Wake_Well Abandonment_20220823

'U1�111:�BAIyD•p, nCOID
116 forrss•con be uitd for eingle er mtilUplb�veUr !v�+ssul UN ONLY.
1.\Yell Conl for Inrnrtnnitans •• -
1VeIIConuaelorName(orrvellu oerpenaul(yebendoningirillbnJdaerprupr�). ForNnmbplrotnfd�nelnQ+�b�dHolral rsrpPJy serf/r ONLY srfds the some
eortrrrvercon/abandrnmrrs�You can subrnrf one jornr.
HC Well Cnntrn for CeWncauou Number 7b.Approtttmate•olnme o[nnter remAlni I ng n eeU(s): aL
N.W. poole Well & pump Co. (g )
Coropnny NaUrc FOR WATER BUITLX WELLS ONLYs
2.WeU Conatrucdon•permlt N: 7e.Type ordblefeelant nredt
LIJt all applrcablr%'rl! r
p ,mere tT.e,Cv+v+q;srofr,v area,lryrcrluq reef[ftnoxn. ��
3.}}'ell we(aback n ell use M-Amoont of dIjInfKtinl used:
FtJAgoSI YP
tIaul(urnj 7L Saling noittritdt tued(cheektlUtht UMunlolpa(plbllo epplyry):
lcnnl ed 0NatCmenL uL(Iicalng/Coolht Supply) senal WalcrSuPPIy(,In " " �cn lonfle Chips or Pcllcls and Cement ludusa/Comecial clay
❑RwidenUel Water supply(eltetvd) 13 Concrete Oroul
f7lrrl allolt � O DHU CulUngs
Non-1Yrrter Supply Well: u-specialty Orout AU G �a 2�2 n�',�rnvel
l7Moniloring ElRentmdicslurtV,
Injection ell: ❑Reeov littuit Lrl 1 r0CSGv'�'jR9 UrMlcr(explain under7g)
0 Aquifer Rechn rge 71.Foreaeh mt,(eri ll ulFeterf ilvovy prvride amount bf matcrlRls used;
❑OruundwalerRemedildlon ..
DAqulfer8tulage and Rccovey ❑Shctil(yl3aMlr
ClAquifer Test
❑SlormwattxDralnago /�r_� !_ /T� / � r
❑Gxperimcnlnl Teohnology, [ISubdldcnco Control
❑Gerilltermal(Closctl Loop) �7g prorlde> blegda�rplo��E
Lae fl f tpeocedure:❑2coUlcnta icttln Coolln Relln 001hor r 7 fJ7i lai
J
— / �� ��
'.Dole trcll(s)abandoned:, ���"� ►� / �� �
30,1VeUloccaa+linu:
A/`�����,,• �i�/�b'f—� ,•�' 'gyp
�sc:hly/Owner Name
_ FaellltyID�(Ihsppicrbla) 8• eN1!(eiUonl
P6ysle'a Address,Clly,and Zip
81pr�ttAr of C I WdU Coataolor or WeU Owner ?;
dole
Cauuly Dy Jigr+fng fhlr.fvrnt,I htrt�y certify Mat fit R11 s tvar w ref abandoned In
Patcolldemliltxdvd No.(?IN) dceorddttct16111ifJ,{'IYC,I0U2C,pjllOarTC.0100(li'eflCotufnrdfoltSfnrrdarda
db.I,aU[udb+tud:Ionylluitp ln'rie reti/minuleihecoadt or deelmtll degrees: dhd Mud a eo11y of fhLr recatrf has been prarided to llte well owner,
(lin•ellflcld,�otie IeVltirig li iii8toleie}
c r 9,811e tlltetttm:or addlHSii.l Tran-detAUs:
N �. You miry t6d to li b.a of Uil pago to provldo additional well silo details or well
e.
ebandonmevt`dbtgjla: tuu may also attach addlllonai pages(fnccessaly.
ArfadhYtTl
�relra'?)W ,;
i t'h�:' A% o80
1i} eel o e , ,: : ,:�i lift ' i be fir rron=lratfr'ngrply.
if I}ldHhre(fl,ji3ketihrubnilrorirjvfm,
ia.Well IbNs lot, : Subinit this furor wiO& 30 days of coalplellolt of Nell
abendorirftetit 16 Ulo''foUiriving:
r=b,'foral flail delttb: , DlvIJIuA'oflVtferResources,Information processing Unit,
(f1) 1617 Min Sirvict Center,Relefgb,NC27.699.1617
lob,h ".
Uorehole diameter:. ��s haddition fu sending Utc fonn to Ole addirss In IOa
(In•) above,AJso'eUtit{it.ofib copy of Utls farm \YlUlill 30 days of co
abandonment i mpletion of well
d.die ibllowing:
'ri•}Voter 6d beloWgr9Uriil'il1rfxl e:.
(!L) blvialon uOVA fir Amore ts'Underground Injection Control progrour,
16�5}(Yi()�erviee Center,RAlelgh,NC 27699-1636
iC•Ou(erCaAing�lengl�(I[ithuirh)s � ., ,
2- —L—vL) toe
the•ed '•'�`.ib'• ��• r In addition to sending Ole Cornt Io
ttvb, also aubntit tmo copy oC Uds form wiUdn 30 days of
Inner casitig/ldbing length(ir•�dwn)t. complelltiti otivoh:abendoninent to Uto coon hcalUt
�r([G) wftgoebandtmed, tY department of Ole County
' .Screen idl tH(I[)iuoiviijl.t: `�
I` Ix 0lV•30
' Ntirih�irollni bep'itimeat bf Psrelrnn,....,._,,,-.. ,_ .

. . � YY.�'i1r,�:,�B;AIYD'O.�EIY�'�CO�D • • (��,,„ 11ONLY: ' . .
71tis fonn•cnn bo used for elnile or mriWple wells 1N1181"0
L}Yell C lra or Inrormnll vs
Well Contractor Nune or 71.Namber o[irdlj belne Abandonedi
( lawnerpenonalV,b,tndcalulHUbnhiAnproprtty) For muhfplr fyeerfon or non•rrorer r�ly stiff, ONLI nhh the ionic
cen,rrvenm✓obondonmen{you con iub,ntl onelenrt.
rlc Well ontrac of CetilllcaUoo Numbs 7b,ApproxImale Tolome of Baler remalning In trellis):
N.W. Poole Well & PUMP Co.
