Granville_Well Abandonment_20220527

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4532-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'$ (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorination-Ca(OCl)2
7c.Type of disinfectant used:
2.Well Construction Permit#: unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)i known l�Z
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips o4WAOs
2022
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill-Cuttingk +Prac U
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 32-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete-8-lb
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and
[]Geothermal(Heating/Cooling Return) El Other(explain under 7g)
filled casing with Bentonite pellets and poured neat cement
4.Date well(s)abandoned: 04.25.2022 until approx., 1-fbgl and poured concrete inside casing to near the
sa.Well location: TOC and placed the lid.on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8. cation:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 _ 05.24.2022
Physical Address,City,and Zip Sign Certified We Contractct or Well Owner Date
GRANVILLE 192313139147 By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —35.64 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface:
—24.39' Division of Water Resources,Underground Injection Control Program,
(ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length.(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELLABANDONMENT RECORD
A$AN For Internal Use'ONI;Y:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
4532-B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'7
Excel-SRP Environmental FOR WATER SUPPLY WELLS ON I LY:
Company Name Chlorination-Ca(OCI)2
7c.Type of disinfectant used:
2.Well Construction Permit unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known �y
7d.Amount of disinfectant used: `�-OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): MAY
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Claylnforprla.`iOn Pry
❑Industrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ❑Drill Cuttings DWQIISOG 9 V rw
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-8-lb Bentonite 32-lb
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete-$-Ib
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
filled casing With Bentonite,pel lets and poured neat cement
4.Datewell(s)abandoned: 04.25.2022 until approx. 1-fbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) & atiep:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 05.24.2022
Physical Address,City,and Zip Sign Certified W 1 tra r or Well Ownei• Date
GRANVILLE 192313139147 By signing this form,I hereby certify' that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude.in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formultiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —35.49 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniectimi Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —25.01' (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Bill Joe Payne Jr
Y y 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-,30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
4532-B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'S (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Chlorination-Ca(0Cl)2
2.Well Construction Permit 4: unknown -C oN ~'List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:_3-0Z
3.Well use(check well use): IV114 T 2022
Water Supply Well: 7e.Seating materials used(check all that app )* 1,
❑Agricultural ❑Municipal/Public a Neat Cement Grout a en o 1�g U�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay ' OG
❑Industrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 32-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete-8-lb
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
filled casing with Bentonite pellets and poured neat cement
4.Datewell(s)abandoned: 04.25.2022 until approx. '1-fbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) r ation:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 r 05.24.2022
Physical Address,City,and Zip Si ertifled Wei/Contractor clWell Owner Date
GRANVILLE 192313139147
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —34.06 eft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 4 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —24.60' (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL:ABANDONMENT RECORD For Internal Use ONLY:
1.We11.C6ntractor'Iriformation: WELL ABANDONMENT DETAILS
Bi I`,Joe Pay he Jr
J' 7a.For,Geoprobe/,DPT or'Closed-Loop'Geothermal Wells having the same-
,well Contractor Name(or well owner personally abandoning well on his/her property) well construction/doth,only l GWI30'is' eeded l_ndlcate TOTAL-NUMBER of
wells abandoned:
45,32 B.'' I -
NC Well Contractor Certification Number 7b.Approximate volume of water iremarning in well(s):; 2 4
Excel-SRP Environmental FOR WATER SUPPLY WELL S;ONLY:
Company;Name;a 7c:Typeofdisinfectantuses:'Chlorination-Ca OCI)2 .
2.W,ell Construction Permit#: unknown ,�.. - v PEJV-
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta)if known ��OZ ` _
7d.Amount of disinfectant used:'
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): :IRfOfBn Ursit
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite-Chips� � 9
❑Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑Diill'Cuttings
❑hri ation' ❑ Specialty Grout ❑Gravel
Non-Water Supply'Well: ❑Bentonite Slurry ❑Other(explain under 79)
SMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb- Bent6nite32. 1b-
❑AquiferStorage'andRecovery ❑Salinity Barrier
❑Aui fer-Test. ❑Stormwater Drains
q . ge Concrete-8-lb
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief descriptiowofithe abandonment procedure:
❑Geothermal.(ClosedfLogp) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Dropped Galciulrl'Hypochorite tablet into__well casing and
filled.casing With Be .tonite'pellets:and,poured-neat cement
4.Date wells abandoned: 04.25.2022
O until approx. 1-fbgl and poured_concrete,inside casing-to near the
5a.Well location: TOC and placed,,the lid an,the manhole°of the well
Fast Fare NC-525.
