WQ0034819_Rescission Request_20221026

GR
Geological Resources, Inc.
October 26, 2022
Mr. Michael Rogers
NCDEQ
UIC Program Manager
via email: [e-mail]
RE: Permit WQ0034819 — Closure Report
Myatt's Corner Store
9602 Poole Road
Knightdale, Wake County
Former UST Incident No. 21553
GRI Project No. 3147
Dear Mr. Rogers:
Myatt's Corner Store is located at 9602 Poole Road in Knightdale, Wake County, North Carolina. On
March 4, 1998, a release (Incident 21553) was confirmed at the site. Three USTs of various sizes were
closed in 2002. On August 26, 2019, one 10,000-gallon gasoline UST and one 7,500-gallon gasoline UST
were removed. No USTs remain at the site. Although the store remains open, no petroleum products
are being sold.
In 2011, a Corrective Action Plan proposed to remediate ground water using a pump and treat system
that would discharge treated water back into the ground. The pump and treat system began operating
intermittently at the site from February 2012 until the NCDEQ UST Section directed that it be turned off
in January 2017. Treated water was discharged as permitted by WQ0034819 from February 2012
through January 2017.
Per the NCDEQ-UST, quarterly monitoring was conducted at the site for one year prior to closing
Incident 21553. Quarterly monitoring events were conducted in November 2020, March 2021, May
2021, and August 2021. Reported contaminant concentrations allowed the site risk to be re-classified as
low. In compliance with the conditional Notice of No Further Action (NFA), all monitoring and recovery
wells that could be located were abandoned on February 7, 2022 (photos and well logs attached). In
addition, a notice of residual petroleum was filed and public notification completed. In April 2022, a
NFA was issued for Incident 21553.
On February 22, 2022, Eric Rice, Water Quality Regional Operations Hydrologist, conducted a site
inspection. He reported depressions in the former areas of MW-8, 10, and 11. Monitoring well MW-8
had not been located since 2016; and monitoring wells MW-10 and MW-11 were reported by the
previous consultant as having been destroyed. These wells were not located during well abandonment
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

Myatt's Corner Store
Page 2 of 2
activities. On March 8, 2022, the licensed driller returned to the site to inspect the depressions. It was
reported to the driller that well screen was observed adjacent to the MW-8 depression; the well driller
reported that the only item near that location was a fiber optic line. The depressions were capped with
concrete and notice was conveyed to Mr. Rice.
On March 10, 2022, Stancil Oil Company dismantled the remediation system and transported the
building off -site (photos attached).
Larry Stancil of Stancil Oil Company has requested that the discharge permit WQ0034819 be rescinded
because a NFA was issued for Incident 21533 was issued in April 2022 and the remediation system has
been removed from the property.
Please do not hesitate to contact the undersigned at [phone] if you have any questions or
require additional information.
Sincerely,
Geological Resources, Inc.
dAo;a4ti 06140-
Rae Troiano Brown, P.G.
Project Manager
Enclosures:
Permit
Photos
NFA (April 2022)
NRP
Abandonment Records
Larry Stancil email
cc: file; client
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENTAL QUALITY
INVOICE
Annual Permit Fee
II''I'I II II �Ili IIII I{ffl II I' II� I II.
* z 0 2 2 P R 0 1 0 0 1 1*
Open
This annual fee is required by the North Carolina Administrative Code. It covers the administrative costs associated with
your permit. It is required of any person holding a permit for any time during the annual fee period, regardless of the facili
operating status. Failure to pay the fee by the due date will subject the permit to revocation. Operating without a valid
permit is a violation and is subject to a $10,000 per day fine. If the permit is revoked and you later decide a permit is
needed, you must reapply, with the understanding the permit request may be denied due to changes in environmental,
regulatory, or modeling conditions.
Invoice Number:
Permit Number:
Larry Stancil
Stancil Oil Co
PO Drawer 188
Selma, NC 27576
2022PR010011
WQ0034819
Wake County
Myatt's Corner Store
Annual Fee Period: 2022-11-01 to 2023-10-31
Invoice Date: 10/04/2022
Due Date: 11/03/2022
Annual Fee: $810.00
Notes:
1. You may pay either by mail with checklmoney order OR by electronic payment (eCheck or Credit Card).
2. If payment is by checklmoney order, please remit payment to:
NCDEQ - Division of Water Resources
Attn: Animal/Discharge/Non-Discharge Billing
1617 Mail Service Center
Raleigh, NC 27699-1617
3. If payment is electronic, please see https:ildeq.nc.govlepaymentslwq to pay electronically. Payments by eCheck will debit your
checking account. Credit card transactions will incur a convenience fee.
4. Please include your Permit Number and Invoice Number on all correspondence.
5. A$25.00 processing fee will be charged for retumed checks in accordance with North Carolina General Statute 25-3-512.
6. Non -Payment of this fee by the payment due date will initiate the permit revocation process.
7. Should you have any questions regarding this invoice, please contact the Annual Administering and Compliance Fee
Coordinator at 919-707-3698.
8. Please verify your facility affiliations using the following link:
http:lldeg.nc.novlabeutidivisionsiwater-resources!water-resources-permitsiwastewater-branch: non-discharge-permitting-unitlapokation
(Return This Portion With Check)
ANNUAL PERMIT INVOICE
11121riiiuuiiini
Open
1
A
*
Invoice Number: 2022PR010011
Permit Number: W00034819
Wake County
Myatt's Corner Store
Larry Stancil
Stancil Oil Co
PO Drawer 188
Selma, NC 27576
Annual Fee Period: 2022-11-01 to 2023-10-31
Invoice Date: 10/4/2022
Due Date: 11/3/2022
Annual Fee: $810.00
Check Number:

