Wake_Well Abandonment_20220801

WELL ABANDONMENT RECORD For haeral Use ONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 7s.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
4330-B wells abandoned.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gaL)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: O�1 ��
Lin all applPersian,0 able xell convrvc non pere. 111C CoveyS, mu, Variorsce,eh:l iJbwwn R
7d.Amount of disinfectant used: V
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): ��Unt
DAgricultural DMunicipal/Public ❑Neat Cement Grout N Bent d
OGe,thermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) Cl Concrete Grout ❑Drill Cuttings
Ellingation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry a Other(explain under 7g)
aMoworing DRecovery
Injection Wen: 7f.For each material selected above,provide amount of materials used:
OAquifer Recharge DGroundwater Remschation Bentonite Pellets —50 Ibs
DAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage Concrete —5 lbs
OExperimental Technology OSubsidence Control
7g.Provide a brief description of the abandonment procedure
OGeothermsl(Closed loop) DTmcer
DGecthermal(Heating/Cooling Return) DOdmrr(explain under 7 ) Cut off top 6 inches of casing below grade.
Abandoned remainder of well in place with hydrated
a.Date well(s)abandoned: 7/27/2022 bentonite pellets to within 6 inches of surface and
sa.well location: topped with concrete to existing grade.
NCDEQ-J.C.Games Service Station 00-0-0000005938
Facikry/Owner Name Facility lD#(ifeppliwble) S.Certification: r�,CJj1 rI9�—lt
g
3400 New Hill Holleman Rd., New Hill 27562 L 7/27/2022
Physical Address,City,and Zip Signature ofCerfified Well Contractor in Well Owner Dare
Wake NA
By signing this form. 1 herein,certify that the well(s)was(were)abandoned in
County Parcel Idemifica6on No.(PIN) accordance with/SA NCAC 01C.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:
(ifweli field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.663888 N -78.928800 N, 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 WELLISI BEING ABANDONED SUBMITTAL INSTRUMONS
Anuch we//cansoun,on rerord/s/rJavm/ubfe.Pormnlrip/ein/onion nr non-x vsereupplr we/la
O.NL F wirh rhr.rvme comtsunrmr ohandenmem,you can.mhes,orw Jarm.
IOa. For AB Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following.
Division of Water Resources,toformation Processing Unit,
6b.Total well depth: 37 Ift.) 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: 8.25 (in) above, also submit one copy of this fomt within 30 days of completion of well
abandonment to the following
6d.W'aler level below ground surface: NM (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Sen-ice Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form in the
addresses)above,also submit one copy of this form within 30 days of completion
of well abandonment to the cowry health department of the county where
61.Inner casing/tubing length(if known): 17 (ft) abandoned.
6g.Screen length(if known): 20 (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For hoemei Use ONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hisNer property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4330-B wells abandoned
NC Well Crimean,Cerofiwrwn Number 7b.Approximate volume of water remaining in well(s):_(gad.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit 8:
List all applicable well uoanrucrmn permia fee 111C,County,Gone,Variance,e/e.)i(known
7d.Amount of disinfectant used: RECEIVE
3.Well on(check well use): 9 - ZUZZ
Water Supply Well: 7e.Seating materials used(check all that apply):
OAgncultural OMunicipatPublic ❑ Neat Cement Grout a BM18CA1 IaP/pIiMMIl9 unk
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
OlndustnaPCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑bn auon ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry e Other(explain under 7g)
11111titnfica ng ORecovery
12*00 Well: 7L For each material selected above,provide amount of materials used:
OAquifer Recharge DGroundwater Remediation Bentonite Pellets —75 lbs
OAquifer Storage and Recovery OSalinity Banner
OAquifer Test OStomo ester Drainage Concrete —5 Ibs
❑Experimental Technology OSubsidence Control 7g,Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTmcer Abandoned well in place with hydrated bentonite
DGeothermal(Heating/Cooling Return) OOther(explain under 7 )
pellets to within 6 inches of surface and topped with
4.Date well(s)Abandoned: 7/27/2022 concrete to existing grade.