Facility/Owner Name Facility ID#(if applicable) e 'nation: -
215 WILL.I,AMSBORO RD, Oxford NC, NC 27565 05.24.2022
Physical Address,City,and Zip Sijnat0Fof Ceitifi We C trnctor or Well Owner Date
GRANVILLE 192313139147
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional'well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# MW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —38.84 (ft) 1617 Mail Service Center,Raleigh;NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) above,also submit'one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —23.50' (ft) Division of Water Resources;Underground`Injectio i'Control Program,
1636 Mail Service•Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 00 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
6E Inner casing/tubinglength(if known): (ft,) abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Bill Joe Payne Jr
Y y 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-M is needed. Indicate TOTAL NUMBER of
4532-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'$ (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorination-Ca(OCI)2
7c.Type of disinfectant used:
2.Well Construction Permit#: unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if knorm R 3-oz E e�
7d.Amount of disinfectant used: SS � 1 ,4,w
3.Well use(check well use): MAY
V
Water Supply Well: 7e.Sealing materials used(check all that apply): MA I 2-7 .21rn
22
❑Agricultural ❑Municipal/Public a Neat Cement Grout S Bentonite 9AMtPr0CZ4;"UM
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay (}V0A0(3
❑hidustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 30-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete-8-lb
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
filled casing with Bentonite,pellets and poured neat cement
4.Date well(s)abandoned: 04.25.2022 until approx. 1-fbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8•C tion:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 0. 05.24.2022
Physical Address,City,and Zip Signa ified Well *tractor Well Owner Date
GRANVILLE 192313139147
By signing this form, I hereby certify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A-NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this farm within 30 days of completion of well
6a.Well ID#: MW-4R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: -'35.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above, also submit one copy of this.form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —23.72' (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Bill Joe Pa Jr
Y Payne 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4532-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4'2 (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name Ch lori nation-Ca(OCI)2
7c.Type of disinfectant used:
2.Well Construction Permit#: unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: —oZ �
3.Well use(check well use): --D
Water Supply Well: 7e.Sealing materials used(check all that apply): MAY ►f 2n22
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets" l'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Yta:rOn Pry g UM
❑hidustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings DMOBOG
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 52-lb
❑Aquifer Storage and'Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete-8-lb
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
filled casing with Bentonite pellets and poured neat cement
a.Date well(s)abandoned: 04.25.2022 until approx. 1-fbgl and poured concrete inside casing to near the
sa.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8.Cer' n:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 05.24.2022
Physical Address,City,and Zip Signature ertified Well ntm for o ell Owner Date
GRANVILLE 192313139147 y signing I y fy () )
B si nin this form, I hereby certify that the wells was were abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit oneform.
10a. For All Wells: Submit this fonn within 30 days of completion of well
6a.Well ID#: MW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —50.00 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface- (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length Cif known): (ft,) abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr 7a.For Geoprobe/DPT or Closed-Lloop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed Indicate TOTAL NUMBER of
4532-8 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate,volume of water remaining in well(s): 1.7 (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name . Chlorination-Ca OCI 2
7c.Type of disinfectant used.
2.Well Construction Permit#: unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown `;_oZ .; :�f°� A
7d.Amount of disinfectant used: • ...l IVi
3.Well use(check well use): �t
Water Supply Well: 7e.Sealing materials used(check all that apply): MAY r�Y 2 ( .2022
❑Agricultural ❑Municipal/Public S Neat Cement Grout S Bent r P lets
Unit
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ' fr
Q113+�
❑IndustnaUCommercral ❑Resrdenhal Water Supply(shared) a Concrete Grout' ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each-material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 31-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete78-Ib
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
filled casing with Bentonite pellets and poured neat cement
4.Date well(s)abandoned: 04.25.2022 until approx. 1-fbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 flo 05.24.2022
�7
Physical Address,City,and Zip Signa erti ed Well o ctor Well Owner Date
GRANVILLE 192313139147 By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use'the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: �35.00' (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —24.48' (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For InternalUse'ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4532-B " wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water riemaining in well(s): 1.6 (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorination-Ca(OCI)2
7c.Type of disinfectant used:
2.Well Construction Permit#: unknown ry'
List all applicable well construction permits(11.e.UIC,County,State,Variance,etc.)if known —oZ
7d.Amount of disinfectant used, J.
3.Well use(check well use): iD
Water Supply Well: 7e.Sealing materials used(check all that apply): MAY 2. 2022
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑D Clay
lnf�x'�n T'rtscc ,o V/�
� Z� g PP Y) PP Y( g ) rY Y ��,���
❑hidustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-&Ib Bentonite 31-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDminage Concrete-8-lb
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Dropped Calcium Hypochorite tablet into well casing and
filled casing with Bentonite pellets and poured neat cement
4.Date well(s)abandoned: 04.25.2022 until approx. 1-fbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the Iid4 on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8. [cation:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 1005.24.2022
Physical Address,City,and Zip Si o Certified ll Co'nitilcttl or Well Owner Date
GRANVILLE 192313139147
By signing this form, I hereby ceKify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —35.00' (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above,also submit one copy of this,form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —25.17' Division of Water Resources,Underground Injection Control Program,
(ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
6f.Inner casing/tubinglength if known): ft. i
g ( ) ( )
6g.Screen length(if known): (ft)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr 7a.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4532-B wells abandoned.-,,
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'6 (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorination-Ca(OCI)2
7c.Type of disinfectant used:
2.Well Construction-Permit#: unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: ` —OZ ie 3.Well use(check well use): 1v .