ROY COOPER
Governor
ELIZABETH S. BISER
Sec+etary
MICHAEL SCOTT
Director
Stancil Oil Company, Inc.
Mr. Larry Stancil
Post Office Box 188
Selma North Carolina 27576
Dear Mr. Stancil:
3147 Received APR 08 2022
NORTH CAROLINA
Environmental Quality
April 5, 2022
Re: Notice of No Further Action
15A NCAC 2L .0407(e)
Risk -based Assessment and Corrective Action for
Petroleum Underground Storage Tanks
Myatt's Corner Store
9602 Poole Road, Knightdale
Wake County
Incident Number: 21553
Risk Classification: Low
A review of information on file with the Underground Storage Tank (UST) Section, Division
of Waste Management, Raleigh Regional Office indicates that soil and groundwater contamination
meet the cleanup requirements for a low -risk release under Title 15A NCAC 2L .0202 and .0400, but
contamination exceeds the limits allowed for the unrestricted use of a site where closed under risk -
based cleanup standards.
Based on the available information, the UST Section determines that no further action is
warranted for this incident. All required actions have been completed.
On April 4, 2022, the UST Section received a certified copy of the Notice of Residual Petroleum
that has been filed with the Register of Deeds in the county in which the release is located, as defined
in NCGS 143B-279.9 and 143B-279.11. On April 4, 2022, the UST Section was provided with proof of
receipt of the conditional Notice of No Further Action letter or of refusal by the addressee to accept
delivery of the letter, or with a description of the manner in which the notice was posted, as required
by 15A NCAC 2L .0409(b).
This determination shall apply unless the UST Section later finds that the discharge or release
poses an unacceptable risk or a potentially unacceptable risk to human health or the environment.
Pursuant to Title 15A NCAC 2L .0407(a) you have a continuing obligation to notify the Department
North Carolina Department of Environmental Quality 1 Division of Waste Management
Raleigh Regional Office I 3800 Barrett Drive I Raleigh, North Carolina 27609
919.791.4200

of Environmental Quality of any changes that might affect the risk or land use classifications that have
been assigned.
Be advised that, as contamination may exceed the groundwater quality standards established
in Title 15A NCAC 2L .0202, groundwater within the area where contamination is present or is
expected to migrate is not suitable for use as a water supply. Be advised that as soil contamination
may exceed the residential MSCCs, the property containing the soil contamination is suitable only for
restricted residential use ("residential" being inclusive of, but not limited to, private houses,
apartment complexes, schools, nursing homes, parks, recreation areas and day care centers), as
stipulated in the Notice of Residual Petroleum.
Interested parties may examine information on file for this site by contacting this regional
office and may submit comments about the site to the regional office at the address or telephone
number listed below.
This No Further Action determination applies only to the subject incident; for any
other incidents at the subject site, the responsible party must continue to address
contamination as required.
If you have any questions regarding this notice, please contact me at the address or telephone
number listed below.
Sincerely,
Mark R. Powers
Regional Supervisor
Raleigh Regional Office
UST Section, Division of Waste Management, NCDEQ
cc: Geological Resources, Inc., via email rtb@ geologicalresourcesinc.com
Wake County Environmental Services via email wellwatersupportftwakegov.com
RRO UST Incident File/RMR
Raleigh Regional Office
1628 Mail Service Center
Raleigh, NC 27699-1628 1 [phone]
North Carolina Department of Environmental Quality I Division of Waste Management
Raleigh Regional Office I 3800 Barrett Drive I Raleigh, North Carolina 27609
919.791.4200

Myatt's Corner Store
Poole Road
Knightdale, NC

Myatt'oCorner Store
Poole Road
Kni8htda|e, N[

Myatt's Corner Store
Poole Road
Knightdale, NC

Myatt'oCorner Store
Poole Road
Kni8htda|e, N[

Myatt'oCorner Store
Poole Road
Kni8htda|e, N[

Myatt's Corner Store
Poole Road
Knightdale, NC

Myatt's Corner Store
Poole Road
Knightdale, NC

Myatt's Corner Store
Poole Road
Knightdale, NC

Myatt's Corner Store
Poole Road
Knightdale, NC

Myatt'oCorner Store
Poole Road
Kni8htda|e, N[

Myatt's Corner Store
Poole Road
Knightdale, NC

Myatt's Corner Store
Poole Road
Knightdale, NC

!•`,UI` COOPER
ELIZABETH S. BISER
MICHAEL SCOTT
Stancil Oil Company, Inc.
Mr. Larry Stancil
Post Office Box 188
Selma North Carolina 27576
Dear Mr. Stancil:
fC7. H CAROLI3JA
Environmental Quality
February 11, 2022
Re: Conditional Notice of No Further Action
15A NCAC 2L .0407(e)
Risk -based Assessment and Corrective Action for
Petroleum Underground Storage Tanks
Myatt's Corner Store
9602 Poole Road, Knightdale
Wake County
incident Number: 21553
Risk Classification: Low
A review of information on file with the Underground Storage Tank (UST) Section, Division
of Waste Management, Raleigh Regional Office indicates that soil and groundwater contamination
meet the cleanup requirements for a low -risk release under Title 15A NCAC 2L .0202 and .0400, but
contamination exceeds the limits allowed for the unrestricted use of a site where closed under risk -
based cleanup standards.
The UST Section determines the subject incident to be eligible conditionally for no further
action status. However, final approval of no further action status is contingent on the filing of the
approved Notice of Residual Petroleum (NRP) with the Register of Deeds in the county in which the
release is located, verified by the receipt of a certified copy of the filed NRP by this office; and receipt
of confirmation that public notice requirements have been completed, as described below.
Be advised that, as contamination may exceed the groundwater quality standards established
in Title 15A NCAC 2L .0202, groundwater within the area where contamination is present or is
expected to migrate is not suitable for use as a water supply. Be advised that as soil contamination
may exceed the residential MSCCs, the property containing the soil contamination is suitable only for
restricted residential use ("residential" being inclusive of, but not limited to, private houses,
apartment complexes, schools, nursing homes, parks, recreation areas and day care centers), as
stipulated in the Notice of Residual Petroleum.
As groundwater contamination may exceed the groundwater quality standards established
in Title 15A NCAC 2L .0202, and soil contamination may exceed the residential MSCCs, pursuant to
rtmer' c`Env°-on. lei t;_x'. Quc ".ity I C v'sirn of
R.3le ^ aior 3I Oft :e 3.,00 Berta ett C R.JI•tigh. North at c 211:Or
91 <.7=,t,•-200