CompmtY Name FOR WATER SUPPLY WELLS ONLY: '
2.IYeU Con+trncllon /,, 7c.Type of dislnrecUnt vied,
Lrarollnr llco8lrrrrn rM��JnitH�l/1�_ e� S K —
lp > ii i
1' tr.e,Cmmq,Slorr,I mimrer,lryreaors,efef(lh,oxn •
I Well use(cbeeltn•ell tsec)t 7d.Amonnt ofdlslnfeclaat used:
11'aler5upply}i'ell: •
OAgrleullurnl 7e-Sealtaa materials tued(cheek in that Apply):
❑Munlolpal/Publlo ❑Neal Cement Orout.110celhcnnni(hlea(Ing/Coolhtg supply) Oesideadd Water supply do e ❑Sand Cement t7�,;t ;., d hm lonhc Chips or I'dlcLs
❑ludustrlal/Contntereltd - PPS( 1�) 9�
❑RmldenUel Weser Supply(slltrrd) ❑COnat,e Orout i i HE 9 l` C ul
.OIrri ollon � r, 202� ]hill CulUngs
Nan-)Valersupplylycll: peetallyGrout pl�r, �; 1 Gravel
Ohtortiloring ❑Ilenlonllo Slurry r(explain tutdcr 7g)
Infection 1Ye11: ❑13sxov
Ifl'rui7'fiFS°t!o:a Fifl'�,$•�"r+'xft�
❑AqufferRechorgo 7f.For each material selecld$}uQir� yfde arootrnt bf maferlals used:
❑Aqulfcralulago mid Recovc ClartrundwalerItcmallnllvn y & a' ,fig�
n' ❑Sallnl(y13ttM,r !r�1'``�'�M ���
0AquifcrTcst I75lvrmwattxDra►t,ago ���'
r7L;cpcHIIlcIlW Teclurology ❑Subaldalco Cvnbvl
00chiennal(Clvs&d Loup) EjTtaacr 7g. lde is brietdescriptlan of the abandonment procedure:
C1C3ealhennal icalin' R cr Iallt outlet 7 .y p
I.gale 11-ell(s)AUAndoned: �` _
an.Wall locallonl J "' p
,acuity tvner Nr me Fe ISIy loll(lralrpDc+blr) 8. er11f(catlonl
Phyrlcal Addr ea,•Clty(anti Zip
(�� f��/ 816n+two o[Ctt W Covtnclm or We0 Omer
Date
County By slgning IhLr.fvrm,I hervr certify Utuf flit )v910)tear Oerel abandoned In
Patcrillde�IDeadorlNo.(PIN) dciorrliuict lU1IJ.(''NClC 01C,0100 or1C.0200)Yell Conitnrcilon Standards
:gib.LaUludb.and:ItinQllpii�In'tlegreei/inldnte:i/secands or deelmal degree : and that d espy ojlbGr rrcord has been provided to the well atvner.
(lrnall'Oeld,'iiod lsllltiig li tuLBiilsrimt) ,
der
9,81te dlairtm:or xddlfibnal Tren'detAUs:
��s N L You mky Yitd t6e.'S°tit:lc of tlile pago to pr°vido addlU and well silo details or well
�' sbandonmutl'dM1s: You may also attach addlllunal pages Unecesswy.
Alfneh'il9i 1 ne '' '•
+rslli bhr ft fri))i'1 Irt' cbtff
a. li�dhtnehl,)dk ekit n+br'r't1f sine fvtm,
in,lYell Iblf: lox,For: II:W'lht submit US frnror willdn 30 days of complell°n Of well
• 1 I abandodint>fil Io'Uto:i'oUiSwing:
b,'I vial n ell Ut)tlh; Illvtrlod'oflYaterResourcrl,Igfurmaflun Frocesslug Unit,
161511iill8ervict Center,Raleigh,NCZXG99-IGI7
r
:c.IloreboledlAmcfert. IDb, r �4�;SY tit In-addhlonlvaatdin Ulcfont v(In, ebvvc 8 t 1 Uic adds ss In I0a
,Els°�sulfu{rofib copy of oils form wlUl6t 30 days of compleliorl of well
abandortnienI id.Iho I`ollowing:
�ri.lVnierlcvel beltirrgrattriit�iirrfacer.•.: '�
(Il) Dlrlslan otlYlfirltesourcea,Underground Infectlon Control Progrnut,
163�'i4 lj�erTlce Center,RAlelgh,NC 17699-I636
•Qulereallnpliygtts(1f1lil0irh);
the e cU°_1n yyet�s; In addition to sending Ott:fomt to
d '. Ee':r{b' 'RIO subtnit one ropy of lids form Madn 30 days of
is Inner caslrig/lilblug-length(lr•)mawn)r c°mplelltip of lvolf.ebnndottinettl,la Uto county health department of Utc cowtly
.—____�_(f;,) wirac nbnirdonszl.
- 5ctce1l•.liti�lti;;(�f,liporvHjl•l' :•"R' i
"imil OW-30
' ' }�otth�eitillnibipiticaaatb[U„irti�M..•,._.r„_.. ,_
I

r
rr U ALA22hMmirmoRD
111i5 fonn•cen bo used for single or•rnult)ple Weer � " �UiONLY.
1.Well Co tlelor inrunnnllour
-
Well Con cl N e or w 7L Number of WdIj being abandonedr
wnsrPorto brcdor InQNutaIdLiyrrproperty) For mulUpJr repot,
i'll or
tlon-realer JtVply trelit ONLY whir the Jame
++ eon,ervener✓obondonmrnt.you emr,ubrnll one form,
1•ICWe1lC nlmc CerrlacatlonNumber 7b.Approxlmalevolnmeeterremeli nngJntrell(e):
NA,, Poole Well & Pump Co. ofn (B )
Coropnny Natne FOR WATER SUITLX WELI 9 pNLY1
`7-{'� �
2,}Yell Conrirnctlon•1'ertn(l H:ai 7�Type ofdlslareelxofuredt_
LIJt all appllco8lr well prrntfta(l.e.Cmmb;Slo'ir,i'vr{errter,fryrelfon,r!e b,
J U a<„ . F
3,}}'ell use(eheCk n•cll rrse); 7d.Amonol of dla(nfeelaut used:
- }YarcrSupply}Yells
OAjlrleullurnl 7e.Sealing mxterple used(chick■Il that apply)s
C1GeoUtcnnAl(1feaLing/Coollrr Su ! 17MunlolpaUpublto ❑Neat Cementareut,w _
8 . pp Y) pidartid 1YelerBu I (single) O Sand Cement �' �}lonfle Cltips orl'dlcls
❑hrduslrlal/Conv»crcllil -. p�Y( �) ����',..d' 5�sC ,1� Clay '
❑Realdrntlel Wales Supply(ehtutcl) U Concrete Gruut
Clbii aunty o NO Cultings
Nun-}Paler Supply Ncll: C'8peclalty Grout p,l�r 2OZZGravel
Cllrionitoring U 13enlonlloSittny
lnJectlotr Well: C3llecov
Irn�mss'av, ,?•�rf�•oW�53:R3�1Rflur(�rpin)nurtdcr7&)
❑Aqulrct•ltecharge 7f.For each me(erial eelrWAj tii ry�pMIde xr oount brmxlerlats ueed:
C lAquirer Storage alyd Recovery �S�llnl[d Bufleremalfelloil
❑AquifcrTest Y
❑Slorinwatot'Dr&b4, L�
❑GxpbriutcnW Tcclurology ,4�1/J � .
❑Geothermal(Closed Loop) ❑Tn aQda!s°Control
7 , rorlde a brief deaer[pilnu of the abandonment procedure:
C1GcoUlcnnel fcatin' Coolin' Reltirn ❑other '"o.
i
✓ labs unda7
4.Untc irell(s)abaudoubd:r, y.
3n.WEB loenttum;
ncillly/t)wner Nsme Feclllly)b�(Irl"llerblr)
8,Cecil floor
1"II�IICrI AdU,OEA,.CIIYI gait ZIp
8lsarlurd o CettWbd W oalrxolor or}Vell Outer Dete
count y g.
y patcdlldeatlfleadodNa,(pW) " thij.
I henDy ceri(fy uwr ulA lvelJ(aJ,vnr�,�eYef abandoned In
4a4(.udh.and;I6nklluild In'degreeilinlautei/eeeandt or declmlll degreer; r�rae}6Jut f J�NClC 01C,01oo or1C,0J00)feel!Corufnrdiort Slarrdnrrls
andfhaf d cofn'GOILt record har been prorlded fo I/Ie Well owner.