Water Supply Well: 7e.Sealing materials used(check all that apply): MAY 9 7 .2022
W.❑Agricultural ❑1vlunicipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dryl `:?,1 Prt?c g UM
❑htdustrial/Commercial ❑Residential Water Supply(shared) 8 Concrete Grout ❑Drill Cuttings D%VQ11S0'
❑Irri anon ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slung ❑ Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: 7E For each material'selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement=8=1b Bentonite 32"Ib
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StorrawaterDrainage Concrete-8-lb
El Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the:abandonment procedure:
❑Geothetmal,(Closed,Loop) ❑Tracer
Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
filled casing with Bentonite pellets and poured neat cement
4.Date well(s)abandoned: 04.25.2022 until approx. 1-tbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare'NC-525
Facility/Owner Name Facility ID#(if applicable) 8.Certif tion:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 05.24.2022
Physical Address,City,and Zip Signature rtified Well C tractor or'*;1 caner Date
GRANVILLE 192313139147
By signing this form, I hereby certify that the well(s) was(were)abandoned in '
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional well site details or well
abandonment details:You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —35.00' (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
4 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —25.03' (fk) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Supply&Iniection;Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
III

WELL ABANDONMENT RECORD For Internal Use ONLY.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr 7a.For Geoprobe/DPT or Closed-L'oop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4532-B wells abandoned:
1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '6 (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name unknown Chlorination-Ca(OCI)2
7c.Type of disinfectant used:
p
2.Well Construction Permit#: ,+�...C �i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown -OZ i
7d.Amount of disinfectant used.
V D
3.Well use(check well use): 7
L
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout e Bent mte to r l�B&zz� q unk
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay OQ
❑hidustrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material'selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 30-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete-8-lb
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal,(Closed Loop) ❑Tracer
Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) []Other(explain under 7g)
filled casing with Bentonite pellets and poured neat cement
4.Datewell(s)abandoned: 04.25.2022 until approx. 1-tbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8.Ce tione
215 WILLIAMSBORO RD, Oxford NC, NC 27565 05.24.2022
Physical Address,City,and Zip Signature o •ertified Well tontractor r Well Owner Date
GRANVILLE 192313139147 By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W `,l, You may use the'back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-10 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —35.00' (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —25.40' (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For InternalUse.ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW'30 is needed. Indicate TOTAL NUMBER of
453243 wells abandoned:
7b.Approximate volume of water remainin in well(s): +�-2' al.
NC Well Contractor Certification Number PP g� (g )
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorination-Ca(OCI)2
7e.Type of disinfectant used:
2.Well Construction Permit#: unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflowwn J—oz
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e..Sealing materials used(check all that apply):A A/t V y ((J�
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentomte Cps or�2iU
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ffW&*fdftn PrOCCt 9 Una
❑hidustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill CDMPAOG
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 45-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDminage Concrete-8-lb
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
filled casing with Bentonite pellets and poured neat cement
4.Date well(s)abandoned: 04.25.2022 until approx. 1-fbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8.Cer'fication:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 05.24.2022
Physical Address,City,and Zip e of Ce t We Contractor or Well Owner Date
GRANVILLE 192313139147
By signing this form,I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• RW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: �37' (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —24.20' (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fk) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of.well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

MW-10
I
CoMMERCI L �,,
MW-9
MW-6
LANIER S EET
MW-4 RW-1
MW-2 �
MW-4R MW-3 MW-5
O
MW-1 O
M W-7
COMMERCIAL
CVS PHARMACY
NOTES
Map not exact for well locations
reference only
UST — Underground Storage Tank
Map adapted from S&ME Site Plan dated
November 3, 2002
Structure and boring locations are approximate.
Excel
REMEDIATION Clvrl&ERvlronmentalAssoclatcs, PLLC
LEGEND COMPOUND 625 HUNTSMAN COURT,GASTONIA,NC PHONE:[phone]
Right—of—Way (Approx) PREPAREDFOR: FASTFAREINCORPORATED
Former UST System (Approx) (FORMER)FAST FARE NC-525
Monitoring Well Location 215WILLIAMSBOROSTREET,OXFORD,NC
® Recovery Well Location MAP TITLE: FIGURE 2;SITE PLAN
Sanitary Sewer Line (Approx) GROUND WATER MONITORING REPORT
Treeline (Approx) PROJECT NO.: DRAWN BY:' SCALE: DATE:
° Sewer Manhole
• 25141 BP 1"=40' S/5/2020
Soil Borings/Water Sampling Location