WI0600149_Injection Event Record_20210823

hart 'Nal hickman
SMARTER ENVIRONMENTAL SOLUTIONS
Via E-Mail & FedEx
September 29, 2021
NC Department of Environmental Quality
Division of Water Resources — UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Attention: Shristi Shrestha
Re: Injection Event Record
Proctor-Silex Southern Pines Site
Southern Pines, North Carolina
DEQ ID: NCD003234549
H&H Job No. SIL-013
Dear Shristi:
Please find enclosed an Injection Event Record for a small-scale injection completed August 23
through August 31, 2021 under Permit No. W10600149 at the Proctor-Silex Southern Pines site.
If you have any questions or need additional information, please contact me at [phone].
Sincerely,
Hart & Hickman, PC
cefilta'
Scott Drury, PE
Project Manager
Enclosure
cc: Ms. Beth Hartzell, NC DWM Superfund Section (via e-mail)
2923 South Tryon Street, Suite 100
Charlotte, NC 28203
704.586.0007 main
3334 Hillsborough Street
Raleigh, NC 27607
919.847.4241 main
www.harthickman.com

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10600149
1. Permit Information
Hart & Hickman, PC
Permittee
Hamilton Beach Brands, Inc.
Facility Name
261 Yadkins Road, Southern Pines, 28387
Facility Address (include County)
2. Injection Contractor Information
Vince Federele / Geologic Exploration, Inc.
Injection Contractor / Company Name
Street Address 176 Commerce Blvd
Statesville
City
NC
State
28625
Zip Code
( 704) 872-7686
Area code — Phone number
3. Well Information
Number of wells used for injection 50
Well IDs IP-120 through IP-169
Were any new wells installed during this injection
event?
ID Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells 50 Temporary DPT
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ® Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Welts
Number of Injection Wells 50
Please include a copy of the GW- 30 for each well
abandoned.
4. Injectant Information
Sodium Persulfate with Sodium bicarbonate
Injectant(s) Type (can use separate additional sheets
if necessary
178 gWL Na2(SO4)2 and
Concentration 95 g/L Ca(OH)2 with chase water
If the injectant is diluted please indicate the source
dilution fluid.Town of Southern Pines municipal wate
Total Volume Injected (gal) 14,829
Volume Injected per well (gal) 296
5. Injection History
Injection date(s) 8/23- 31/2021
Injection number (e.g. 3 of 5) 3 of 3
Is this the last injection at this site?
❑ Yes ❑ No X Unknown
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT. J
clias
do
SIGNATURE OF INJECTION CONTRACTOR DATE
Vince_ red c r to
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: U1C Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016

WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0600149
Lust all applicable well construction perniiis (i.e. WC, County, State, ;variance, etc)
3. Well Use (check welt use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ l nd ustr is IfCommerc ial
❑ Irrigation
❑MunicipallPubl is
DResidential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > 100,000 GPD
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (1-leatingfCooling Return)
19Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 08/30/21 Well IDP
5a. Well Location:
PROCTOR - SILEX
IP-148
Facility/Owner Name Facility ID11(if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35° 11'24.60" N 79°22'41.01"
6. ls(are) the well(s): ❑Permanent or ClTemporary
7. Is this a repair to an existing well: ❑Yes or 115No
!f this it a repair, fill out known well coHsirnrirrn, lafi,rniatian and explain she nature of the
repair under +t11 remarks section or an the back ofthis firm.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW- I is needed. Indicate TOTAL NUMBER of wells
drilled: I
9. Total well depth below land surface: 21.0
Isar multiple wells list all depths ifdifT rent (example- 3 .200 and 2Ql00')
10. Static water level below top of casing:
1'trairr Jeref it abase caring, are " - "
II. Borehole diameter: 2.25 (in.)
12. Well construction method: DPT RODS
(It.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
136. Disinfection type: Amount:
For Internal Use Only:
14, WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
iS. OUTER
CASING (for
multi -cased wells) OR LINER (if up limbic)
FROM
TO
DIAMETER
TIICKNESS MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
R.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in,
H.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
R.
rt.
I9. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
fr.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (co lot, hardness., suilhnrk type, grain sine, etc.)
0.0 rt
21.0 rt,
DIRECT PUSH
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
09/22/21
Signature of Certified Well Contractor Date
By signing f/us final. ! hereby certify that the urll(.ej ups (were) constructed to accordance with
ISA NBAC 02C .0100 or 15,4 M'AC 02C .0200 Well Construction Standare[r and duo a copy
of -this record has been provided to the well miner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (]UC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form OW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6.6-2018

WELL ABANDONMENT RECORD
For Internal Use ONLY:
"this form cart be used for single or multiple welts
I, Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning well on his/her property)
A - 3552
NC Welt Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2, Well Construction Permit #: WI0600149
DV all applicable weft consirrrcttan periniis (i.e. County, State, Variance. etc,) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring 0 Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
°Groundwater Remedial ion
OSalinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 08130/21
5a. Well location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility lDt (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one ialllong is sufficient)
35° 11' 24.60" N 79° 22' 41.01"
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Anaelr well construction recoil(%) if available. t'hr multiple injection nr won -water supply
hells ONLY with the .ranee cnnriruction'ahandannreiu, you can submit one frrrnr.
6a. Well IDH: IP-148
6b. Total well depth: 21.0
6c. Borehole diameter: 2.25 (in.)
G[l, 11'ater• level below ground surface: (ft.)
6r. Outer casing length (if known): (ft.)
61. Inner rasing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Form C W-30
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
o Bentonite Slurry
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 1
For multiple infection nr nnu-water supply wells ONLY wish ;he same
construction'abandaament, you can submit acre farm.
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials used (check all that apply):
❑ Neat Cement Grout 0 Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7I For each material selected above, provide amount of materials used:
3.5 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
8. Certification:
Signature of Certified Well Contractor or Welt Owner
09/22/21
Date
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
accordance with 15,4 NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this reconl has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
16b. 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
abandonment to the following:
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
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.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised i•larch 201