(Ifwell'fleld,'tiae 1�111biig li It7FHefei,t}
t o e 9,SIIA Jlagtxrn.ur r(ddltlbbal well'detalle:
You Wily tud,tlf6�aaJc of Kith pago to pruyldo addlllonel well site details or well
N ebandonmerlt'detalls: You miry also attach acldl(Ional pages lfnecessaly,
v rllt ON `1' li
#1tr11)i'f1r'r' m c' lfl}r' -crl` abafidaaioilil���••^ ib aiier.narixallr'ngrply'
c8rrrubrrllrtiHrfofm,
till.1}'ell Ib/f: 1Da,For:A_ 1 1 •Submit ads furor witldn 30 days of complellon ur well
ebandudinurit Io nl'o''following;
t:hl'1'ola(fvelldelrlh: ® Dlvlelori•ol`1YA(crResourcei,Iyfurma(InnFruccs,lugUnll,
(it.) 1611 Willi Service Center,Hilelgh,NC27.699-1617
,
Isar ehole dlartrcter:. lobE+�+-!!u Yltlt=lYE�i1 In.addll(oll Io aalding file fnnn to Ole Wit's Ill IN
nbovo,tdeo'�UNMIt"'Jio .
Abandonment id.11tofollowing;of tills fornt }viWln 30 days of completion of well
:6.lvnier level below gratlriil iirrfacer..:
(fi) Divlefbn afi%Urlietuureu,Underground In)ecllon Control Frograul,
1a );p Hervlce Center,Raleigh,NC 27699-1636
^.•Outer eaiiing leygtlr:(I[ltilu`rsb)1 '
lho Ad : In addition to sending lire foml to
•nbt)vb;'aleo Aubmlt ono copy of(1de form widdn 30 days.aC
Inner easldg/ldbing I,ng�u(If Iwirwn)1 completldri of ivoll'abatrdoninetrl to dre coon hcAldl de
Abandoned, �' pettmertl of Ole courtly
_ Scrcetltltti�lNi;(�f�(iiioivb)1,(;.
(R)
"�tre!r0}V•30 •• •

rr�'iL111:�Dc�lyD-UMN I CORD
FCtoal U�c ONLY:
71tia fonn-cnn bo used for aingle or•mnluplb wells '
1.\Vitt n lrxclor Inrura�nllon: "
Zile
` - V
1Ve11 ConUaclor Nuns(or Well
Owner pen�(yabadonlnpir�l] y 7A Number o[ireli:beng AbaadonedrItILib port For multiple injection or nmt-xafer tt¢,ply trrlL ONLY urrh nce aon,e
conirrvenen/abondonmrnA you can fub,nll onepr7ri.
NC Well Cannxclor Cerglicauon N=ber 7b•Apprasim,tte•olnme of eAler remAlning In xeu(s): al.
N.W. Poole Well & PUMP Co.
CoropanY Naute FGR WATER SUITLX WELLS ONLY;
2.}Yell Construction 7c Type of dlslafeetaut need:
..Permit hf: v ./7
L!a!all apprlcab, u•trt r,mrld h N '
p 0.e.Co,e, S!o'ir,I'artarrcr,I ectlam r!e)t(}n Q
3.)Ydl use(t heck n'ell use d•Amount Of dlslnfeeliui used:
}}'alerSupply
}}'ell; ° •
l7Agrleullurnl 7e.SWIng m,lterliti-nded,(chick,&UathA Afrpl
❑Munlol el/Pllblto 1:.:' , �. 2 )l
lJGcolllcnnal(lieaung/Coollll Su 1 p C Neat Cement GruuF.. �w,$
g pp Y) esldeuual Water Su 1 eln a ❑Band Crantsll Grout ° � 41aJh onlle Chips or 11cllctS
❑ludustrial/Commerclnl pp Y( �) ❑ Dry Clay
❑Resldutuel Water Supply(slurred) 17 Concrete Grout A.IJ C, � ?
.Curti allon J 202.t7 Drill Culungs
Nan-Water Supply ly,11: )9ptchdly Grout,
OMoniloting I713entonlloaituy4r en i'r�e. '7 vet
InJttuar Wellt 011txov ;`3l#rt i l l7 Otl,cr(exPirdn under7g)
❑AqufferIlechargo 71.For Exch miieNAl selecled above,prvvlde Afilvuol brmAlerlxls used:
0Aquiferelotago mid Recovery ❑5a11nitY CICIrutuldwaler BarrieremedlRlmt K 11A A�!J 57 0
DAquifer Test
6 i-0116
4/I�( /Q�,❑5tormwalerDra(;,ago
❑E'X*lllcnW Teciutology
❑CcoWcrtnal(Closed Loup) OT cacr Control
7g.Prvrlde x brie[deavfpllan Of the Abrtndonment procedure;
❑Ocolllcrntal icatln' Coolln Rcltirn ❑Other islet undet 7 y
4.lh(c}rell(s)mbmudoned:
5n.11'e�l IDCmIIUIII Q��
raon►iyiomner Nerve`
' FecllltylDll(iC,y,pllcr6le) 8.Certi!(eAtfon�_._
Pbyelo I Addreaa,•Chyt end Zip
111an1 tar of CtMid 611 Contractor br Wep Otrner 6+
Date
Couuly
Patc611dculld By signing lh4.jvrrrr,I hem certify Utat the wells)spar(were)abaltdolled trl
tadwNa.(piN) dccorddrlCet�iQj'/J,'NClC01C,0100or1C,0700M11CollitnictionStandard;
3b.LAulud6.Aud:ttit]jtlltiiiit In'rlegree,drillnntei/secondC or declmAl degree,: mid thal a copy ojlhIr racvnf has been provided to the well ownar.
(lCnelf(3eld,'ood lal/Ibtig li}tiFll'eleixJ ,
O. 9,Sl(e ditgrwt;ar addllibhal Trell'detalls:
f N 7�..�7�5D You mky u�d the aolc UriWs pago to proYide additiund Well site details or well
�' abandonment'delalle;`You may,Idso altach addlllond pages if necessary,
ve111 bly' :''! MRUAL
M MY `rdtirtlabni�dli:` b!nOn Srarir'ngrply
tnr6l,jtlk edit sub�tjr tiriefctm,
'ix,Well Ibil: IOA, r 'Submit lids form Within 30 days of completion of well
abandodhlent to Ntull6wing:
t-b,Taint tr'ell depth; D1vlslori oflYAterResOurcee,Iyrormallva Frviceulug[loft,
(fl) 1615 I'll Service Center;RAlelgh,NC27,699-1617
i Iorehole dlanr leer lob. Ea eernrt'Nn
r In,eddldvn IO satding Ole form to Ole addrrss In IN
(In,) nbove,hlao"huhill'oho copy of Oils foml Wililbr 30 days of completion of well
Cy7 abandonment Id.die'following:
'ci•.Voter level bel6fv•groUnl{'itiH•Aeer Dlvlilba of:tiYtilbrlseltinrces,Underground fief ecllon Control Fro rout
(�) ( ,
W �-ff ldervitie Center,RAlelgh,NC 27699-1636
o•t7uler ea6ing lengitlt(If ltiitUFrn); `�
lho ed In addition to sending die fomt to
ab ' atop subutJt ono copy of ads form Wllldu 30 days of
r:lnllercrosltig/ltiblug•lenglh(Irllnuwn)! '� cotnpletlori orivbll.abaitdo'inettl to the coon ftcnlut do
-(ff) where nbnndoned, county partincul of Ole courtly
_•Gcrcettjli't�tH,(lf,kitiivtijl't; • �� •
"�>ttt O1V•30 .