NCGS 143B-279.9 and 143B-279.11, you must file the approved plat and declaration for a Notice of
Residual Petroleum with the Register of Deeds in the county in which the release is Iocated and
submit a certified copy to the UST Section within 30 days of receipt of this letter,
As groundwater contamination may exceed the groundwater quality standards established
in Title 15A NCAC 2L .0202, and soil contamination may exceed the lower of the residential or soil -
to -groundwater MSCCs, public notice in accordance with 15A NCAC 2L .0409(b) also is required.
Within 30 days of receipt of this letter, a copy of this letter must be provided by certified mail (or
otherwise be made available by posting in a prominent place if certified mail is impractical,) to the
local health director, the chief administrative officer of each political jurisdiction in which the
contamination occurs, all property owners and occupants within or contiguous to the area containing
contamination, and all property owners and occupants within or contiguous to the area where the
contamination is expected to migrate.
Within 60 days of receiving this letter, this regional office must be provided with
documentation showing that each party included in the listing above either received or affirmatively
refused to accept delivery of the copy of the letter, and/or documentation describing the manner in
which the letter was publicly posted, where applicable. Interested parties may examine information
on file for this site by contacting this regional office and may submit comments about the site to the
regional office at the address or telephone number listed below.
This conditional No Further Action determination will not become valid until the UST
Section receives a certified copy of the Notice of Residual Petroleum which is filed with the
Register of Deeds and until public notice requirements are completed.
If you have any questions regarding trust fund eligibility or reimbursement from the
Commercial Leaking Petroleum Underground Storage Tank Cleanup Funds, please contact the UST
Section Trust Fund Branch at [phone].
If you have any questions regarding this notice, please contact me at the address or telephone
number listed below.
Sincerely,
Mark R. Powers
Regional Supervisor
Raleigh Regional Office
UST Section, Division of Waste Management, NCDEQ
cc: Geological Resources, Inc., 113 W. Firetower Rd, Suite G, Winterville, NC 28590
Wake County Environmental Services via email wellwatersupportPwakegov.com
RRO UST Incident File/RMR
Raleigh Regional Office 11628 Mail Service Center I Raleigh, NC 27699-1628 I [phone]
Ne .11 Ca , ' r... C .par_rr_ ET . !r Jr1,•x;Ital. Qv 'it; D -,ior. of',V,tste M :.ic. .
R .:: iy?r Reairn el t?, :ce :-,Oi> C.. re tt Dr @ R..Sei911. North CG rolt:— 77 O )
9r,79€,42v0

E h` V
C=Ie o t cq a C.aA
MAKE COUNTY, NC 67
TAMMY L. BRUNNER
REGISTER OF DEEDS
PRESENTED $ RECORDED ON
03/18r2022 12:06:04
BOOK:018959 PAGE:0079? - 00801
NOTICE OF RESIDUAL PETROLEUM
Myatt's Comer Store , Wake — County, North Carolina
The property that is the subject of this Notice (hereinafter referred to as the "Site") contains
residual petroleum and is a petroleum release incident from an Underground Storage Tank (UST)
under North Carolina's Statutes and Regulations, which consist of Article 21A of Chapter 143 of the
General Statutes (N.C.G.S.) and the regulations adopted thereunder. This Notice is part of a
remedial action for the Site that has been approved by the Secretary (or his/her delegate) of the North
Carolina Department of Environmental Quality (or its successor in function), as authorized by
N.C.G.S. Sections 143B-279.9 and 143B-279.11 for the purpose of protecting public health and the
environment. The North Carolina Department of Environmental Quality (or its successor in
function) ,hall hereinafter be referred to as "DEQ".
NOTICE
Petroleum product was released and/or discharged at the Site. Petroleum constituents remain on
the site, hart are not a danger to public health and the environment, provided that the restrictions
described herein, and any other measures required by DEQ pursuant to N.C.G.S. Sections
143B-279,) and 143B-279.11, are strictly complied with. This "Notice of Residual Petroleum" is
composed of a description of the property, the location of the residual petroleum, and the land use
restrictiom on the Site. The Notice has been approved and notarized by DEQ pursuant to N.C.G.S. Sections
I43B-279.9 and 143B-279.11 and has/shall be recorded at the Wake County Register of Deeds' office in
Book , Page
SOURCE :'ROPERTY
Clarence idl. Kirk Jr. and Philip G. Kirk
of Wendell, NC is the owner in fee
simple of all or a portion of the Site, which is located in the County of Wake, State of North Carolina, and
is known and legally described as:

BEGINNING at the intersection of the Raleigh and Wendell Road, and the Shotwell andKnightdale Road,
thence East 40 yards; thence South 40 yards; thence West 40 yards; thence North 40 yards, containing
one-fourth (1/4) acre, more or less.
For protection of public health and the environment, the following land use restrictions required by
N.C.G.S. Section 143B-279.9(b) shall apply to all of the above -described real property. These restrictions
shall continue in effect as long as residual petroleum remains on the site in excess of unrestricted use
standards and cannot be amended or cancelled unless and until the Wake County Register of Deeds receives
and records the written concurrence of the Secretary (or his/her delegate) of DEQ (or its successor in
function).
DECLARATION OF PERPETUAL LAND USE RESTRICTIONS
Soil: The Site shall be used for industrial/commercial use only. Industrial/commercial use means
where exposure to soil contamination is limited in time and does not involve exposure to children
or other sensitive populations such as the elderly or sick. The real property shall not be
developed or utilized for residential purposes including but not limited to: primary or secondary
residences (permanent or temporary), schools, daycare centers, nursing homes, playgrounds,
parks, recreation areas and/or picnic areas.
Groundwater.- Groundwater from the site is prohibited from use as a water supply. Water supply wells
of any kind shall not be installed or operated on the site
ENFORCEMENT
The above land use restriction(s) shall be enforced by any owner, operator, or other party responsible
for the Site. The above land use restriction(s) may also be enforced by DEQ through any of the
remedies provided by law or by means of a civil action, and may also be enforced by any unit of local
government having jurisdiction over any part of the Site. Any attempt to cancel this Notice without
the approval of DEQ (or its successor in function) shall be subject to enforcement by DEQ to the full
extent of the law. Failure by any party required or authorized, to enforce any of the above
restriction(s) shall in no event be deemed a waiver of the right to do so thereafter as to the same
violation or as to one occurring prior or subsequent thereto. -
IN WITNESS WHEREOF, has cause this Notice to be executed
pursuant to N.C.G.S. Sections 143B-279.9 and 143B-279.11, this l day of Fetar4ke.-) , 20
By:
LCVNA.--\
(name of responsible party if agent is signing)
(signature of responsible party, attorney or other agent if there is one)
qc,,side c) 1
(Title of agent for responsible party if there is one)