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit WI0600149
List all applicable well construction permits (i.e. Ill(.', County. Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ irrigation
❑ Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Dwells > 100,000 GPO
Non -Water Supply Well:
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geotherma! (Healing/Cooling Return)
MGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 08/30/21 Well IIP-153/158
Dt1
Sn. Well Location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility IDel (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE 858215742538
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lifwall field, one tat/long is sufficient)
35° 11' 24.60" N 79° 22' 41.01"
6. Is(are) the well(s): ❑Permanent or l9Temporary
7. Is this a repair to an existing well: ❑Yes or MINo
If this is a repair, fill run known well construction i formation and explain the nature of the
repair under a21 rennarke section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 2
9. Total well depth below land surface: 25'0 (ft.)
for oothipie wells fist all depths ifdi different (example- 3 a 00' and d r(/0U')
10. Static water level below top of casing:
if water level is above casing, use "
11. Borehole diameter: 225 (in.)
12. Well construction method: DPT RODS
(i.e. auger, rotary, cable, direct push, etc-)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FRO41
TO
DESCRIPTION
D.
ft.
ft.
ft.
---,
15. OUTER CASING (for multi -eased wells) OR LINER (if ap lice We)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL,
ft.
ft.
in.
ft.
It.
in,
_17, SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
I 8. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
h.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
rt.
ft.
ft.
20. DRILLING LOG (attach additional sheets if neceSsry)
FROM
TO
DESCRIPTION (robe, hardness, nelUrnrk lypt, ram size, etc.)
0.0 rt.
25.0 ft.
DIRECT PUSH
It.
ft.
ft.
h.
ft.
rt.
ft.
Ft.
ft.
ft.
ft.
ft.
21, REMARKS
22, Certification:
1
09/22/21
Signature of Certified Well Contractor Date
By signing this form. 1 hereby certify' that the Ira(e) Ivan (were) courrucIed in accordance with
15,4 N('A(' 02(- _0101J or I5A N('A(' 02(' _0200 Well ('unsrnecNrur Standards and duet a copy
of this recant has beenprorided to the urll owner-
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-I within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
246. For Injection Wells: Copy to DWR, Underground Injection Control (WC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form OW-1
North Carolina Department of Environmental Qua€ily - Division of Water Resources
Revised 6.6-20 18

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning welt on his/her property)
A - 3552
NC' Welt Contractor Cenificalion Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #: WI0600149
List all applicable well caartrmvion permits (i.e. County, State, Variance. etc) if known
3. Well use (check well use):
�Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Ind ustriallCommerc is I
El Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
IEGroundwater Relnediation
❑Salinity Barrier
❑Stonmvater Drainage
❑ Subsidence Control
❑Tracer
DOther (explain under 7g)
4. Date well(s) abandoned: 08/30/21
5a. Well location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility IDd (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel ldenlification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one 1st/Iona is sufficient)
35° 11' 24.60" N 79° 22' 41 01"
❑ Neat Cement Grout
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
ID Bentanite Slurry
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
For multiple injection or non -water supply wells ONI.Y n•ith the strut
consiruclian'abandoiwjeni, you can .submit one firm.
2
7b. Approximate volume of water remaining in well(s):
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Scaling materials used (check all that apply):
❑ Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
4.0 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
S. Certification:
1( 1�
09/22/21
Signature of Certified Well Contractor or Well Owner Dale
By signing this form, I hereby cerit# that the wells) was (were) abandoned in
accordance with I5A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach welt construction record(s) iforalfoble. I'or multiple injection or non -caner supply
wells ONLY trtlh the savor consm•nctlwi abandonment, you can submit one form.
6a. Well IDTh IP-153/158
6b. Total well depth: 25'4 (ft.)
6c. Borehole diameter: 2.25 {in.)
6d. Water level below ground surface: (IL)
6e. Outer casing length (if known): (ft.)
6l. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if knit, n): (ft.)
Form OW-30
SUBMITTAL INSTRUCTIONS
lOa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. 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
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Sunnl►' & 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 abandoned.
North Carolina Department ofEnvironmcnl and Natural Resources —Division of Water Quality Revised March 2013

WELL CONSTRUCTION RECORD (GW-11
I. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Welt Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: 1Ni0600149
1.i.rt oil applicable well construction permits (i,e. UIC Camay, Slate, Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
o Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑Wells > 100,000 GPD
Non -Water Supply Well:
❑ Monitoring ❑Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
O Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
DTracer
❑ Other (explain under 421 Remarks)
D8/24/21 - oe12s121
4. Dale Well(s) Completed:
5a. Well Location:
PROCTOR - SILEX
Well ID# IP-159/168
NCD003234549
Facility/Owner Na3nc Facility ION (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address. City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one lat/long is sufficient)
35° 11' 24.60" N 79° 22' 41.01" W
6. ls(are) the well(s): OPermanent or MTemporary
7. Is this a repair to an existing well: ❑Yes or No
!f this is a repair. fill our kaolin n•e/I construction information and explain the nature of -the
repair haler +.21 remarks section nr an the hock of this farm.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 2F.0 (ft.)
For mnlliple bells liv all depths ifs/Aerenl (example- 3 rr 200' and 2®I00')
10. Static water level below top of casing:
If water level is above caring, wee " -
I1. Borehole diameter: 2.25 (in,)
12. Weil construction method: DPT RODS
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
n.
rt.
IS. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS + MATERIAL
f .
ft.
in.
Ir
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft,
fr.
in.
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD& AMOUNT
ft.
ft.
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL.
FafPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color.IlalthlcSS. lailinsek extze,graia site, clr.)
0 o ft.
26.0 ft*
DIRECT PUSH
ft.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
1
Signalure of Certified Well Contractor
09/22/21
Date
By signing ans./am I hereby cent, that the well(s) liar (were) constructed in accordance with
15A N(#C 02/ .0I00 or 15A N('A(' 02(:.0200 Well Construction Standar& and that a copy
of1his• record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
248. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IOC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24r. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over I00,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 276119-161 ]
Form OW-1
North Carolina Department ofEnvironmcnlal Quality - Division of water Resources Revised 6.6.2018