YY�'iL1 :�1BAIyDOIY�YIEIYT CORD u
ibis fonn-can ba ustd for single or tntillJple weUt � � I um O11LY.
!.\Yell Cunl actor lnrvrwnllons •
1Vcll C tltractor Nuns(or well Owenpenoaal .btndoaln ` 7a.Number ofWdis being ttbraudonedl
BiriUbai"Llb-property) For mulllplt lnJeellon or
non•rrelrr rs rrrlrt ONLY utrh dm tamr
� eonrrrvrao,s/vbondonmra{you can rubinrl our formi,,
tlC Well> vatreclOt Cattlnaadon Number 7b-Approximttletolume of haler remaining In eell(a): al•
N.W. Poole Well & Pump Co. �tg )
Connpnny Natnc FOR WATER BUPFLY WELLS l7NLYt
2,iYeU Conetrnction / g fj/� f�`4 7r-Type of dlsenfeotant utedt /L�,
LIJI all o l limb'j,n,rlr Q�'lj O.L.N:M�'v� I r
1p p (l. Co+mry,S/on,rarlmrcr,fryrctlon ucJ(/,Moan
J.Well use(check well use): 7d•Amount of dlslafecUnt used: Y
ii'aler Supply ii'e11:
LIAg'r(eullurni 7e.Seall ig m,t(eritds sued(check■U that t�pply);
❑OcoUtcttnal(Iiealing/Caol(rt Supply) OMunlolpd/Publlo 0 NeatCem rvut..,a ,;
8 pp Y) Aealdellfld Water Supply(tingle) ❑Sand Ccmgtl©riatu 'I;:-" "V a'~ Dry May
a Chips or!'cllcls
❑luduslrlalfCornnterclal es(dentid Water Supply shuld) 0 Canertic aroul �Y Clay
.OItr{ allott pp Y( � 0 IhiU CulWgs
lr2
Nan-iYtticr Supply�Ycll: 9pocidty Oroutp• w 02 0 Ora vet
Oblanlloring ❑13cntanllo gs1 f
InJec(lon Well: 011ecov Into ,r.;i0� i�f�C :" U0100ler(explaln Inldcr7g)
❑flqulfcrRechargo 7r.For e,rehmaterlatP'eleefeAa rgprvvide;tritaItntbrmatrrlalsusea:
OAqulferstorage and Recovery' Ma lbtlidHturlr(aemallallOil �,���
❑Aquifer Test
❑SlormwatcrDraGlago .G.
OlixpctintenW Tcclulology OSubsldcn"Control
❑Geothermal(Closed Loop) OTraacr 7g.Prtrride a btie[descripilun of the■bandonment procedure:
❑(IeoUtcmlel lWin" C0611n Rcltirn 1701hor lainundtx7
14.lJnlc tl•ell(s)abandoned: "°' '���, ����1F�LL1�•�,��'��"'�J�
3n.lvaulocation!
racillly%prrner Neme FasilUty IDFL((fyrpparblr)
r, 8.CerilticiUout
fhyrlcel Address City ndlp " ��s 8lanrllao'o+(.C.e�t
Wnmoalorbr Well bmaer Date
Cotaly — By signing ilJl.jvmi,I hire
Patc y eer7(/y 0XI(lie )veu(J)war(were)abandoned in
el ldeml0tadod No.(PIN) dei;ordmldf 10110SA IVC O 02C,0100 or 2C,0200)i'e11 Colutnlctlon Standards
:fib.La(lludb+tnd;louQlluil�ln'rfegreeshnlcnlei/teeoads or dedmal degrees: andthaia cW of d rct:tlr oniku been provided to the well owner.
Orn•ell'tleld,'oosi 1nV1 itig li lt7FAeleist}
9,Blle dlsgrxm.or ttddlUohal yell delalls:
'7Z. You mky usd;tlie '"i: of Mile pago to provido addiaund well site details or well
t.
ly abandonmwt'dttalfs: You may also allach addllional pages If necessary,
AriacNYli!1�J ��. '• '
relli dJV P ltl Jji'flri ir:` cb11f ``CrlfhC�alsR{tr?dNtnelif 4k r^ i� on Or non-iralir'ngply S
�) c8rr ryb+i+lr uric jotm, _
!;E!,Well IN: lox,For, li'Sy ll': Submit lids furor wiO n 30 days of complelion of well
ebandonineril to llto:[oll&wing:
t+�bt Total fi'e11 depth: Dlvtriari'af}ytlterResourcrs,Information Processing Unit,
'
(M) 161711ii11 Bernice Center,Raleigh,NC27699-1617
lob,
"'•Dot'ohole diameter;. �eC- '.. y.S;r In eddll(oll to sanding file fonts to Ule adds' In IOa
(In,) abort,tlso'ei1U>r(lt'ofio copy of tills foml WIU:hn 30 days of complelion of rvcll
abandonment Id.th following;
'!i•1Valerlei'elbelo'tvgrattnil'iitrftt¢et..� D MIND oltiYft6rRestinreeatUndergroundlnfecllonCoutrulPro( ) grant,
l9ervice Center,Relelgh,NC 27699-1636
:��•Outer eaelnp lleugill(If ltild�•h);
the ad10 '"" ''' In addition to sending utc fonts to
(at'.abti* a16p submit (me copy of tills form widdn 30 days o[
`:Inner casitiglldblug Ienglln(IPknuwn)l '�� eolnpletl6ti of ivbll'abaindonenenl to Ole county hcalUt department of Utc county
KilcmabandonM.
-�u"crcctl'Ie!»�tH,(Ifliivivti)►'r "—
itrtn 4W30
• ` North•ClittillniUep'iuitaaatb[L,rima,....,._.,,t_.. ._

'or NT�co� .
"'Is form cnn be used for eingle or•tnnllipl'e well, � �8(G{IHI U0 ONLY. ! ,
!.)Yell Cunt•ail •r Inr�„llont
STAU
«'oil Collhelar Nune(or well oW°er enoa,lly,bmdanln 72.Number of hails being'AbAndonedi
airiUbnhlJherprop,tiy) For mu111pir in/eeilon os norr-xahr rtgrply ircll+ ONLY ,rd, the Tome
..► eonsimcdonlabondanmt n�you emr+vbrnil one form,
1N. ell Conte of Cetti " uo N"obtr 7b,Appruximale•olume of water remaining In wqs): al.
N.W. Poole Wefl & Pump Co. -���—�•�(g )
Conipnny Name FOR WATER BUPPLy WELLS ONLYi
2,11'eU Con LZ
alrnction.1'ertnit N: +� , 7�Type of dLlafeetant need,•
trrr all appi(c6birti•tn rrndlr r s
p (i.e,Covnry;Sloir,i vrlartec,lrl/tcl i rlc)l(brokn , /)
3,}Veit Use(ebeckwell use); 7d,Amonnl oldts[nfeelAntnsed; Pill
1VatcrSupply}Yell: '
CAgrleullurnl 7e.Stiiing materj %:ua
❑Muniol td/Publlo s �uAt pale ' .