5a.Well location:
NCDEQ-J.C.Garnes Service Station 00-0-0000005938
Facday/Owner Name Facility ma(ifapplicable) 8.Certification:
3400 New Hill Holleman Rd., New Hill 27562 7�27/2022
Physical Address,City,and 7'p Signature of Certified Well Contractor or Well Owner Dace
Wake NA By signing this Jam, I herein,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 oJthis record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ho/long is sufficient) 9.Site diagram or additional well details:
35.663910 N -78928921 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(SI BEING ABANDONED SUBMITTAL INSTRUCTIONS
AnrJn wet/conrvucnon retard/.r/lun+uluble. F'ormWtp/ein/eotonornon-xulrrsupplrxe//s
ONLY with the sane corulnxnon abu u/omnem.you curs suhmu arse)rm.
IOa. For All Wells: Submit this form within 30 days of completion of Well
6a.Well IDB: MW-2 abandonment to the following.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 8.25 (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: NM (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Sen'ice Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA Ift•) IOc.For Water Supply&Injection Wells: In addition to sending the form to the
addresses)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
61.Inner casing/tubing length(if known): 5 Ift) abandoned.
6g.Screen length(if known): 45 Ift.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For lntemal Use ONLY.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 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 canstruction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4330-B wells abandoned
NC Well Conuachn Certification Number 7b.Approximate volume of water remaining in welbs): (gat.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit M: Q
L,r,all appbcubfe u e(1 conslruonnn perm,,,fi.e.if]('.County..Stare. Von,—,em./i/known 1
7d Amount of disinfectant used:
ECEIV
3.Well use(check well on): _ -
Water Supply Well: 7e.Seating materials used(check all that apply): ..�a��ytppn PfOC UNI
OAgricultmal DMunicipal/Public ❑Neat Cement Grout a Bettf> t£ChtoNd"(3
DGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
Olndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
Oft-rigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurn s Other(explain under 7g)
SMonaming ❑Recovery
Injection Well: It.For each material selected above,provide amount of materials used:
OAquifer Recharge OGroundwater Remediation Bentonite Pellets -50 lbs
OAquifa Storage and Recovery OSalinity Barrier
DAquifer Test OStormwater Drainage Concrete -5 Ibs
❑Experimental Technology OSubsidence Control 7g,Provide a brief description of the abandonment procedure:
OGeothermal(Closed loop) OTracer
(Heating/CoolingDGeothermal Return) OOther(explain under7 ) Abandoned well in place with hydrated Bentonite
pellets to with in 6 inches of surface and topped
4.Date wdl(s)abandoned: 7/27/2022 with concrete to existing grade.
5s.Well location:
NCDEO-J.C.Garnes Service Stabon 00-0-0000005938 1
Facility-Owner Name Facility IDa(ifapplicable) g.Certification: V�
3400 New Hill Holleman Rd., New Hill 27562 7/27/2022
Physical Address,City.and Zip Sigm[ure of Certified Well Conuactorur Well Owner Date
Wake NA By signing this form. I hereby certify that the welf(s) was(were)abandoned in
County Parcel ldemifi,imini No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Co tsouctiat 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 Iatilong n sufficient) 9.Site diagram or additional well details:
35.663742 N -78.928955 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
A//xh wea conslruc/ion mord(a/,faw/fubfr. F'ormn(npfe m/eauun nrm n-wmrrsupplr weth
ONLYwilhrhe.r,,m e.auctlonabu/alanrnenr.wtu..urb.1.,J nn
IOa. For All Walls: 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: 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (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: NM (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer easing length(if know it I: NA (ft) 10c.For Water Suuolr&Initetioo Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days ofcompletion
of well abandonment to the county health department of the county where
61. Inner casing/tubing length(if known): 5 (fL) abandoned
6g.Screen length(if known): 30 Ift.)
Faso GW-30 North Carohm Department of Environmental Quality-Division of Water Resources Revised 2-22.2016

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e FORMER
LISTS
MW-2
1 MW-1
WSW-1
FORMER
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• 'q i s s yV_3 y r
QSa'i�i '
• vol sz
LEGEND _
a .:w P. WSW:2 'B
• Abandoned Monitoring s a
Well (Type 11) -_
© Active Potable
Water Supply Well
e Inactive Potable
Water Supply Well
Approximate Location
of Former UST System
Lj Parcel Boundar
y a eogr phics. NE54'drt �s ^vS
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 30 15 0 30 60
Ed iiiiij Feet
"1OJCT J.C. GARNES " E FIGURE
SERVICE STATION
CATLIN H340 OLLEMAN HILL
ROAD SITE MAP
Engineers and Scientists NEW HILL, NC
INCIDENT NO. JOB No, OATE SCNE d MBYK:HKK OBY
23649 221045 JULY 2022 AS SHOWN "ACISJO