Signatory's name typed or printed:
LA1 co nr L
NORTH CAROLINA
�l:I1l�S�r COUNTY
(Name of county in which acknowledgment was taken)
I certify that the following person personally appeared before me this day, acknowledging to me
that he or she signed the foregoing document: L_ CA i i 4 Sit n C , l
WITNESS my hand and official seal, this the 714h day of ce.b f ttii , 20 ).
- CSC)
(signature of Notary Public)
nci ASS
(printed or typed name of Notaty Public)
Notary Public
My commission expires:
(signature of Nolan., Public)
DEPARTMENT OF ENVIRONMENTAL QUALITY APPROVAL
Approved for the purposes of N.C.G.S. 143B-279.11
(signature of Regional Supervisor)
MIPRK :� �c��✓ 25
(printed name of Regional Supervisor)
Wake Regional Office
UST Section
Division of Waste Management
Department of Environmental Quality
, Regional Supervisor
NORTH CAROLINA
W akt-- COUNTY
(Name of county in which acknowledgment was Laken)
1 certify that the following person(s) personally appeared before me this day, each
acknowledging to me that he or she signed the foregoing document:
Mark R. Powus
(printed full name of Regional Supervisor).

WITNESS my hand and official seal, this the
(Official Seal)
� ```�ttillitill,v.
•
1 i °' day of r-.t,bruL r3 , 20 .Q a
(sagnature of Notary Public)
Rut -lb A j
(printed or typed name of Notary Public)
Notary Public
My commission expires:
Ql 1y laoaG

WELL ABANDONMENT RECORD
For Internal Use ONLY:
Form GW-30
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, Stale, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ In dustrial/Contme rc i al
❑Irrigation
❑Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
e Monitoring ❑ Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
El Groundwater Remcdiation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under 7g)
4. Date well(s) abandoned: 02/07/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility IDIl (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake
County
1762-47-1164
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s)ifavailable. For multiple injection or non -water supplywells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
MW-1
6b. Total well depth: 38 - 74 (ft.)
6c. Borehole diameter: Unknown (in,)
6d. Water level below ground surface: 35- 96 (ft.)
6e. Outer casing length (if known): n'a (ft.)
6f. Inner casing/tubing length (if known): 25 (ft.)
6g. Screen length (if known): 20 (ft.)
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed, Indicate TOTAL NUMBER of
wells abandoned:
76. Approximate volume of water remaining in well(s): 0' 45 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
PI Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
❑ Sand Cement Grout
JS Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
50 Ibs of Bentonite
15 lbs of concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. �ertiTiC Yitorl'
02/10/2022
Signature of Certified Well Contractor or W` e see Date
By signing this form, I hereby certifii that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lOb. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his7her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applcahle well construction permits (i. e. UIC, County, State, Variance, etc.) if known
3. Well use {check well use):
Water Supply Well:
:Agricultural
❑Geothermal (Heating/Cooling Supply)
❑IndustriallCommercial
❑Irrigation
Non -Water Supply Well:
• Monitoring
❑ Municipal/Public
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
EGeothermal (HeatinglCooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Storrnwater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/07/2022
5a. Well location:
Myatt's Corner Store
00-0-0000005849
Facility/Owner Name Facility MI (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well constructionrecord(s)(/available. For multiple injection or non -water supply wells
ONLY with the same consh-uction/obandonment, you can submit one form.
6a. Well UV: MW-2
6b. Total well depth: 38.35 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 36.51
6e. Outer casing length (if (mown): nia
6f. Inner casing/tubing length (if known): 20
6g. Screen length (if known): 20
Form GW-30
(ft.)
(ft.)
(ft.)
(ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7h, Approximate volume of water remaining in well(s): 0.30
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
❑ Sand Cement Grout
• Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
10 Ibs of concrete
7g. Provide a brief description of the abandonment procedure:
4. Certip ati-
Signature of Certified Well Contractor .., :, v wner
02/10/2022
Date
By signing this form, I hereby certi that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on hislher property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
NIA
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
❑ Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
El Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/07/2022
5a. Well location:
Myatt's Corner Store
00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County
Parcel Identification No. (PIN)
5b. Latitude and Iongitude.in degrees/minutes/seconds or decimal degrees:
(dwell field, ono lat/long is sufficient)
35,7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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.
6a. WelI ID#: MW-2R
6b. Total well depth: 47.08 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 36.61
6e. Outer casing length (if known): nia
6f. Inner casing/tubing length (if known): 20
6g. Screen length (if known): 30
(ft.)
(ft.)
(ft.)
(ft.)
WELL ABANDONMENT DETAILS
7a. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1.71
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
• Bentonite Chips or Pellets
❑ Dry Clay
Cl Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
0 Sand Cement Grout
b Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
60 lbs of Bentonite
10 lbs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
Certititati '�
Signature of Certified Well Contractor wner
02/10/2022
Date
By signing this form, I hereby cent fy that the well(s) was (were) abandoned in
accordance with 15,4 NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a, For A1I Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
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
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
IOc. For Water SuPDIV & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Farm 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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
DAgricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Cornmercial
❑ Irrigation
❑Municipal/Public
:Residential Water Supply (single)
:Residential Water Supply (shared)
Non -Water Supply Well:
• Monitoring
❑ Recovery
Injection Well:
DAquifer Recharge
:Aquifer Storage and Recovery
❑Aquifer Test
:Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑Tracer
DOther (explain under 7g)
4. Date well(s) abandoned: 02/07/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility tD# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one latllong is sufficient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s)ifavailable. For multipleinjection ornon-water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: M W-3
6b. Total well depth: 39.96 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 36.56 (ff.)
6e. Outer casing length (if known): n/a
(ft.)
6f. Inner casing/tubing length (if ]mown): 20 (ft.)
(ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
6g. Screen length (if known): 20
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Welts having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0' 55
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7c. Sealing materials used (check all that apply):
• Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
❑ Sand Cement Grout
Concrete Grout
0 Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
50 Ibs of Bentonite
10 lbs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. Certilieatiri:
Signature of Certified Well Contrac a. r W
02/10/2022
Date
By signing this form, I hereby cent(' that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For Al] Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Welts: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the faun 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.
Revised 2-22-2016