00cudicrnlal(1-ieaUng/Coolbi Supply) p C Neat Cement 0rbut.'�y-
8 ^"Idpltial Willer supply do o 0 Sand Cemrnl Grout rnlonlle Cllips or Pellets
C1uJustrtal/Conuncrclal _ pP Y( Bl) AUG 202 ' �Y Clsy
❑RaldrnUel Waltr Supply(alllutxi) ❑Ctxta Mc Otnvi `'
Cirri alion -0 Drill Cull
Non-1Yeler Supply Nell; 'Bpoclalty Grills;y<,@;,c r'r�C ,.ti r�1�J18bei
OMoniloring 0 Bml°rdtoBlurry ^vtx!a`:7CPG
Injection Well l3Rxov Ci Odicr(czplaln wiJcr7g)
❑AqulferIlcc"B"a 7f.7 For
�ere�e�hnmtfeNaI selected fetrwy provide amount bf maicrisls used;
❑Aqulfcr Btonage and Recovery' Q�J(ni(d B�r{txem�(�lal
❑AquifcrTest yl��
❑SlotmwatlxDralnege
❑CxperinlcnW Tcclulology
❑Cchicrnal(Clow!Luop) �Trnbal�dairo Cortlrol .
7g. oxide A bde[deaerlpllon of the Abandonment procedure:
❑(IeoUiernial lcatln' Conlin Reld ❑Olhor lain undo 7
3a.1Ya4e ,
facili 4 ty/Onr Neme• PeclUty IDpti(lrtpppe,61,)
8,Cer11lfeaUoui
Phy,lcel Address,4Cllyl end Z(p
�� el tuno Caliiled liholororWellOwnerS=Lief' i�Z•�� Defe
cauaiy D li,
y rigrdng lhll.fvrm,I herv�cerf((y Owl the lvel/�.rr) r,(were abandoned In
PatetilldetdldtadodNa,(PW); Qluiie Iri tlegreedinlhatei/stconds icco rdd7dt
1e,010Dab.La(ludE d ar1C,0 100 'elfCorutnrdfmi5►andarr3
ordetl ahlhaia °l3vIthLrzcorthar beenprarldedto the ue! m(Ifivell'a,eld,noe 111061N idklent) mAl degre,:-71 UP -��fy 9-811a tllAgt�.vr tddlll6hal well delaUs;
N U I�l 72 ' You mW '' bakVilqd6a ofa pago to pirovido addiimd wel l silo de(ails or ivellobandow : You mny also ah addillona pages Ifnecessay,
...ft
Q�N+�jr e!!s'tijV Y i�l)i'1RY `rdtirVabcliddliiri;7il ib on be non-irarrr•nq ply' S
`•• rutSrr'llr crir fern,,
�u.Well Ibft: 10a'ZWALL&I Submit Uus furnt wi(ltin 30 days of contplclloti of,veil
ebandodiituti!to Uto'folliiwing:
%
%)j+Tc lnl-h-ell Uelilh; � blvtrloti'o0Ytlter.Resources,Information Processlug Unit,
(fl) 1619 Alill Service Center,Raleigh,NC 27.693-1617
Ilot ehole dlantctcri lob, t In'liddidull to sanding Ole form to Ulo address hi IUa
(In,) about,blao''tiil8i ilt�' a copy of Ulls fuml WlUiht 30 days of completion of,Yell
abandonment Id.die following:
ri.IVnter level beloty gr°ttnil ilttfi6et..:
(il.) I)lulalbn ok%lbrHetourctat Underground Injection Control Prograul,
llervice Center,Raleigh,NC 17699-1636
,'e•t7uler eaiing llphgtlli(j(l�d+rh): �_'
(U) 10t. '
the ed ' ' III addition to sending Uie form to
.•dbdvi;;nlig submlt Due copy of Urfa form wiII 30 days of
Inner cesltig/ltili Iengtlt(Irllnifwn)r colnpletlnti otW611'abithdoninettt to Ole r.0lm hciddn do stiiicro idiabdoned, ty department of I cowtly
-+Strcenlitri�iHi,(Il,iiuurvhjt�I;�• '�'
O
`lmu OW-30
' NorihCiriillniDep'iiiraautb[�,.t�,��,.-r._�.r_.. ._ •

rY L�:�B;AIYD'OIY IY'T WORDit
"'is fonn•cnn be used for single or•mtiltipl'e weds ��0I V9C ONLY.
I.Well C lr elor Inronnntlonr
We Coutraclar N•une(or well owner en 7L Number of wells beln j rtbendonedl
P rxul�Yabrndarilugirillbnhlr - ropf ) For multlplr 1 rellon
t• N or
� cnn,rrverron/o l non-tro/er rrq,ply tr,ll, ONLY u•Irh the bo same ndanmrn{yoV�emr rubrnll one form,
11C Well Contrselor Cettlneallon Number
7b.APprasJmale volume of voter remelntn 1
N.W. Poole Well & PUMPg n neu(a):
Co. -�d��--
Compnny Nanro FOR WATER BUPFLY WELLS ONLYt
2.Wett Construction `) " //�� ��ee lc-Type of dlslnfectant sued;
U,ronappl(cabfr urlf rrrrl fmtt N: �(� lr
I' (I.r,Co,nth,S/orr,rarfmrer,INtcnoti r eJ(/b,oxn
3.}dell Uae(Chef!(n-01 use): 7d•Amount of dialnrcetint used:
1Vafcr Supply Well:
OAgrieullurni 7e.Sienna mtrleytds rued(cheek■ll thet apply):
OOcodlennai(I•fenling/CooWr 5u i ❑Muttlolpel/Publfo ❑Neat Cement drtsl�l.•'""',yam
g pP Y) dldattlal Water Supply(single) O Sand Cement(3rb`l !1`- ;`fixd lClale Chips or I'ellcls
171udusUfal/Cont11terclnl - ❑Raldcrttiel Water Supply ahead) ❑Conacie Clay
I r r y
OItti titian Ppy( A J ZQ2 Drill Cultings
Non-ZVeler Supply}yell: =Specially Grout � J
❑ Gravel
OMottltoring ❑13entonllo 9lujC;,;,�;.31 ;�rvC ,'.x"?�� cr(ezpinlrt wider 7g)
Injection Well: ❑Recov
OAquffer Recharge 7f,For each majeNal aelecled nbrrvy pruylde Amount bf mttlerlals used:
❑AtlufferBtorago and Recovery• OSCaI(n1(dBaiijerer emaitellmt
❑Aquifer Test
y � 7� �
❑SlormwatcrDralnago
❑lixperir:lcnlal Tcclutology '
❑Geolltcnnal(Clonal Lvo OSubaldenco Control
p) ❑Tracer 71 t'aride a brief descripilon of the ibendonmenf procedure;
100coulemial lcatln' Co.olln Reli' / .
❑Other lainunder.7
• rf
�?.])tile»•ell(s)abandoned: "' � � -' Z
3n.11'ed localinnl/�� -
Cacillly%gtvner Nettie• Fecldty IDiI(IfeppScrblr)
4
i'hys csl Addr aa,•Chy,end Zlp � �•'�j'�rfJ!1�t`DfCnt1W&dWiU �Ira�olo rorV/ep truer
� v
��^^ Dele
Couuty By tl8rdn8/hlt.fvrrn,I herrby eerf(fy Olaf Ilse Ivell(a)tear(were)abandoned!n
PatcclldentlLlrxdodNa.(PIN) By
orddgdilllllh IJ�`NClGtO1C.0100 or1C.D1D011'ell Corufnrcflon 5landmrls
(IrL.af ehl,:6tudb d*1*-M2?11i(ttite In tlegreeslsidnntei/seconds or deelmal degrees: andThal a o hli rrcord has beers pr'ot'Ided fa file well owner.