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
I. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning well on hisihcr property)
A - 3552
NC Well Contracior Cen i citation Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #: WI0600149
list all applicable well nnurruction permits (i.e. County, State, Variance, etc} Ifknown
3. Well use (check well use):
Water Supply Well:
DAgricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑ Irrigation
❑Municipal/Public
DResidential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring 0 Recovery
injection Well:
❑Aquifer Recharge
0 Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
EIGroundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 08j24/23 08/25/21
5a. Well location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility IOW (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address. City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong a sufficient)
35° 11' 24.60" N 79° 22' 41.01"
❑ Neat Cement Grout
0 Sand Cement Grout
❑ Concrete Grout
0 Specialty Grout
El Bentonite Slurry
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
For nnrhiple infection ur non -Crater supply wells ONLY with the same
construction abandonment, you can submit one joow
2
76. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7r. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Bentonite Chips or Pellets
0 Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
4,25 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
S. Certification:
09/22/21
Signature of Certified Well Contractor or Well Owner Date
By signing this form. 1 hereby cert5 that the treks) was (were) abandoned in
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.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF 1VELL(S) BEING ABANDONED
Attach nrell coirrtFilet irul remrd(s) iforailnhle. For multiple irjrctinn nr non -sorer supply
welts ONLY with the sane ccutstrnctian abandonment, you can .submit one Innit
6a. Well IDI#: IP-159/168
6b. Total well depth: 26.0 (ft.)
6e. Borehole diameter: 2.25 (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Form GW-30
SUB,11ITfAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
iDc. For Water Simply & 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 abandoned.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised March 2013

WELL CONSTRUCTION RECORD (GW-1
For Internal Use Only:
4. Date 1VeIl(s) Completed:
SR. well Location:
PROCTOR - SILEX
1. Well Contractor Information:
VINCE FEDERLE
Well Conrraclor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0600149
Lisa all applicable well construction permits (i.e. (li(.'. County; Sate, Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
0Agricultural
OGeothermal (Heating/Cooling Supply)
❑ 1 ndustrial/Comm ercia I
❑Irrigation
❑MunicipallPublic
DResidential Water Supply (single)
[]Residential Water Supply (shared)
❑ Wells > 100,000 GPD
Non -Water Supply Well:
❑ Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (CIosed Loop)
❑Geothermal (Heating/Cooling Return)
!Groundwater Remediat ion
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 021 Remarks)
08f24/21-oar25/21 Well tali
IP-155/166
NCD003234549
Facilit lOwner Name Facility ID( (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laulollg is sufficient)
35° 11' 24.60" 79° 22' 41.01 " 1►,
6, ls(are) the well(s): DPermanent or ©Temporary
7_ Is this a repair to an existing well: °Yes or ElNo
ff this is a repair, fip out known well construction infnrmtatlan and explain the nature rt! Ntc
repair under ::2I remarks section or on the bock aphis farts.
8. For Geoprobe1DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW- I is needed. indicate TOTAL. NUMBER of wells
drilled: i
9. Total well depth below land surface: 27.0 (fI.)
For multiple wells lint all deptAs ifdifferetu (example- 3@200' and 2@100)
10. Static water level below top of casing:
If water level is abort casing, use
il. Borehole diameter: 2.25 (in.)
12. Well construction method: DPT RODS
(R•)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (ifap rlicable)
FROM
TO
DIAMETER
TICKNESS y
H
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBINGJgeothermal closed -loop)
LFROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT AI ECHOD&AMOUNT
ft.
ft.
ft.
ft.
Ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
Ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color. hardness, soitirock type, grain size, en.)
0.0 ft'
27.0 ft•
DIRECT PUSH
ft.
ft.
ft.
ft.
Fr.
D.
Ft.
Ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
09/22/21
Signature of Cerlified Well Contractor Date
By signing this fare; i hereby certifj. that the wall(s) was (were) constructed in accorrkince with
iSA NCR(' 02C .0100 or ISA NCAC' 02C .0200 Well Construction Standards anti that a copy
of this record has been prarirlrrl so the melt miner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'see Over in Remarks Box). You may also attach additional pages if necessary
24. SUBMITTAL INSTRUCTIONS
Submit this OW -I within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC. Raleigh. NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (LUC)
Program, I636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental healtEdepartment of the county where installed
24d. For Water Wells producing over 100,000 GPO: Copy to DWR, CCPCUA
Permit Program. 1611 MSC, Raleigh, NC 27699-1611
Form OW -I North Carolina Department of Environmental Quality - Division of Water Resources
Revised 6.6.2018

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
I. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning well on his/her property)
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit WI0600149
List all applicable well construction permits (i.e. County, Stare, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cool ing Supply)
❑ lrrd ust rialYCom mere ial
❑lrr tstion
Non -Water Supply Well:
❑Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
/Groundwater Remediation
❑Salinity Barrier
❑Stonmvater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under 7g)
-
4. Date well(s) abandoned: 0$j24/21 08/25/21
5a. Well location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility IDk (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
County Parcel tdeniification No. (PIN)
5h. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lalllong is sufficient)
35° 11' 24.60" N 79° 22' 41 01"
858215742538
❑ Neat Cement Grout
0 Sand Cement Grout
0 Concrete Grout
❑ Specialty Grout
l Bentonite Slurry
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
Fur multiple injection or non -wafer supply wells ONI,Y with the
runslruriior/ aba ulon,nent, }via can snhnrii one firm
7b. Approximate volume of water remaining in well(s):
same
(gal•)
FOR WATER SUPPLY WELLS ONLY:
7r.Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain tinder 7g)
7E For each material selected above, provide amount of materials used:
4.5 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
S. Certification:
Signature of Certified Well Contractor or Well Owner
09/22/21
Date
By signing this form, I hereby cerify that the well(s) was (were) abandoned in
accordance with ISA NCAC 02C .0I00 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided ro the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CQ1NSTRUCT1ON DETAILS OF WELL(S) BEING ABANDONED
Attach wenti construction record(s) Ff ratifiable. For multiple lnjectiwt or nun -water supply
wells ONLY with the same construction'abandonment you con submit one fora.
Ga. Well IDS:IP-155/166
Gh. Total well depth: 27'0 (ft.)
Gr. Borehole diameter: 2.25 (in.)
Gd. Water level below ground surface: (ft.)
Ge. Outer casing, length (if known): (fL)
6f. Inner casing/tubing length (if known): (ft.)
Gg. Screen length (if known): (ft.)
Form GW-30
SUBMITTAL INSTRUCTIONS
UOa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
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
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
IOc. For Water Supply & Injection Wells: In addition to sending the tuna 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 abandoned.
North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised March 2013

