.REMARKS
Lee 9660-5343-3200
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Ce.tifica�in:
(if well field,one lat/long is sufficient)
35.407950 N 79.115805 W 04/18/2024
Signature of Certified Well Contra ,. Date
6.Is(are)the well(S): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Direct Push 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

40
Geological Resources,Inc.
SITE INFORMATION
Site Name: J Mart Date: 04/18/2024
Project Number: 4238 Log Completed By: L.Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. Drill Type: Direct Push
Driller: Matt Steele License Number: 4548
BORING INFORMATION
Boring ID: IP-19 Depth (ft): 24
Diameter: 1.5" OD Completion Details:Abandoned with native soil
Depth (ft) PID Lab Lithology
From To (ppm) Sample Description Color Moisture Odor
0 0.5 Asphalt
0.5 5 Silty clay red/brown
5 24 DPT;no recovery
i
Photo 1: Preclearing Photo 2: Completion

40
Geological Resources, Inc.
SITE INFORMATION
Site Name:J Mart Date: 04/18/2024
Project Number:4238 Log Completed By: L.Weathersby
DRILLING INFORMATION
Company:Geological Resources, Inc. Drill Type: Direct Push
Driller: Matt Steele License Number: 4548
WELL CONSTRUCTION INFORMATION
Boring ID: IP-19 Top of Casing:
Diameter: 1.5" OD Depth to Water(ft):
Sand Outer Casing
From (ft) I To (ft) From (ft) To (ft) Diameter (in)
N/A 24
Bentonite Inner Casing
From (ft) To (ft) From (ft) To (ft) Diameter (in)
N/A N/A N/A
Grout Screen
From (ft) To (ft) From (ft) To (ft) Diameter (in)
N/A N/A 24
DIAGRAM - MONITORING WELL
Grout
Casing
Bentonite
N/A
N/A
Sand
Screen
24 24

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Matt Steele 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft' 24 ft.
4548
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. rt. ft. in.
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft' N/A ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public N/A ft' 24 ft in. in.
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) f. in.
❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation N/A ft.
Non-Water Supply Well:
ft-
❑Monitoring ❑Recovery B N/A
Injection Well:
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier N/A rt. 24 rt.
❑Aquifer Test ❑StormwaterDrainage rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed LOOP) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 It. 0.5 ft. Asphalt
4.Date Well(s)Completed: Well ID#
04/18/2024 IP-19 0.5 It- 5 ft. Silty clay
5 ft- 24 ft. DPT; no recovery
5a.Well Location:
J Mart 00-0-0000024866
Facility/Owner Name Facility ID#(if applicable) rt ft.
5654 NC Highway 87 South, Sanford, NC
Physical Address,City,and Zip
21.REMARKS
Lee 9660-5343-3200
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer
(if well field,one lat/long is sufficient)
35.407950 N 79.115805 w 04/18/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑✓Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Direct Push 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

0
Geological Resources, Inc.
SITE INFORMATION
Site Name: J Mart Date:04/17/2024
Project Number:4238 Completed By:L. Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. License Number: 4548
Driller: Matt Steele
WELL ABANDONMENT INFORMATION
Bentonite (Ibs): 10
Boring ID: IP-1 thru iP-8 Grout (Ibs): 5
Total Depth Outer Casing
40 From (ft) To (ft) Length (ft)
0 n/a 0
Depth to Water Inner Casing
From (ft) To (ft) Length (ft)
0 n/a 0
Water Volume (gal) Screen
6.40
. ^ O From (ft) To (ft) Length (ft)
�+ n/a 40 40
PHOTOS
Pre-Abandonment Post Abandonment

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matt Steele 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
4548 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 6.40 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑ Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 10
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑StormwaterDrainage
Grout 5
El Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned. 04/17/2024 Wells were used for in situ chemical oxidation
5a.Well location: Abandoned with bentonite after injection
J Mart 00-0-0000024866
Facility/Owner Name Facility 1D#(if applicable) o.Cer a
5654 NC Highway 87 South, Sanford, NC 04/17/2024
Physical Address,City,and Zip Signature of certified Well Contractor or Well _ ner Date
Lee 9660-5343-3200
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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.407950 N 79.115805 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: I P-1 th ru I P-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
0 (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): 0 (ft.) abandoned.
6g.Screen length(if known): 40 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