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personalIy abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc,
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
( Monitoring
DRecovery
Injection Well:
❑Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
❑ Groundwater Remediation
0 Salinity Barrier
❑ Stormwater Drainage
El Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/07/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name
Facility IDH (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one latilong is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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.
6a. Well DM:
MW-4
6h. Total well depth: 35-42 (ft.)
6c. Borehole diameter: Unknown _(in )
6d. Water level below ground surface: 33.30 (ft.)
(ft.)
6f. Inner casing/tubing length (if known): 25 (ft.)
6g. Screen length (if known): 15 (ft.)
6e. Outer casing length (if known): n/a
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only l GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7h. Approximate volume of water remaining in well(s): 0.35
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
D Neat Cement Grout
❑ Sand Cement Grout
El Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
El Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
45 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. Certtt ,a ' -
G
02/10/2022
Signature of Certified Well Contractor or Well : ner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with I5A NCAC 02C .0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
14b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. U/C, County, State, Variance, etc.) if known
3. Well use (cheek well use):
Water Supply Well:
❑ Agricultural
C]Geothermal (Heating/Cooling Supply)
❑ lndu s trial! C ommerc ial
❑ Irrigation
❑Municipai/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
INIMonitoring
❑ Recovery
Injection Well:
DAquifer Recharge
L Aquifer Storage and Recovery
❑ Aquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
El Groundwater Remediation
El Salinity Barrier
❑ Stormwater Drainage
El Subsidence Control
El Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/07/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latflong is sufficient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) tfavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment you can submit one form.
6a. Well ID#:
MW-5
6b. Total well depth: 39.85 (ft.)
6e. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 35.38 (ft.)
6e. Outer casing length (if known): n'a (ft.)
6f. Inner casing/tubing lengtb (if known): 15 (ft.)
6g. Screen lengtb (if known): 25 (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe(DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0.73 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
C Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
❑ Sand Cement Grout
El Concrete Grout
0 Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
60 Ibs of Bentonite
10 lbs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. Certificmtio�n•s.
02/10/2022
Signature of Certified Well Contractor or ;...;: ocr Date
By signing this form, I hereby cetiify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County. State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (fleating/Cooling Supply)
❑ Tndustrial/Commercial
❑Irrigation
❑MunicipalPublic
EResidential Water Supply (single)
EResidential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring
❑Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
17 Groundwater Remediation
El Salinity Barrier
❑Stormwater Drainage
Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/07/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name
Facility UD# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweil field, one lat/long is sufficient)
35.7462569 N 78.4466727 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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.
6a. Well ID#: MW-6
6b. Total well depth: 39.48 (ft.)
6c. Borehole diameter: Unknown
6d. Water level below ground surface: 34.77 (ft.)
6e. Outer casing length (if known): n/a
(ft.)
6f. Inner casing/tubing length (if known): 23 (ft.)
6g. Screen length (if known): 1 6.5 (ft.)
WELL AEANDONMENT DETAILS
7a. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0.77 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
e Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
E Gravel
❑ Other (explain under 7g)
Neat Cement Grout
❑ Sand Cement Grout
• Concrete Grout
❑ Specialty Grout
0 Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
55 lbs of Bentonite
10 lbs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
R. Kertifgritig�r�^"
Signature of Certified Well Contractor or VrIer
02/10/2022
Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15,4 NC,4C 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-30
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
For Intemal Use ONLY:
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/ber property}
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Municipal/Public
CI Residential Water Supply (single)
CI Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring
ERecovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediatian
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
Other (explain under 7g)
4. Date well(s) abandoned: 02/07/2022
5a. Well location:
Myatt's Corner Store
00-0-0000005849
Facility/Owner Name Facility M# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction records) if available. For multiple injection or non -water supply wells
ONLY with the same�esnslnuction/abaadonment, you can submit one form.
6a. Well ID#: M Y V -7
6b. Total well depth: 81 .50
(ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 33.60
6e. Outer casing length (if known): nia
6f. Inner casing/tubing length (if known): 75
6g. Screen length (if ]mown):
Form GW-30
(ft.)
(ft.)
(ft.)
(ft.)
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s):
7.81 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
e Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
b Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
75 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. Certifleation:
Signature of Certified Well Conn
02/10/2022
ner Date
By signing this form, I hereby cert fy that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lob. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1, Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) ifknown
3. Well use (check well use):
N/A
Water Supply Well:
EAgricultural
DGcothermal (Hcating/Cooling Supply)
❑ Industrial/Commercial
❑ irrigation
❑Municipai/Publie
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
( Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: 0210712022
5a. Well location:
Myatt's Corner Store
Facility/Owner Name
00-0-0000005849
Facility lD1/ (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PM)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
,4ttach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well D)#: M W-9
6b. Total well depth: 38.36 (ft.)
6c. Borehole diameter: U nknown (in)
6d. Water level below ground surface: 32.30 (ft)
6e. Outer casing length (if known): n/a (ft.)
6f. Inner casing/tubing length (if known): 20 (ft.)
6g. Screen length (if known): 20 (ft.)
WELL ABANDONMENT DETAILS
7a, For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0.99 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
L Sand Cement Grout
s Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
• Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
0 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
50 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. Certifrc .tio
Signature of Certified Well Contra
02/10/2022
wner )Date
By signing this form, I hereby cert( that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
1013. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this forth within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) ifkoown
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ In dustri all Co mm erc i a l
Irrigation
OMunieipalfPublie
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Weil:
( Monitoring
❑ Recovery
Injection Well:
❑ Aquifer Recharge
Q Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Iieating/Cooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 0210812022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.7462569 N 78.4466727 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s)ifavailable. For multiple injection or non -water supply wells
ONLY with the same �confstruction/abandonment, you can submit one fonn.
6a. Well ED#: M V pv -1 4
6b. Total well depth: 68.97
(ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 32.82 (ft.)