4. Date Well(s) Completed:
5a. Well Location:
PROCTOR - SILEX
WELL CONSTRUCTION RECORD (GW-I)
1, Well Contractor Information:
VINCE FEDERLE
Well Contraclor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permits: WI0600149
List all applicable well construction permits (i.e. WC, County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells a 100,000 GPD
Non -Water Supply Well:
❑ Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
['Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
@7Groundwater Remediation
❑Salinity Barrier
❑Storm.+ater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
o8/24/21-OC/25/21 SEE REMARKS
Well ID#
NCD003234549
Facility/Owner Name Facility I Da of applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address. City, and Zip
MOORE
858215742538
Calmly Parcel Idenlificalion No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
[if well field, one lat./long is sufficient)
35° 11' 24.60" 1v 79° 22' 41.01 " 1v
6. Is(are) the well(s): ❑Permanent or C9Temporary
7. Is this a repair to an existing well: DYes or BNo
Turns is a repair, fill out known well construction infirrrnatiurr and explain the nature of the
repair under `21 remarks section or on the back alibis prat.
8. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW- l is needed. Indicate TOTAL NUMBER of wells
drilled: 1'
9. Total well depth below land surface: 28.0 (ft.)
for multiple wells tat all depths ifd erent (example- 3@240' and 2 .100 )
10. Static water level below top of casing:
/f seater lr re! is above camp, use
11, Borehole diameter: 2.25 (in.)
12. Well construction method: DPT RODS
(ft.)
(i.e. auger, rosary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
I5. OUTER CASING (for multi -eased wells) OR LINER (if ap
licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
Ft,
rt.
in.
16. INNER CASING OR TUBING (geothermal closed -loopy
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SIA 'SIZE
THICKNESS
MATERIAL
H.
D.
in.
ft.
ft.
in.
19. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METI{OD& AMOUNT
ft.
ft
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
fr.
rt.
2o. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION {color, hardness, soil/reek type. grain size, err.)
0.0 ft'
28.0
DIRECT PUSH
ft.
ft.
ft.
ft.
ft.
R.
ft.
R.
ft.
ft.
fr.
R.
21. REMARKS
IP-129/137/152/157/160/161/163/164/165/167
22. Certification:
09/22/21
Signature ofCertified Well C oniractor Date
Hy signing this Arm, i hereby cur* that the well(s) was (were) rout tructed in accordance with
15A NCAC 02C .0100 or 1 SA NC'AC 02C .0200 Well Construction Standards and that a copy
of this record ltas been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (1UC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR. CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Fonts GW-1
Norili Carolina Department of Environmental Quality - Division of Water Resources Revised 6.6.2018

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Ilse ONLY:
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning well on his/her propeny)
A - 3552
NC Well Contractor Certilicailon Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit N:WI464D149
List all applicable Well cotrstruslon permits (i.e. Caumy, Stole, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agrictdtural
C°Geothermal (HeatinggCooling Supply)
° Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring Cl Recovery
Injection Well:
°Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
o Geothermal (Heating/Cooling Return)
OGroundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under 7g)
d. Date well(s) abandoned: 08124121 08125121
5a. ►Veil location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility 1UN (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iaiflong is sufficient)
35° 11' 24.60" N 79° 22' 41.01"
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction rrcrurl(y) ifaraifoble. for multiple Injection or Iron -water supply
x•el/s ONLY wish the scum constructiuu'abatulonnrew,, you con submit one firm.
SEE REMARKS
6a. Well lD#:
6b. Total well depth: 28'0 (ft.)
Gr. Borehole diameter: 2.25 (in.)
6d. Water level below ground surface: (ft.)
6c. Outer casing length (if known): (It.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Form OW-30
El Neat Cement Grout
o Sand Cement Grout
Cl Concrete Grout
❑ Specialty Grout
O Bentonite Slurry
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 10
For muhlpfe lnjecrian or non -water supply wells ONLY Trish the same
am.Nruclion. abandoiunent, you can su6uirr one Ann
7b. Approximate volume of water remaining in fir ell(s): (gal)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
O Gravel
° Other (explain under 7g)
7R For each material selected above, provide amount of materials used:
4.5 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
IP-129/137/152/157/160/161/163/164/165/167
8. Certification:
09/22/21
Signature of Certified Well Contractor or Well Owner Pate
By signing this form, 1 hereby cert4 that the wells) was (were) abandoned in
accordance with 1 5f1 NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Cenler, Raleigh, NC 27699-1617
Bib. 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
abandonment to the following:
Division of Water Quality, Underground Injeclion Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
1Oc. 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 abandoned.
North Carolina Department of Environment and Natural Resources — Division of wale rQuality Revised March 2013