(Ifwalfgefd,�iiod Isllltittgli tuf&eleiat} CDPy f f
-7 9,61te tll>,gMm.or addlabnal trell•detalls:
N 3 D You miry ii;dt�e,�alitc of t)ila page to provldo additional well site details or well
obandonmeat'deialla: tuU may also alinch additional pages If necessary,
ArladN'(lYi '• .
cons erlffr►l°beff'ddHtri''9 '• , iE on6rnolkralir'n"Iy,
ruWit ili faun,
';n,Well fbf1: 10e,For•. II:Sy'tlir .Submit rids furor Wititin 30 days of compiellon of well
ebendori8rttrit to llro:talliSWing;
5b,Tufal n-elf depth., Dlvlsloti'DAVxterRraources,ItIformatlnn Processlug Call,
(f�) 16i9 hiAll 8ervlce Center,Rnlelgb,NC 27699.1617
lob, r
i .Ilorebole diameter:• F dl[s In,eddlaull to aatding Ole form to Ole addrrss In IN
(In,) .,above,ldao'hlJMIl-bfio copy of Otls form wldt6t 30 days of complcliort of well ld:liio following:
:ri.lVnlerleiel beloft grouniiiitrfaber..:
(!1) Dlylafbn of:}�'RtbrRetlinrccsI Underground Inlecllon Conlrul Program,
Quiet Center,Rnlelgh,NC 27699-1636
�• ensing lehgtll(If ltnttivn)t
the.eddriii( In addition to sending Ole funn to
EM nbbvS;also aubmJF Ono copy of Oila form Widiln 30 days or
Inner caslrig/ldbing length(If lrniirpn)t. �- complelloti of ivcll;abandotlinetrl Io the coon If Odt wflere ebithdoned, t department of Ole county,
4al OW-30
_ ttllfti�fti,(I[•kpd�h)t�i;•
' ` North•CrutillniUep''ittmardbtL„1�,�,.....�._.,.,... ._ .

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple ityection or non-crater supply wells ONLY with the satue
construction/abandonment,you can submit one form.
C - 4421 1.0
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknouvt 7d.Amount of disinfectant used:_
3.Well use(check well use):
7e.Scaling matcr�ala,used(checic.aJLthgt.gpqly,):
Water Supply Well:
❑Agricultural ❑Municipal/Public ❑Neat Cement Gt kt 'v,,,.P L_._; 1i d�7LBI,6nite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout AUG ✓ G 20ZZO Drill Cuttings
❑irri ation ❑ Specialty Grout
Non-Water Supply Well: ❑ Bentonite Slurry ;Dty ❑ Other(explain under 7g)
OMonitoring ❑Recovery
7f.For each material selected above,provide amount of materials used:
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 7.75 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
08/12/22
5a.Well location:
HONEST GROCERY CITGO
Facility/Owner Name Facility ID#(ifapplicable) g•Certification:
6901 FALLS OF NEUSE ROAD RALEIGH 27615 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WAKE By signing this form, /hereby certify that the ivell(s)ivas(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 ladlong is sufficient) 9.Site diagram or additional well details:
780 37' 31.30" You may use the back.of this page to provide additional well site details or well
350 52' 47.59"
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple ityection or non-water supply
,tells ONLY with the satne consirtictioniabandonn,e,rt,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 Quality,Information Processing Unit,
48.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Iniection Wells: In addition to sending the form to the address in i0a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter- 2'0 —(in.) abandonment to the following:
42.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft•) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft•) 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/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple ityection or non-crater supply hells ONLY with the same
construction/abandonment,you can subtnit one form.
C - 4421 0.1
7b.Approximate volume of water remaining in well(s): (gal-)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munici al/Public ❑Neat Cement Grou3 j ,. tQ Bentonite Chips or Pellets
P t ;'� ?
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cemer#-XGr of i,_�"s-,_a t It.._.L9'Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
f
❑lrri ation ❑ Specialty Grout AIJG 3 'S 20Z_ ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry Pther(explain under 7g)
❑Monitoring ❑Recovery rt"- �;Qt3
FoAquifer
ion Well: 7f.For each material sclec1WA')(ove,provide amount of materials used:
Recharge ❑GroundwaterRemediation 8.0 GALLONS
uifer Storage and Recovery ❑Salinity Barrier
uifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/12/22
5a.Well location:
HONEST GROCERY CITGO
Facility/Owner Name Facility iD#(if applicable) g•Certification: .
6901 FALLS OF NEUSE ROAD RALEIGH 27615 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WAKE By signing this form, I hereby certify that the ivell(s) ivas (were) abandoned in
County Parcel identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) 9.Site diagram or additional well details:
35° 52' 46.92" 780 37' 31.64" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well consiruciion record(s)if available. For nnultiple ityection or non-wafer supply
hells ONLY with the sane consiruction'abandonnetrl,you can subtnit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
M W-3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
50.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection 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
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
43.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft•)
I
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple ityeclion or non-[rater supply wells ONLY trilh the .same
construction/abandonment,you can submit one form.
C - 4421 10
7b.Approximate volume of water remaining in well(s): . —(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Counl,State,Variance,etc)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Munici al/Public ❑ Neat Cement Q.Quts, .�%�a'f {' 9fl�entonite Chips or Pellets
❑Agricultural p N•�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑ Sand Cemen Grotto t i 1: a -iglbry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑ Concrete Grout D ❑ Drill Cuttings
❑ Specialty Grout AUG + � �� _ ❑ Gravel
F
upply Well: 0 Bentonite Slurry n, 1¢]Rther(explain under 7g)
r.l!!.❑Recoveryov7f.For each material seYecfe a ove,provide amount of materials used:
ll:charge ❑GroundwaterRemediation8.0 GALLONS
orage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
d.Date well(s)abandoned:
08/12/22
Sa.Well location:
HONEST GROCERY CITGO
Facility ID#(ifapplicable) 8•Certification:
Facility/Owner Name
6901 FALLS OF NEUSE ROAD RALEIGH 27615 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WAKE By signing this form. /hereby certify that the well(s)was (were) abandoned ill
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 or 2C.0200 Well COnstrziction 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:
35° 52' 47.15" N 78° 37' 31.42" 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)iif'available. For inulliple injection or non-waler supply
wells ONLY with the same construction/abandonntenl,you can submit one forin. 10a. For All Wells' Submit this form within 30 days of completion of well
6a.Well ID#:
M W-4 abandonment to the following:
Division of Water Quality,Information Processing Unit,
50.0 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Total well depth: (ft.)
10b. For Infection 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
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
41.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

ENT RECORD ONLY:
WELL ABANDONMENT For Internal Use
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) Far multiple injection or non-haler supply wells ONLY with the same
construcdon/abandonntent,you can submit one form.