6e. Outer casing length (if known): n'a (ft.)
61. Inner casing/tubing length (if known): 67 (ft.)
6g. Screen length (if known): 5 (ft.)
WELL ABANDONMENT DETAILS
7a. For GeoprobelDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 5.89 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply);
0 Neat Cement Grout a Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
0 Gravel
❑ Other (explain under 7g)
❑ Sand Cement Grout
S Concrete Grout
O Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
65 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. C:rtttcatio- nn;
Signature of Certified Well Contractor or
02/10/2022
Cr Date
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
accordance with 15.4 NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner,
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10e. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name A I
2. Well Construction Permit #:
List all applicable well construction permits (i.e, UIC, County, State, Variance, etc,) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geotbemial (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
lMonitoring
❑Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility [DO (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latilong ie sutficient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction records) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well 1D#:
MW-15
6b. Total well depth: 70' 30 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 35.84 (ft.)
6e. Outer casing length (if known): n/a (ft.)
6f. Inner casingltubing length (if known): 68 (ft.)
6g. Screen length (if known): 5 (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 5.62
(gal,)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
• Concrete Grout
❑ Specialty Grout
0 Bentonite Slurry
• Bentonite Chips or Pellets
0 Dry Clay
0 Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7L For each material selected above, provide amount of materials used:
70 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
S. Cert;fication:
Signature of Cerdfied We i r'Tra
02/10/2022
Owner Date
By signing this form, I hereby certtjj) that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
IOb. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the forrn 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.
Font 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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: NIA
List al! applicable well conduction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑irrigation
❑Municipat/Public
DResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
• Monitoring
E Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
DExperimental Technology
IaGeothermal (Closed Loop)
DGeothermal (Ileating/Cooling Return)
❑ Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake
County
1762-47-1164
Parcel Identification No. (PIN)
5b. Latitude and longitude in degreeslnunutes/seconds or decimal degrees:
(if well field, one latilong is sufficient)
35.7462569 N 78.4466727 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavaifabfe. Far multiple injection or non -water supply wells
ONLY with the same contraction/abandonment, you can submit one form.
6a. Well ID#:
MW-16
6b. Total well depth: 39.68 (ft.)
6c. Borehole diameter: Unknown (in)
6d. Water level below ground surface: 31.82
(ft.)
6e. Outer casing length (if known): n/a (ft.)
6f. Inner casing/tubing length (if known): 20 (ft.)
6g. Screen length (if known): 20 (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe(DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 ' 28 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
• Bentonite Chips or Pellets
O Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7€. For each material selected above, provide amount of materials used:
50 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8 Cert[%t`tiors; -.
Signature of Certified Well Contractor o
02/10/2022
evner Date
By signing this form, 1 hereby cert( that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
l0c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑IndustriaUCommercial
❑ Irrigation
❑ Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
• Monitoring Recovery
Injection Weil:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store
00-0-0000005849
Facility/Owner Name Facility IDl# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lntlong is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELLS) BEING ABANDONED
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.
6a. Well ID#: MW-1 9
6b. Total well depth: 45.27 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 38.14 (ft.)
6e. Outer casing length (if known): n'a (ft.)
6f. Inner casing/tubing length (if known): 25 (ft.)
6g. Screen length (if known): 20 (ft.)
WELL ABANDONMENT DETAILS
7a. For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1.16
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
e Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
e Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
60 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. Certification•
Signature of Certified Well Contras:
02/10/2022
Date
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/ber property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
NIA
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ IndustriallCommercial
E Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
e Monitoring ❑ Recovery
Injection Well:
EAquifer Recharge
EAquifer Storage and Recovery
EAquifer Test
Experimental Technology
EGeothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
Groundwater Remediation
❑ Salinity Banger
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02108/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PLN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field, one lot/long is sufficient)
35.7462569 N 78.4466727 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-21
6b. Total well depth: 39.63 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 32.54
(ft.)
6e. Outer casing length (if known): n'a (ft.)
6f. Inner casing/tubing length (if known): 20 (ft.)
6g. Screen length (if known): 20 (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 . 16 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (cheek all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
IS Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
• Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f, For each material selected above, provide amount of materials used:
50 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
e. Cert! fi +r.
Signature of Certified Well Contract , v, Owner
02/10/2022
Date
By signing this form, I hereby certti, that the well(s) was (were) abandoned in
accordance with I5A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
loa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lob. For Injection Wells: In addition to sending the form to the address in Loa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. For Water Supply & Injection Wells: In addition to sending the fore 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.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e.
3. Well use (check well use):
UJC, County, State, Variance, etc.) if blown
Water Supply Well:
❑ Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ In dustrial/C ommercial
❑Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
•Monitoring
❑Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
ElGroundwater Remediation
❑ Salinity Bather
❑Storrnwater Drainage
❑Subsidence Control
❑Tracer
❑ Other(explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility 1D11 (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake
County
1762-47-1164
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat./long is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well IDli: MW-23
6b. Total well depth: 39.79 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 33.47
6e. Outer casing length (if known): n/a
6f. Inner casing/tubing length (if known): 20
6g. Screen length (if known): 20
Form GW-30
(ft.)
(ft.)
(ft.)
(ft.)
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
WELL ABANDONMENT DETAILS
7a. For GeoprabelDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1 .03
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
• Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
❑ Sand Cement Grout
P. Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
50 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
• Cer,41..atio ••
Signature of Certified Well Contractor
02/10/2022
wner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lOb. For Infection Wells; In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injecton 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.