WELL CONSTRUCTION RECORD (GW-I1
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0600149
List all applicable well construction permits (r.e. UIC, Courtly. State. Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑ Municipal/Public
❑ Residential Water Supply (single)
:Residential Water Supply (shared)
❑Wells a 100,000 GPD
Non -Water Supply Well:
❑Monitoring °Recovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
3Groundvrater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 88l24l21 08/30/21
5a. Well Location:
PROCTOR - SILEX
Well Ina SEE REMARKS
NCD003234549
Facility/Owner Name Facility ID# (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(If well field, one ial/lottg is sufficient)
35° 11' 24.60n 79° 22' 41.01"
6. Ware) the well(s): ❑Permanent or ©Temporary
7_ is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill am known well coostructtan infarmotiem and explain the nature of -the
repair under r:21 remarks section or on the bark of this form
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 7
9. Total well depth below land surface: 29-0 (CO
For multiple wells Hsi all depths ifd //urea (example- 31rt 200' and 2@100)
10. Static water level below top ofcasing:
1J rntrr km is above casing, use "
11. Borehole diameter: 2'25 (in.)
12. Well construction method: DPT RODS
(R•)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14, WATER ZONES
FROM
TO
DESCRIPTION
R.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap
licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
fr.
ft.
in.
IS. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
D.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
R.
in.
ft.
ft.
in.
IS. GROUT
FROM
TO
MAI En IA
EMPLACEMENT METHOD & AMOuNT
it.
ft.
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK li r applicable)
FROM
TO
MATE:RIM.
l:M l'I.A C t: M ENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color. hardness, soil/rock type, grain size, etr.l
0.0 ft•
29.0 11'
DIRECT PUSH
rt.
D.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
Cl.
ft.
21, REMARKS ___.
I P -12 0/ 13 3 / 138/ 139/ 140/ 156/ 162
22. Certification:
1
Signature of Certified Well Contractor
09/22/21
Date
By signing this fame, I hereby certify that the ue// fr) was (were) contracted in accewektnre with
15A NCR[' 02C .0I00 or ISA NCAC 02C .0200 Well Consirucfian Standards and that a copy
ofthts record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Ore? in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this OW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit. 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-161 1
Form O W- I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For internal Use ONLY:
1. Well Contractor Information:
VINCE FEDERLE
Weil Contractor Name for well owner personally abandoning well on his her property)
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit 0: WI0600149
List all applicable nett! caustruc'tlon permits (i.e. County, Starr, Variance, etc.) ;annuli
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothenmal (Heating/Cooling Supply)
❑ lnd ustrial/Cote mere ial
Olrrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothennal (Heating/Cooling Return)
O Groundwater Reinediation
❑ Salinity Barrier
❑Storm water Drainage
❑Subsidence Control
❑Tracer
❑other (explain under 7g)
4. Dale well(s) abandoned: 08/24/21 08/30/21
5a. Well location:
PROCTOR - SILEX
N C D003234549
Facility/Owner Name Facility I➢# (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
511 Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one tat/bong is sufficient)
35° 11' 24.60" N 79° 22' 41.01" 1v
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) tfarailoblr. For multiple injection or non -water supply
wells ONLY with the same construction obarnlmmnenc you cm, submk one form
63. WeIl1Dd: SEE REMARKS
6b. Total well depth: 29'0 (ft.)
6c. Borehole diameter: 2.25
6d. Water level below ground surface: (ft.)
Ge. Outer casing length (if known): (ft.)
6E Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Fenn GW-30
❑ Neat Cement Grout
CI Sand Cement Grout
❑ Concrete Grout
0 Specialty Grout
O Bentonite Slurry
WELL ABANDONMENT DF: t'Att.S
7a. Number of wells being abandoned: '
Fur multiple injection or non -water supply sells ONLY with the .sonic
construction abandonment, you con submit one Arm.
7b. Approximate volume of water remaining in well(s): (gal./
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
4.75 GALLONS
7g, Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
IP-120/133/138/139/140/156/162
S. Certification:
09/22/21
Signature of Certified Well Contractor or Well Owner Date
By signing this form. I hereby cert(6, that the wells) was (were) abandoned in
accordance with 15.4 NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lob. For Injection Wells: In addition to sending the form to the address in IOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10e. For Water Supply & Injection Welts: 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 abandoned.
North Carolina Department of Environment and Nalural Resources — Division of Water Qualify Revised March 2013

WELL CONSTRUCTION RECORD (GW-11
I. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0600149
List all applicable well eonsiruciiwt permits (i.e. WC. Camay, Stair, Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
UIrrigation
❑ Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wel Is > 100,000 GPD
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
INGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under b21 Remarks)
4, Date Well(s) Completed: Well
-oa/30/h1 Well ID# SEE REMARKS
5a. Well Location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Natne Facility lob (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllang is sullicrenq
35° 11' 24.60" N 79° 22` 41.01 " W
6. Is(are) the well(s): ❑Permanent or I9Temporary
7. Is this a repair to an existing well: ❑Yes or MiNo
!f this is a repair, fill nut known well conslrucrktn information and explain die unsure of the
repair wider :.11 remarks section or nip the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW- I is needed. Indicate TOTAL NUMBER of wells
drilled s
9. Total well depth below land surface: 3a'� -_ (ft.)
)'nr nutlriple steps list all depths rfdrrjerent (example- 3@200' and 2(100)
10. Static water level below top of easing:
lfxater level is above casing, else "1 "
11, Borehole diameter: 2,25 (in.)
12. Well construction method: DPT RODS
(i.e. auger, rotary, cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
Oa. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
IS. OUTER CASING (for multi -rased welts) OR LINER (IFap licablc)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
In.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
fr.
ft.
ft.
19. SAND/GRAVEL
PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT MEn110D
Ft.
It.
ft.
ft.
20, DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (ruler, hardness, soil/rock type, era in size, etr.)
0.0 R.
30.0 D'
DIRECT PUSH
R.
Ft.
ft.
D.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
IP-134/144/149/154/169
22. Certification:
09/22/21
Signature ofCerIificd Well Contractor Date
By signing ribs finrnt, 1 hereby cerlFfy that the well(s) owes (were) eanstructedin accordance wish
114 N('AC 02(' "0100 or 114 Nt"AC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the tic)! owner,
23. Site diagram or additional well details:
You may use the hack of this page to provide additional well construction info
(add 'See Over in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-I within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 M C, Raleigh, NC 27699-1611
Form O W- I North Carolina Department of Environmental Qualify - Division of Water Resources
Revised 6-6-20 18