C -4421
7b.Approximate volume of water remaining in well(s): 3'0-(gal-)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply 1 Well: 7c.Sealing materials used(check all thl1
...�. a 3
❑Agricultural ❑Municipal/Public ❑ Neat Cement Gto ,sea tii' X"dBe ttonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout nn ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ElConcrete Grout A.ii r' r 2l'2� Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ avel
Non-Water Supply Well: ❑ Bentonite Slutfty'�'i ,�0 L7 Other(explain under 7g)
vG
RIMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 9.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/12/22
5a.Well location:
HONEST GROCERY CITGO
Facility/Owner Name Facility lD#(ifapplicable) $•Certification:
6901 FALLS OF NEUSE ROAD RALEIGH 27615 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WAKE By signing this form, I hereby certify that the ivell(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:
(iPwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35° 52' 47.59" 780 37' 32.08" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if arailable. For multiple it jection or non-water supply
wells ONLY with the sane co»strnctioniabandotunent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-5 D abandonment to the following:
Division of Water Quality,Information Processing Unit,
59.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection 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
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface: 40.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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.
611 Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple it jection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
C - 4421
7b.Approximate volume of water remaining in well(s): 1' (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Stale,Variance,etc)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling mate i01s,uaed(,cheGlc a)1 i¢;
❑Agricultural ❑Municipal/Public El Neat Cement 'roti �Y, ,'� ET ti_^t yentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
nn
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout AUG I'd :':s 2l1 _ ❑ Drill Cuttings
❑ Specialty Grout U Gravel
❑)rri ation Rti
Non-Water Supply Well: ❑ Bentonite Sti9tiy �1': 0G ❑ Other(explain under 7g)
Fti � ❑Recovery
: 7f.For each material selected above,provide amount of materials used:
arge ❑Groundwater Remediation 8.0 GALLONS
age and Recovery ❑Salinity Barrier❑Storrnwater Drainage —
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/12/22
5a.Well location:
HONEST GROCERY CITGO
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
6901 FALLS OF NEUSE ROAD RALEIGH 27615 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WAKE By signing this for»h, 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hat/long is sufficient) 9.Site diagram or additional well details:
35° 52' 47.59" 780 37' 32.38" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-waler 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-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
50.0 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Total well depth: (ft.)
lob. For Infection 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
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
39.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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/tubing length(if known): (ft.)
6g.Screen length(if known):
'I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-waier supply wells ONLY ivith the sane
construction/abandonment,you can submit one form.
C - 4421
7b.Approximate volume of water remaining in well(s): 1'0 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout...]a., . . ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cerrte�n46S,41t-11 t� �' —.0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout r ❑Drill Cuttings
❑Irri ation ❑ Specialty Groh.li r v 2022 ❑ Gravel
Non-Water Supply Well: El Bentonite Slu ff r �. 3 Ur Other(explain under 7g)
Infio;ri,F3 �� r t . :�.. i:�,
(Monitoring ❑Recovery rt� ,�}� rQU
r0AqcL1ifer
ion Well: 7C For each matcriaiJselA& above,provide amount of materials used:
Recharge ❑GroundwaterRemediation 8.0 GALLONS
ufer Storage and Recovery ❑Salinity Barrier
ufer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/1 2/22
Sa.Well location:
HONEST GROCERY CITGO
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
6101 FALLS OF NEUSE ROAD RALEIGH 27615 ' 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WAKE By signing this form, 1 hereby certify that the wells) ivas (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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
35° 52' 47.53" 780 37' 32.16" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonneni,you can.submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
M W-7 abandonment to the following:
6a.Well iD#:
Division of Water Quality,Information Processing Unit,
50.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection 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
6e.Borehole diameter: 2'0 (in.) abandonment to the following:
40.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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/tubing length(if known): (ft.)
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For nmlliple injection or non-water supply wells• ONLY wish the .sanie
constructioniabandonment,you can submit one forni.
C -4421
7b.Approximate volume of water remaining in well(s): 1.0 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well conssiruction permits(i.e.County,Slate,Variance,eic)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check allthat apply):
❑Agricultural ❑Municipal/Public El Neat Cement GrotL" 73 l � Bent!mite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout AUG ','1 7029 Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑Irri ation ,',�f�i ';�•G -:"�. 1 n
Non-Water Supply Well: ❑ Bentonite SlurgrRTCi+:+a�_- f r © ief(explain under 7g)
InMonitoring ❑Recovery �DL✓
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 8.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/12/22
Sa.Well location:
HONEST GROCERY CITGO
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
6901 FALLS OF NEUSE ROAD RALEIGH 2761 S ' 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WAKE By signing!Iris form, I hereby certify that the ivell(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
35° 52' 46.48" 780 37' 28.84" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For mulliple injection or non-water supply
wells ONLY wish the same construciioti/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
MW-8 abandonment to the following:
Division of Water Quality,Information Processing Unit,
50.0 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Total well depth: (ft.)
10b. For Infection 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
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
41.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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/tubing length(if known): (ft.)
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandon ed: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple it jection or non-water supply wells ONLY with the same
construction✓abandonment,you can subotii one form.
C - 4421 1.0
7b.Approximate volume of water remaining in�vell(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc)ifknovn 7d.Amount of disinfectant used:
3.Well use(check well use):
upply Wel 7e.Scaling materials used(check all that apply):
Water S 1:
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑ Sand Cement Crfouf—' d=' `,';. N? 1�ry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) _..;^ �..� - s
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑ Concrete Grout "' '-t:-Drill Cuttings
❑Irri anion ❑ Specialty Grout n��r f ❑ Gravel
Non-Water Supply Well: El Bentonite Slurry AUG ❑ Other(explain under 7g)
❑Monitoring ❑Recovery Una
Injection Well: 7f.For each m)nwl ill"sele;kellboye,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRetmediation 8.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/12/22
5a.Well location: -- - - -
HONEST GROCERY CITGO
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
6901 FALLS OF NEUSE ROAD RALEIGH 27615 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WAKE By signing!Iris form, 1 hereby cerlij5,that the ivell(s) ivas (here) 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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
35° 52' 46.59" 780 37' 33.30" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(v)if available. For nnultiple injection or non-water supply
watty ONLY wilt the same cmaviructiott/abaudonment,you call submir one form. 1 Oa. 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 Quality,Information Processing Unit,
50.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection 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
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
42.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Infection Wells: In addition to sending the form to
6c.Outer casing length(if known): (ft.) 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/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of water Quality Revised March 2013

i R�r Rn
i If I1/L1r/:hahl��U�, l�'�',�►4�VQ.t�I/ f f
TJtis form-can be used for alin or•tn ay:
_
I.\Yell Contractor Inrortnalton,
I r1 - .,k P IZTAIL�9
�t'ett on to N e(orwell.owner enonallysbsndvnlua$ilj�bldy� 7a.Numberotirelbbelagabandoaedl
cOn q
propstty)' muhlplt ft!lrellon or non-xafer t¢rply xelb ONLY a•nh the Jame
onlfritenot✓oboltdo t
nalfn{rpte ecn nJ6M1I en[JOrm.
NC Weil Contractor CettlncaUon Number 7b.Approz)male•olome of aaler remai I
ning n nell(s):
N.W.' Poola Well & Pump Co.
Corupany Nanle FOR WATER BUPYLY WELLS ONLY:
r
1 2•Well Conrtrnctlon.I'erm(t H: �� I 7m Type ordislareetaaf need
UJr all appllenble writ psrmrrs�,r,Co+ar ,
q, _Jay"irvrimrer,!r .