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1, Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
NIA
List all applicable well construction permits (i,e. UIC, County, State, Variance, etc) [known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
0 Municipal/Public
Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
• Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Beating/Cooling Return)
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
LlTracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 021Q812022
5a. Well location:
Myatt"s Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latflong is suf ieient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELLS) BEING ABANDONED
Attach well construction record(s) if available, For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Weil ID#: MW-24
6b. Total well depth: 39.44 (ft.)
6e. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 34.26
6e. Outer casing length (if known): nlla
6f. Inner casing/tubing length (if known): 15
6g. Screen length (if known): 25
(ft.)
(ft.)
(ft.)
(ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 0.84
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout • Bentonite Chips or Pellets
❑ Sand Cement Grout
Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
50 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
$. Lertif._ati •
Signature of Certified Well Contract()
02/10/2022
caner Date
By signing this form, 1 hereby cerl fy that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
106. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Sunuly & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this forth within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Weil Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
:Industrial/Commercial
❑ Irrigation
❑Municipal/Public
DResidential Water Supply (single)
10 Residential Water Supply (shared)
Non -Water Supply Well:
( Monitoring
❑ Recovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: 0210812022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.7462569 N 78.4466727 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s)ifavailable, For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one farm.
6a, Weil ID#:
MW-25
6b. Total well depth: 43.20 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 33.86 (ft.)
6e. Outer casing length (if known): n/a (ft.)
6f. Inner casing/tubing length (if known): 20 (ft.)
6g. Screen length (if known): 25 (ft.)
WELL ABANDONMENT DETAILS
7a. For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1.52
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check ail that apply):
• Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
0 Other (explain under 7g)
0 Neat Cement Grout
❑ Sand Cement Grout
• Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
60 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8 Certiflsation:
Signature of Certified Well Con
02/10/2022
caner Date
By signing this form, 1 hereby cert.!), that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
I0b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
1pc. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i. e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industri al/Commerci al
❑Irrigation
❑ Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
iMonitoring
0 Recovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
0 Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store
00-0-0000005849
Facility/Owner Narne Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35.7462569 N 78.4466727 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well consttuctionrecord(s)ifavailable. Far multiple injection arnon-watersupplywells
ONLY with the same construction/abandonment, you can submit one form,
6a. Well ID#:
MW-26
6b. Total well depth: 74.87 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 36.39 (ft.)
6e. Outer casing length (if known): n/a (ft.)
61. Inner casing/tubing length (if &mown): 70 (ft)
6g. Screen length (if (mown): 5 (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: 7b. Approximate volume of water remaining in well(s): 6.27
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout • Bentonite Chips or Pellets
❑ Sand Cement Grout
IR Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
O Dry Clay
❑ Drill Cuttings
O Gravel
O Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
70 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
S. Certification:
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NC/IC 02C .0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
1013. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
l0c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
( Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
E Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
0 Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under 7g)
4. Date wells) abandoned: Q2/0S12022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility 1D# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identiftcation No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat./long is sufficient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-27
6b. Total well depth: 44.72 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 36.69 (ft.)
(ft.)
(ft.)
6g. Screen length (if known): 20 (ft.)
6e. Outer casing length (if known): nia
6f. Inner casing/tubing length (if /mown): 25
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 1.31
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
IN Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
e Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
0 Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
60 Ibs of Bentonite
10 lbs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. (Lrtificat; ,n: --y
Signature of Certified Well Contractor or W
02/10/2022
Date
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C ,0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
l0c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of -completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industria1fCommarcial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
s Monitoring
❑ Recovery
Injection Well:
LiAquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No, (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction records) if -available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: RW-1
6h. Total well depth: 53.98 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 35.80 (ft.)
6e. Outer casing length (if known): n'a (ft.)
6f. Inner casing/tubing length (if known): 25 (ft.)
6g. Screen length (if known): 30 (ft.)
Form GW-30
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 2.96
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
E Concrete Grout
0 Specialty Grout
0 Bentonite Sluny
e Bentonite Chips or Pellets
❑ Dry Clay
0 Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
220 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. ('_rtificat:un..
Signature of Certified Well Contractor or
02/10/2022
ier Date
By signing this form, 1 hereby cert fy that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner,
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lob. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Contractor Information;
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ In dustri a l/C ommerc i al
❑ Irrigation
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
UMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
EAquifer Storage and Recovery
Aquifer Test
[Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility MN (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latAong is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) tfavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
RW-2
6b. Total well depth: 52.65 (ft)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 32.91
6e. Outer casing length (if known): nla
6f. Inner casing/tubing length (if known): 22
6g. Screen length (if known): 30
(ft.)
(ft.)
(ft.)
(ft.)
WELL ABANDONMENT DETAILS
7a. For GeoprobelfPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed, Indicate TOTAL NUMBER of
wells abandoned;
7b. Approximate volume of water remaining in well(s): 3.22
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
as Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
D Sand Cement Grout
e Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
250 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. C.ertitiep'ran:
.,r
Signature ofCertiticd Well Contractor or
02/10/2022
r Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For Ali Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, 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 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.
Form GW-30
North Carolina Department ofEnvironmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on bis/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, Stale, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/C ommercial
❑Irrigation
❑Municipal/Public
CIResidential Water Supply (single)
EResidential Water Supply (shared)
Non -Water Supply Well:
•Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
EAquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
C7 Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake
County
1762-47-1164
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.7462569 N 78.4466727
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s)ifavailable. For multiple injection ornon-water supply wells
ONLY with the same construction/abandonment, you can submit one form,
6a. Well ID/1: RW-3
6b. Total well depth: 54.89 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 33.30 (ft.)
6e. Outer casing length (if known): of a (ft.)
6f. Inner casing/tubing length (if known): 25 (ft.)
6g. Screen length (if known): 30 (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 3.52 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
• Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
❑ Sand Cement Grout
• Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
325 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. Ctrnticpiion:
•
Signature of Certified Well Conte
02/10/2022
.ner Date
By signing this form, 1 hereby certi that the well(s) was (were) abandoned in
accordance with ISA NC,IC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner,
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
1Ob. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells. In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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. Well Contractor Information:
Matthew Steele
Well Contractor Name (or welt owner personalty abandoning well en his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit 4:
NIA
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
© Monitoring ❑Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Gcotherral (Heating/Cooling Return)
CI Groundwater Remediation
❑Salinity Ranier
❑ Stormwater Drainage
❑Subsidence Control
Tracer
DOther (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility IDlf (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one latllong is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well m#: RW-4
6b. Total well depth: 53.75 (ft.)
6c. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 33.01
(ft.)
6e. Outer casing length (if known): nla (ft.)
6f. Inner casing/tubing length (if known): 25 (ft.)
6g. Screen length (if known): 30 (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 3.38
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (cheek all that apply):
II Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
❑ Sand Cement Grout
d Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
250 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
S. CzititicaLon:
Signature of Certified Well Contra . wife r
02/10/2022
Date
By signing this form, I hereby cert fy that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner,
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the fallowing:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10h. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
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:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on hislher property)
4548 A
NC Well Contractor Certification Numbcr
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑ Municipal/Public
❑ Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
( Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
0-Geothermal (Closed Loop)
❑ Geothermai (Heating/Cooling Return)
DGroundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: 0210812022
5a. Well location:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 2.73
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (cheek all that apply):
❑ Neat Cement Grout
D Sand Cement Grout
M Concrete Grout
❑ Specialty Grout
0 Bentonite Slurry
PI Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f, For each material selected above, provide amount of materials used:
250 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility ID# (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well 1DIt:
RW-5
6b. Total well depth: 49.55 (ft.)
6c. Borehole diameter: Unknown on.)
6d. Water level below ground surface: 32.81
(ft.)
6e. Outer casing length (if known): n/a (ft.)
6f. Inner casing/tubing length (if known): 25 (ft.)
6g. Screen length (if known): 30 (ft.)
02/10/2022
Signature of Certified Well Conlracwr o Vell Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form OW-30
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
For Internal Use ONLY:
Form GW-30
1. Well Contractor Information:
Matthew Steele
Well Contractor Name (or well owner personally abandoning well on his/her property)
4548 A
NC Well Contractor Certification Number
Geological Resources, Inc.
Company Name
2. Well Construction Permit #:
N/A
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
DAgricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
s Monitoring
❑Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
E Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
Subsidence Control
❑ Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 02/08/2022
5a. Well location:
Myatt's Corner Store 00-0-0000005849
Facility/Owner Name Facility IDn (if applicable)
9602 Poole Road, Knightdale, NC
Physical Address, City, and Zip
Wake 1762-47-1164
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iatllong is sufficient)
35.7462569 N 78.4466727
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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.
ba. Well ID#:
RW-6
6b. Total well depth: 49.38 (ft.)
bc. Borehole diameter: Unknown (in.)
6d. Water level below ground surface: 32- D 3 (ft.)
6e. Outer casing length (if known); n'a
(ft.)
6f. Inner casing/tubing length (if (mown): 25 (ft.)
6g. Screen length (if known): 30 (ft.)
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): 2.83 (gat)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
a Concrete Grout
O Specialty Grout
❑ Bentonite Slurry
In Bentonite Chips or Pellets
O Dry Clay
❑ Drill Cuttings
0 Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
175 Ibs of Bentonite
10 Ibs of Concrete
7g. Provide a brief description of the abandonment procedure:
Pour
8. rerfific :W- ort;,,
Signature of Certified Well Contractor W-• .veer
02/10/2022
Date
By signing this form, I hereby cent that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
IOb. For Iniection Wells: In addition to sending the form to the address in l04
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
l0c. 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.