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning well on hisfher property)
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Welt Construction Permit #: W106OO149
l ssr all applicable well canstruclionpermits (i.e. County; Slare, f'rrriance, etc.) iJ'Rnmrn
3. Well use (check well use):
Water Supply Welt:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ l nd ustrial/Com m ercia I
❑ irrigation
Non -Water Supply Well:
❑ Monitoring
DMunicipalfPublic
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
OGeothermal (Heating/Cooling Return)
4. Date well(s) abandoned:
Sa. Well location:
PROCTOR - SILEX
© Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under 7g)
08/25/21 - 08/30/21
NCD003234549
Facility/Owner Name Facility IDS (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
County
858215742538
Parcel Identification No. (PIN)
5b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one ladlong is sufficient)
35° 11' 24,60" N 79° 22' 41 01"
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 5
For multiple injection or non -water supply wells ONLY with the same
col sfrneiron•abamloluneni. you can submit one form.
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7r. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
0 Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
m Bentonite Slurry
❑ Bentonite Chips or Pellets
❑ Dry Ctay
❑ Drill Cuttings
El Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
4.75 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
IP-1 34/144/149/1 54/169
S. Certification:
1
09/22/21
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certf0 that she weA(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and Mar a copy of this record has been provided lo the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL SBEING ABANDONED
Ateach well construction record(i) if available. For nuduple injection or son -water supply
u•etlr ONLY with lire same cansrrurlloirabanclanment, you con submit nne form.
6a. Well ILO:SEE REMARKS
6h. Total well depth: 30'0 (ft.)
6c. Borehole diameter: 2.25 (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
61'. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Form GW-30
SUBMITTAL INSTRUCTIONS
lOa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
IOb. For Injection Wells: in addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
We. For Water Suonlr & 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 abandoned.
North Carolina Department of Environment and Natural Resources - Division of Water Qualify Revised March 2013

WELL CONSTRUCTION RECORD (OW-11
For Internal Use Only:
4. Date We11(s) Completed:
5a, Well Location:
PROCTOR - SILEX
I. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0600149
List all applicable well construction permits (i.e. MC. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Coaling Supply)
❑ Industrial/Commercial
❑Irrigation
❑ Municipal(Public
GResidential Water Supply (single)
17Residential Water Supply (shared)
❑ Wells 100,000 GPD
Non -Water Supply Well:
❑Monitoring ['Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
['Experimental Technology
❑Geothermal (Closed Loop)
❑Geothernal (Heating/Cooling Return)
LRGroundwater Remediation
❑ Salinity Barrier
❑ Storm water Drainage
°Subsidence Control
❑Tracer
°Other (explain under fl21 Remarks)
08/23/21-08/31/21 SEE REMARKS
Well ION
NCD003234549
Facility/Owner Name Facility ID# (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
well field. one lot/long is sufficient)
35n 11' 24.60" N 79° 22' 41.01"
6. Is(are) the 1vell(s): []Permanent or C1Temporary
7. Is this a repair to an existing well: ❑Yes or EINo
If this is a repair, fill nut known well construction) hifnrniatlon and explain the nature of the
repair tinder =21 remarks section or on the hack of this forest.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 13
9. Total well depth below land surface: 31.0 [ft J
Far moltiple u•e1Lr llst all depths rfdtaRrcnt (example- 3@200' and 2Q100')
10. Static water level below top of casing:
If water lever is abort caring. use "< "
11. Borehole diameter: 2.25 (in.)
12. Well construction method: DPT RODS
(i.e. auger, rosary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Id. WATER ZONES
FROM
TO
DESCRIPTION
rt.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (ifap Iicabte)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft,
rt.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in,
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
L
in.
IS, GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD& AMOUNT
ft.
ft.
ft.
ft.
ft,
ft.
19, SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
D.
n
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTION l rotor, hardness, sailhnck type, groin Sae, tic.)
0.0 ft'
31.0 ft,
DIRECT PUSH
ft.
fr.
R.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
IP-121/123/124/125/127/128/131/143/145/146/147/150/151
22. Certification:
I
Signature ofCcrlified Well Contractor
09/22/21
Dale
By signing ng this form. I hereby err* that the sells,) was (were) cotrrtructetlint accordance with
15A NC A(' 02C' .0100 or 15A NC AC 02C .0200 Well Construction Sratslardc and that n COPY
of this record has been provided so the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Ore? in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-I within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
246. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPO: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form OW -I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6.6.201 S

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning well on his/her properly)
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit it:W10600149
List all applicable lie// construction (worths the. Corsi}; Slate. Irariatce, et(.) if kraut
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commerc iat
(a Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring ❑Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
/]Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under 7g)
08/23/21 - 08/31 /21
4, Daly well(s) abandoned:
5a. Well location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility IN (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35° 11' 24.60" N 79° 22' 41.01 "
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Mach well construction recrurl(.s1 if available. For multiple injection or ,lair-u•oler supply
wells ONLY with the same can trmction nha,ularurrett, you can submit one foam.
6a. Well mu:SEE REMARKS
6b. Total well depth: 31.0 (ft)
6c. Borehole diameter: 2.25 (in.)
6d. Water lcvcl below ground surface: (ft.)
Gr. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Font OW-30
❑ Neat Cement Grout
❑ Sand Cement Grout
Q Concrete Grout
❑ Specialty Grout
© Bentonite Slurry
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 13
For multiple injection or non -water supply wells ONLY with the .sante
no, isirontiorrnbamloinrrerrr, you can submit one form.
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7r, Type of disinfectant used:
7d. Amount of disinfectant used:
7c. Sealing materials used (check all that apply):
❑ Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
5.0 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
IP-121/123/124/125/127/128/131/143/145/146/147/150/151
8. Certification:
09/22/21
Signature of Certified Well Contractor or Wei/ Owner Date
By signing this form. I hereby terrify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
10a, For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lOb, For ltdgction 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
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Sunnly & 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 abandoned.
North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised March 2013