3.Well use(check well use t/rcflorti sre)(/'.tnoxn 7d.Amount of dlalnfeclaat used; '
s`a
11'atcr Supply}yell: '� -r
ElAgrioultural 7m Sealing malerlals rued(check all that apply),
❑Munlolpel/publfa ❑Nwt Cement t3rout,, PP y),
C1Ceolltcrntal(Efeating/CoolJng supply) FZealdeudel Waler9u I s!n e ❑Send Cemmt't�6mijr—g a ` "culonlle Chips orpellets
f7iuduslrial/Comtnerclal PP Y( �) e3)}ry Clay
❑R'Idential Wale;Supply "`�
CJirti anon PPII'(ahuul) ❑Curlxetd Qrout CI Drill CulWrgs
Nun-Water Supply ,�peclally smut AIJ r � S 2022
pp y}1'cll:
0mulliluring ❑Iletdonite Bluny 11 Gravel
Injection Well; 131lecov
;i,kic� '; `� "�7 Urtdther(explain under 7g)
❑AquifcrIlceherge nt.t+ Got
7f.For each maierill seh'cllir�i y pru-dde amauut trf materials used;
❑Qroundwaler Remedlallort
❑Aquifer Btong and Rccove
O quiferTest lY ❑Salfnlfyljarrirr
A ❑Storrnwalcr)Jrah:ago � :
176xpbrbnenial Tcclrnolo
%3 f7Subsldrnsv Control
❑Geo•illennal(Closed hoop) ❑Traver 7g.Proride a brief descriptlan of the abandonment procedure;
Ot3colllctnlal catln Coolln Rcttim
11701hor lain undcr:7
,Uatc wcll(s)abandoned,
50 Well locntivnl (
ai
ci ty/Owner Ndme
,, � _ FeefdtyID�(IrtJrpdcsble) g.Cert111caOonr - ,�
Pbye e,City,trod Zrp
// �',, 81aniNto of CstSlDid Wd on binr or Welf'Oxner Date
C0u"`y py llgrrtn8 flJj.fo�I htnDy Teri am[the lvel!(af war(ryere)abandoned in
PafeelldeatltleadotiNo,(PW) deoordmedat4jthISINNdo y 2C,0100or1C.01001YtIIColufnrdlonSmndards
�h,J.aOtudE.and;l6nQiludeln degreedminntet/seconds or declmaldegrees: dW thin a
(Jr_well'neld ynny�b �i} �i,nl) �P1'�fltLr rtcortf frar beers provided to the trell olrner.
X
?�/� �jR 9,Bller llnl uor additioi;rl well deteUr:! V / r Yount.. it�d:t�e "s'i of Vila plrgo to prnvldo additional tivell silo detsils or well
absndotlmeat dtialls, l�ou mtty also attach addllional pages ifttecessary,
e
J , , f:3. is On br.neri•irartr?rgply ,- .
rrJ c6n} 'rd`'c✓Salkldlihifil 's)kc0iituh,rjlydritfohn. .
,3%Well IbNI lug,ZM'AL:-UQt •Submit this form wiOdn 30 days of complellon of well
i abandotitlterit to lho"i'vUvwlrrg:
Gh,Total hell depth: IAvlslod of Wafer Resources,Igformaftvn Process
(ft). I6i7litill Strvlca Center,Raleigh,NC 17 ing Unil,
,G99-IGI7
5c,Ilnrehole dlamhlcrr. ,
addidurl to sendin Ole f
8444 °1t'N�il'r Ur• g form to Ilto address In IDa
(In,) above,Jdso'sUbuflfoiio dopy of Oils form w)dlin 30 days of completion of well
abandolutieni Id.tho lbllowing;
n•}Valsrlcvelbclv�ygrotlni(iurface;..:
(It) blrislon.oi;l�'tilbrI;estinrcea,Underground Injecdon Control Program,
I 11✓arviea Ccnterr Rill NC 17G99-1 G3G
II =;a.Oulcrca}In�lewgthi(f[ltnif�n): '�°'®
tlU at In addition to sending Ole rurm to
Inne 'nbdYb, also submit one ropy of Oils form
I r casing/ftibing length(Itknittva r '" completlott of lvoll abandonincnt to the Doan hrallh deOiln 30 days of
where abandondd. tY partmerll of Ole cow,ty
iti�,(If;ldoivii)ht:
� ' tJorlr't•�aivj�nabep'tlmeatblPaTbbomeal}ndNrt� Ia1tl Aeivia'oei«DtYLloh orWster)t..a,,....
:

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Wel!gpntractor Information: WELL ABANDONMENT DETAILS
9 7a.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same
I Well Contractor Name( well owner personally abandoning well on his/her property) well construction/depth,only I G 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): a� (gal.)
N.W. Poole Well and Pump Company FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
j 2.Well Construction Permit#:
G W-081451-2022 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflarown 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Ceme'f CrN p`�'°a f- Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑ Sand Cement Grou'f Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout P I( Q 2�2� ❑Drill Cuttings
J � .e a
❑Irri ation ❑ Specialty GroutGravel
Non-Water Supply Well: ❑Bentonitel►Slt3nay3a''Dr i?i•OC3"il a U 24 Other(explain under 7g)
❑Monitoring ❑Recovery rD%vQ/BoG
Injection Well: 7f.For each material selected above,provide amount of aterials used:
❑Aquifer Recharge ❑Groundwater Remediation /�
❑Aquifer Storage and Recovery ❑Salinity Barrier '' - `r
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
!I 7&Xrovide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) 5_r!�p'�;� d° i A�' .�✓I—
4.Date well(s)abandoned:
r
1 Sa.Well location:
A Squared LLC Well #2
Facility/Owner Name Facility IDN(if applicable) g• ffication:
235 Grand Avenue, Raleigh NC 27606
P Address,City,and Zip Signature of Ce ed We ontmctor or Well Owner Date
Me
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15ANCAC 02C.0100 or 2C.0200 Well Construction Standards
I Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and That a copy of this record has beet:provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.794058 N -78.717038 W You may use the back of this page to provide additional well site details or well
I
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record(s)ifavailable.For multiple injection ornon-water supply wells SUBMITTAL INSTRUCTIONS
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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth. (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in IOa
6e.Borehole diameter: (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): (gt,) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): G� (ft.)
Fonn GW-30. North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016

i
ake: U'unfiy.Welf-R.' "'itepo -./. Wollheadfly .a.. ctio n request
wo
Wake County Well Repair permit# • Owner: n k'
GY►�uS Jr,"
Site address: o-1 of VJ Hw I Owner contact phone number: UL)(c1 Gfi26'
1
City; {7i 5bore ZIP Code: 2-U2
Well type: Well tag located? No Casing depth:
static level: Water zones; N/Pr Wpll yield:
2$�fi 5Pr^-
Camera Inspection?. Existing.11ner or screen? Well depth:
s 3 00-F4
Evidence or original grout: Total depth of liner or screen; Wellhead above grade?
Watt �n IIlk, C-as Glf
�224-.—
I •
I
f Weil depth: 3 60 Ft Well yield: �-
Water zones ; Static level;
N A
Water zones:
N�J�
Liner Installed? Uher depth from top of casing;
S YEf�
Screen installed?
(V c Depths of screened sections?
i Well hyft fractured? NO
Wellhead rasa a ov e
W Ilhe d raised b a grad 7
T"JI-f -fo Qj�� — yl��( (p�� `iht i boo+ . �v�c�uGl� lg 1 4 of y T V WC�
C W to I o
S Ac r wad Misc. -A'AI S, A�4 labor.
�h�orina+•� wcl� r e .. •
Contractor Ra,Me:
Nc�V�'tCC =certilIcation number: Aic 9512—C
Signature of contractor: Date: 6113/-)-2-
Contractor phone number: (919) 239-33.yq
I
I
Wake County well repair report7/09yer,.
I .