Rae Brown
From: Larry Stancil <[e-mail]>
Sent: Tuesday, February 22, 2022 5:34 PM
To: Rae Brown; Eric Rice. Ncdenr. / Corner Grocery
Subject: Corner grocery knightdale
Hi Rae. I got a call from Eric Rice with Ncdenr after he did an inspection today.
He say that
Mw's. 8- 10- 11 have open bore holes and need to be closed.
I told him you'll were in the process of closing out the site.
He is concerned that the wells are open.
He is copied on this email.
His phone number is. 919-791-4242. Please handle this. Thanks tarry
Sent from my iPhone

Rae Brown
From: Rae Brown
Sent: Wednesday, October 26, 2022 3:59 PM
To: Rogers, Michael
Cc: Larry Stancil; Manuel, Vanessa; Vinson, Scott
Subject: FW: WQ0034819- FW: [External] FW: Myatt's (GRI 3147)
Attachments: Permit .pdf; Notice of NFA; 04.05.2022.pdf; mime -attachment
Mr. Stancil's request for rescission is below.
Rae Troiano Brown, P.G.
Project Manager
Geological Resources, Inc.
Celebrating 5o years of serving our clients
113 Firetower Road, Suite G I Winterville, NC 28590 I website I facebook
704-845-4010-office 1 252-227-3005-cell 1 252-321-6094-fax
From: Larry Stancil <[e-mail]>
Sent: Wednesday, October 26, 2022 2:25 PM
To: Rae Brown<[e-mail]>
Cc: Sandra Bass <[e-mail]>
Subject: Re: WQ0034819- FW: [External] FW: Myatt's (GRI 3147)
Rescind the permit
Sent from my iPhone
On Oct 26, 2022, at 2:18 PM, Rae Brown<[e-mail]> wrote:
Good afternoon Larry,
Please respond to the email below requesting a recension of the Permit WQ0034819 — send to all the
addresses shown in the previous email. I will forward photos of the system removal and well
abandonment records.
Rae
Rae Troiano Brown, P.G.
Project Manager
Geological Resources, Inc.
Celebrating 5o years of serving our clients
113 Firetower Road, Suite G I Winterville, NC 28590 I website I facebook
704-845-4010-office 1 252-227-3005-cell 1 252-321-6094-fax
From: Rogers, Michael <[e-mail]>
Sent: Wednesday, October 26, 2022 1:48 PM
To: Rae Brown<[e-mail]>; Larry Stancil <[e-mail]>
1

Cc: Vinson, Scott <[e-mail]>; Manuel, Vanessa <[e-mail]>
Subject: WQ0034819- FW: [External] FW: Myatt's (GRI 3147)
Rae -
See attached email chain on this subject. If the system has been closed
and wells plugged and abandoned, provide a closure report on what
was specifically done and when. Include photos and well abandonment
records (GW-30s).
Also, Please have Mr. Stancil reply to this email requesting the permit
be rescinded.
Finally, remove Shristi from your mailing list as she transferred to
DWM.
Thanks
From: Rae Brown<[e-mail]>
Sent: Wednesday, October 26, 2022 10:12 AM
To: Rogers, Michael <[e-mail]>
Cc: Shrestha, Shristi R <[e-mail]>
Subject: [External] FW: Myatt's (GRI 3147)
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to Report Spam.
Good morning,
I would like to request recission of the attached permit (WQ0034819). Per directive from NCDEQ, the
system has ceased to operate since 2018 and the incident was closed in 2022. The system was
dismantled in May 2022.
Thank you for your help,
Rae
Rae Troiano Brown, P.G.
Project Manager
Geological Resources, Inc.
Celebrating 5o years of serving our clients
113 Firetower Road, Suite G I Winterville, NC 28590 I website I facebook
704-845-4010-office 1 252-227-3005-cell 1 252-321-6094-fax
2