WELL CONSTRUCTION RECORD (GW-1]
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit ti:
WI0600149
List all applicable well construction permits (i.e. CAC, County. Stare. Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
►°Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > 100,000 GPD
Non -Water Supply Well:
❑Monitoring ©Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Lop)
❑ Geothermal (HeatinglCooling Return)
► Groundwater Remediation
❑ Salinity Barrier
❑ Stonnwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 08l25l21-08126121 Well ID# SEE REMARKS
Sa. Well Location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Maine Facility ID€! (ifapplicablc)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
35° 11' 24.60" N 79° 22' 41,01"
6. Is(are) the well(s): ❑Permanent or MTemporary
7. Is this a repair to an existing well: ❑Yes or [MNo
if this is a repair, Jill me known n eN construction information and explain the nature of the
repair under '21 remarks.rrclian or ore the hack of this farm.
8. For GeoprobeiDPT or Closed -Loop Geothermal Wells having the same
construction, only I OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 4
9. Total well depth below land surface: 32'Q (ft.)
For niudliple u'ellt list all depths [referent (example- 3 r®200' and 2@100)
I0. Static water level below top of casing: (ft.)
wader level is phone casing, me •', „
I1. Borehole diameter: 2.25 (in.)
12. Well construction method: DPT RODS
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpnl) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
re.
n.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap limbic)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMi,'TER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
ft.
in.
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMan' METHOD & AMOLINT
ft.
ft.
ft.
ft.
ft.
ft.
19, SAND/GRAVEL PACK (if applicable)
FROM
TO
A1A'rERlAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (attach additional sheets Ifnecessary)
FROM
TO
DESCRIPTION (color, hardness, sat llroc k type, grain size, etc.)
0.0 B.
32.0 ft'
DIRECT PUSH
n.
ft.
ft.
B.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21, REMARKS
IP-126/135/136/142
22. Certification:
09/22/21
Signature of Certified Well Conseactor Dale
/ly signing this form, i hereby certify that the well(s) was (acre) constructed in accordance with
15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24h. For Injection Wells: Copy to DWR, Underground Injection Control (lUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27694-1611
Form G W- I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Use ONLY!
i. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning well on his her property)
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Nance
2. Well Construction Permit if:VIIIO6OO149
List all applicable wet/ construction pernrirr (.e. {'aunty, State, Variance, err,) ij•known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Ind ustrial/Corn m ercia I
❑ Irrigation
❑Municipal/Public
0/Residential Water Supply (single)
0 Residential Water Supply (shared)
Non -Water Supply Well:
0 Monitoring 0 Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
OGroundwater Remediation
❑Salinity Barrier
O 5tormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other(explain under 7g)
4. Date well(s) abandoned: 08j25/21 0$/26/21
Sa. Well location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility 10i1 (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Identification No- (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35° 11' 24.60" N 79° 22' 41.01"
CONSTRUCTION DETAILS OF WELLS) BEING ABANDONED
Attach well construction recce -AO) if available. For multiple injection or non -water .supply
wells ONLY with the some c,urvrructiot abandonmernt, you can submit one form.
6a. well lD!€: SEE REMARKS
6b. Total well depth: 32'0
6c. Borehole diameter: 2.25 (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
fif. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Form GW-30
❑ Neat Cement Grout
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
O Bentonite Slurry
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 4
For murrple injection or non -water supply wells ONLY with the sonic
conetrurtion'abandonnrent, you can submit one form.
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Bentonite Chips or Pellets
❑ Dry Clay
O Drill Cuttings
0 Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
5.25 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
IP-126/135/136/142
8. Certification:
Signature of Certified Well Contractor or Well Owner
09/22/21
Date
By signing this form, I hereby certib, that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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
SUBMITfAL INSTRUCTIONS
lfla. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
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
abandonment to the following:
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
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.
North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised March 2013

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Cenilication Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit #: WI0600149
List all applicable well construction permits (i.e. WC, County, Stoic, Variance. etc.)
3. Well Use (cheek well use):
Water Supply Well:
❑ Agricultural
OGeothermal (Heating/Cooling Supply)
❑ 1 n dustrial/Commercial
❑ irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑ Wells a 100,000 GPD
Non -Water Supply Well:
❑ Monitoring DRecovery
Injection Well:
❑ Aquifer Recharge
l]Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
OGroundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 08/27/21 Well [D#
5a. Well Location:
PROCTOR - SILEX
IP-122
NCD003234549
Facility/Owner Name Facility IDi! (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address. City, and Zip
MOORE
858215742538
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field. one latllang is sufficient)
35° 11' 24.60" 79° 22' 41.01" ►v
6. ls(are) the'well(s): ❑Perutanent or ElTemporary
7. Is this a repair to an existing well: ❑Yes or MNo
///Ais is a repair. Jill out known bell construction i,Jormauon am! explain the natare alike
repair render a21 rentarkr seeliw! or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 33,0 (ft.)
For multiple wells list all depths dfd Brent (example- 3@200' mx12®/00)
10. Static water level below top ofeasing: (ft.)
if water !ere) is above c'asirng, use " * "
11. Borehole diameter: 2.25 (in.)
12. Well construction method: DPT RODS
(i.e. auger, rotary. cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: A mount:
For Internal Use Only;
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
IS. OUTER CASING (for multi -cased wells) OR LINER (if ap
[treble)
FROM
TO _
DIAMETER
THICKNESS
MATERIAL
R.
fr.
in.
16, INNER CASING OR TUBING (Reorhermal closed-[ooa.
FROM
TO
DIAMETER
THICKNESS
MATERIAL
R.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLAC EMENT 11IETHOD&AMOUNT
ft.
ft.
R.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
R.
ft.
ft.
20. DRILLING LOG (attach
additional sheets if necessary')
FROM
TO
DESCRIPTION (velar, hardness, stNroek type, grain rase, eic.J
0.0 ft.
33.0 R•
DIRECT PUSH
fr.
fr.
ft.
ft.
R.
ft
ft.
ft.
D,
fr.
ft.
ft.
21. REMARKS
22. Certification:
09/22/21
Signature of Certified Well Comraclor Dale
By signing this pre'. I hereby cerih' flint the well(s) was (were) constructed in accordance with
154 N(:AC 02C .0100 or 15A NCA(' 02C .0200 Well Construction Srarulants and that a copy
ofthis record /air been provider! iu the dsell owner.
23. Site diagram or additional welt details:
You may use the hack of this page to provide additional well construction into
(add 'See Over' in Remarks Box) You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Perms[ Program, 1611 MSC, Raleigh, NC 27699-1611
Fenn GW-1
North Carolina Department ofEnvirommenxal Quality - Division of Water Resources Revised 6-6-2018