0
Geological Resources, Inc.
SITE INFORMATION
Site Name: J Mart Date:04/18/2024
Project Number:4238 Completed By:L. Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. License Number: 4548
Driller: Matt Steele
WELL ABANDONMENT INFORMATION
Bentonite (Ibs): 10
Boring ID: IP-9 thru IP-16 Grout (Ibs): 5
Total Depth Outer Casing
40 From (ft) To (ft) Length (ft)
0 n/a 0
Depth to Water Inner Casing
From (ft) To (ft) Length (ft)
0 n/a 0
Water Volume (gal) Screen
6.40
. ^ O From (ft) To (ft) Length (ft)
�+ n/a 40 40
PHOTOS
Pre-Abandonment Post Abandonment

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matt Steele 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
4548 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 6.40 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑ Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 10
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑StormwaterDrainage
Grout 5
El Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned. 04/18/2024 Wells were used for in situ chemical oxidation
5a.Well location: Abandoned with bentonite after injection
J Mart 00-0-0000024866
Facility/Owner Name Facility 1D#(if applicable) 8.Certifir:,tion_>.
5654 NC Highway 87 South, Sanford, NCB 04/18/2024
Physical Address,City,and Zip Signature of Certified Well Contractor net Date
Lee 9660-5343-3200
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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.407950 N 79.115805 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: I P-9 th ru I P-16 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 4O (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
0 (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): 0 (ft.) abandoned.
6g.Screen length(if known): 40 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

0
Geological Resources, Inc.
SITE INFORMATION
Site Name: J Mart Date:04/18/2024
Project Number:4238 Completed By:L. Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. License Number: 4548
Driller: Matt Steele
WELL ABANDONMENT INFORMATION
Bentonite (Ibs): 10
Boring ID: IP-17 and IP-18 Grout (Ibs): 5
Total Depth Outer Casing
2Q From (ft) To (ft) Length (ft)
V 0 n/a 0
Depth to Water Inner Casing
From (ft) To (ft) Length (ft)
0 n/a 0
Water Volume (gal) Screen
4.48
. ^8 From (ft) To (ft) Length (ft)
�+C7 n/a 28 28
PHOTOS
Pre-Abandonment Post Abandonment

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matt Steele 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
4548 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4.48 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑ Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 10
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑StormwaterDrainage
Grout 5
El Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned. 04/18/2024 Wells were used for in situ chemical oxidation
5a.Well location: Abandoned with bentonite after injection
J Mart 00-0-0000024866 _
Facility/Owner Name Facility ID#(if applicable) 8.Certill
5654 NC Highway 87 South, Sanford, NC-,' 04/18/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or." Date
Lee 9660-5343-3200
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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.407950 N 79.115805 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: I P-17 and I P-18 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 28 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
0 (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): 0 (ft.) abandoned.
6g.Screen length(if known): 28 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

0
Geological Resources, Inc.
SITE INFORMATION
Site Name: J Mart Date:04/18/2024
Project Number:4238 Completed By:L. Weathersby
DRILLING INFORMATION
Company: Geological Resources, Inc. License Number: 4548
Driller: Matt Steele
WELL ABANDONMENT INFORMATION
Bentonite (Ibs): 10
Boring ID: ip-19 Grout (Ibs): 5
Total Depth Outer Casing
2 From (ft) To (ft) Length (ft)
4 0 n/a 0
Depth to Water Inner Casing
From (ft) To (ft) Length (ft)
0 n/a 0
Water Volume (gal) Screen
3.8^ From (ft) To (ft) Length (ft)
C��+ n/a 24 24
PHOTOS
Pre-Abandonment Post Abandonment

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matt Steele 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
4548 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3.84 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑ Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 10
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑StormwaterDrainage
Grout 5
El Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned. 04/18/2024 Wells were used for in situ chemical oxidation
5a.Well location: Abandoned with bentonite after injection
J Mart 00-0-0000024866 _
Facility/Owner Name Facility ID#(if applicable) 8.Csitifi aeon:
5654 NC Highway 87 South, Sanford, NC . `f 04/18/2024
Physical Address,City,and Zip Signature of Certified Well Contra .or el .er Date
Lee 9660-5343-3200
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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.407950 N 79.115805 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: I P-1 9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
0 (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): 0 (ft.) abandoned.
6g.Screen length(if known): 24 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016