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
I. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name (or well owner personally abandoning well on hisiher property)
A - 3552
NC Well Cwstraclor Certi ficatiou Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #: VIII0600149
List all applicable well construction pennies (I.e. County, State, Variance. etc.) ((known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
[]Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
DMunicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring El Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
lGroundwater Reinediation
OSalinity Barrier
❑ Storm water Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under 7g)
4, Date well(s) abandoned: 08/27/21
5a. Well location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility 1Dl (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel Idemification No. (PIN)
5h. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iaulong is sufficient)
35° 11' 24.60" N 79° 22' 41.01"
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well cwrstriiciinu record(s) if available. For multiple injection or non -water supply
irel&r ONLY silt the sane cunstrucrirw abantknnnens, you can submit one farm.
IP-122
6a. Well ID#:
6b. Total well depth: 33.0 (ft.)
Gr. Borehole diameter: 2.25 (in.)
6d. Wafer level below ground surface: {ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Fonn ❑ W-3fl
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
For multiple injection or non-uarer supply wells ONLY irirlr the .sane
constrtchioir obandonnwnt, you can subnai one form.
7
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
© Bentonite Slurry
❑ Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ GraveI
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
5.5 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
11. Certification:
1
Signature ofCcnified Well Contractor or Well Owner
09/22/21
Date
By signing this fonts, 1 hereby cer4 that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
1Oa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
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
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
IOc. For Water Sunnly & 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 abandoned.
Norlli Carolina Department ofEnvironmeni and Natural Resources - Division of Water Quality Revised March 2013

4. Date 1Ve11(s) Completed:
5a. Well Location:
PROCTOR - SILEX
WELL CONSTRUCTION RECORD (GW-1)
I. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
Company Name
2. Well Construction Permit fl: WI0600149
List all applicable well construction permits (i.e. INC, 1.'manty, Smte, Variance. etc.)
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ l n d ustriallCom mercia I
❑Irrigation
LlMunicipal(Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑ Wells > 100,000GPD
Non -Water Supply Welt:
❑ Monitoring ❑Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 421 Remarks)
08/26/21 - 08/31/21 SEE REMARKS
Well ID#
NCD003234549
Facility/Owner Name Facility IDS (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelI field. one Iat/lanng is sufficient)
35° 11' 24.60" N 79° 22' 41.01 "
6. Is(are) the well(s): DPermanent or f!lTemporary
7. Is this a repair to an existing well: DYes or MNo
If this is a repair, fill inn known well construction inf irirariuu acid explain the minim oldie
repair under -21 remarks section arena the back of this Jurnt.
8. For Geoprobe/DPT or Closed -Loop Geothermal Welts having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 34'0 (ft.)
Far multiple wells list all depths if difjercnl (example- 3 c(200' and 2Q100)
IQ. Static water level below top of rasing:
Ifseater level h above casing, use "+"
11. Borehole diameter: 2.25 (in.)
DPT RODS
12. Well construction method:
(ft.)
(i.e. auger, misty, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
fr.
ft.
I5.OUTER CASING (for multi -cased wells) OR LINER (ifap
Humble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
D.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
i7. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in,
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT WTI OD & AMOUNT
ft.
ft.
ft.
ft.
n.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
R.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, svilhvektype, grain size. eIc.
0.0 tt.
34.0 fir-
DIRECT PUSH
ft.
ft.
ft.
ft.
ft.
ft.
D.
ft.
ft,
ft.
fr.
ft.
21. REMARKS
IP-130/132/141
22. Certification:
09/22/21
Signature of Certified Well Contractor Date
13)., signing this form. !hereby certify that the well(s) was (were) constructed in accordance with
1SA NCAC 02C .0100 or 1SA NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been prm'idee/ to the nee/l owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Ore? in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-I within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Oren -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 109,006 GPD: Copy to DWR, CCPCIJA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form G W- I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name tar well owner personally abandoning well on his/her property)
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #: 'VVI0600149
list all applicable well cost trtrcrian permits (i.e. County. State. Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring DRecovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothennal (Heating/Cooling Return)
LGroundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: 08/26/21 08/31121
Sa. Well location:
PROCTOR - SILEX
NCD003234549
Facility/Owner Name Facility IDS (if applicable)
261 YADKIN ROAD SOUTHERN PINES 28387
Physical Address, City, and Zip
MOORE
858215742538
County Parcel ldemification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35° 11' 24,6O" 79° 22' 41 01 "
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 3
For multiple injection or non -water supply wells ONLY with the stone
corisrrnctlwYobuuel tnnteut, you eon submit one form.
7b. Approximate volume of water remaining in well(s): [gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
0 Sand Cement Grout 0 Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
a Bentonite Slurry ❑ Other (explain under 7e)
7f. For each material selected above, provide amount of materials used:
5,5 GALLONS
7g. Provide a brief description of the abandonment procedure:
ABANDONED VIA TREMIE PIPE
IP-130/132/141
8. Certification:
Signature of Certified Well Contractor or Well Owner
09/22/21
Date
By signing this form, 1 hereby cert fy that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DE'CAILS OF WELL(S) BEING ABANDONED
Attach well construction records) if available. l iir multiple rnierriwr or non-uwler supply
wells ONLY with the some cwtsrruclkai 'abandonment, you can submit one form.
6a. well 1D#: SEE REMARKS
6b. Total well depth: 34.0 (rt.)
6c. Borehole diameter: 2.25 (in.)
6d. Water level below ground surface: (ft.)
6c. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (It.)
6g, Screen length (if known):
Form GW-30
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
16I7 Mail Service Center, Raleigh, NC 27699-1617
10h. 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
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
IOc. For Water Supply & Injection Wells: in addition to sending the form to
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.
North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised March 2013