__20221118

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
I.Well ntractor Information: A WELL ABANDONMENT DETAILS
� ems/'5 7a.Number of wells being abandone
_or
For multiple injection or non-water I supply wells ONLY with the same
Well Contractorblame(or well owner personally abandoning well on property)his/herconstruction/abandonment,you can submit one form.
NC Well C ntractor Certification Numb7b.Approximate volume of water remaining in well(s): (gal.)
�A I 4).-/onji'c.
S�OG FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Al
2.Well Construction Permit#: f
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used: vvv
3.Well use(check well use): 1
SupplyWell: 7e.Sealing materials used(check all;that p ).
Water r Meat Cement Grout Bentonite Chips or Pellets
❑Agricultural ❑MunicipaVPublic ! ��
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
t 0 Drill Cuttings Grout❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete ❑Gravel
❑Irrigation 0 Specialty Grout
N -Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery ,° o
In etion Well: -Le(a e ;i 'o ,ach materiaar�ll sele/`cted above,provide//amount of materialsT used:
❑Aquifer Recharge ❑Groundwater Remediation 1 J�q AS. ken711k1y'c Ale elvf... I ) /9), (y�e i r i71 itaL
❑Aquifer Storage and Recovery ❑Salinity Barrier NOV 1 8 L, l� ` /_ /_/� � p�/(hG.L
❑Aquifer Test OStormwater Drainage : ,,,,,,_, A A.t,)Uh,; ��Y
❑Experimental Technology ❑Subsidence Co ro Da Q39 37g.Provide a brief description of/the',abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer 1 lj U� !C puce, Wirpl i lit /e ,i/v y phi(fir ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /I �' (y /dr t to t/
4.Date well(s)abandoned: I 1�J a� 4- z/-d 0 ed- (,),,e1 A Lark /t Lt/// 4
Sa ell location: iV " i" 0` Je lu'k'tIt A s��`e'
l^G ur` 8.Certif ion: ‘
Facility/Owner Name Facility ID#(if applicable) ,
2r>UE, pi<ttiS , N
of 'fled Well Contractor or Well Owner Date
.4 7.-710 / 11/1/AL
Physi I Address,City,and Zip
.kCN► By signing this form, I hereby cerih'i that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beenlprovided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9 Site diagram or additional well details:
(if well field,(j one 1at/long is sufficient)
3 S,(1 t I 1-g q N ©iC O t 3 You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple Injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
1'7 W
1 /e I_7 abandonment to the following:
6a.Well ID#: /r 1 Division of Water Resources,Information Processing Unit,
Q 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: I V (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
4 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: I'
2 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: I. (ft.) 1636 Mail Service Center;Raleigh,NC 27699.1636
1Oc. For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): 0 VI�K (ft 1 the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): �_ (ft.)
Oft b D kh 1
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells ; I
1.We ontractor nfor n WELL ABANDONMENT DETAILS
Q`� A '/rj( Ps� 7a.Number of wells being abandoned:
Ill✓✓✓ For multiple Injection or non-water supply wells ONLY with the same
Well Contractor/Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit re form.
37 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well CoCoAttractof CecificaticrpNumber
e FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: /�
2.Well Construction Permit#:
List all applicable well permits(i.e.Cormry.State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
7 Sealing materials used(check all that app ):
Water Supply Well:❑Agricultural ❑Municipal/Public Neat Cement Grout ` entonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 and Cement Grout Dry Clay
.� Concrete Grout 0 Drill Cuttings
❑Industrial/Commercial OResidentia aterV fiajr �' pecialty Grout 0 Gravel
❑Irrigation ❑Other(explain under 7g)
N n-Water Supply Well: NOV 1 8 2022 ❑ Bentonite Slurry
Monitorin ❑Recovery
g 7f.For each material selected
l above,provider amount of m4;,u
terials used:
ctifeon Well: IfaterRd31s 1 t"r7 3c:sHi V ��5' 6eMfltldl {/t I� PlV4 l��' - : �arf1 Lem
❑Aquifer Recharge ❑Groundwater Renweo,'ft usr s [ `
❑Aquifer Storage and Recovery ❑Salinity Barrier 3, ph,O 1} udelte
i [f, lowicw/ 4 em,IvH x
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of theab//andonment procedure:/
OGeothermal(Closed Loop) OTracer f su(4t /)pxlt 4je,r,�ypl(2 fide- /la 9 I . tle well
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) L t
Ott/a).- &Anil! l iarn e 1 l� l t). !:f" &Tr- i 4i/e �u vrre./well(s)abandoned: ,,C� [QY,�t deco„ /I � i1/ 1'`I`4t it te `
•
4.Date
5a ell location: 5�(�'1
.i(/�,/V'c'at 8.Certif lion:
Facility/Owner Name Facility ID#(if applicable)
I'lean Al• ‘' z 7-la 11AIII
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
0 u f By signing this form, /hereby eery.,that the well(s)was(were)abandoned in
County cJ Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards`
and that a copy of this record has beenIprovided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient)
3 I 12� N 0
gf Oil r6[1
t q ( J You may use the back of this page to:provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
welts ONLY with the same construction/abandonment.you can.submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
N,l ,„p,� abandonment to the following:
6a.Well ID#: /V UV i
Division of Water Resources,Information Processing Unit,
t 1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: (ft.)
106.For Iniection Wells: In addition to sending the form to the address in 10a
�j h above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: O (in.) abandonment to the following:
1 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: I l� ' (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c. For Water Supply&Injection{[Wells: In addition to sending the form to
6e.Outer casing length(if known): v h kn 0 1" (ft.) the addresses) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
.I i
6g.Screen length(if known): v yk kno WA (ft.) 1
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: !
This form can be used for single or multiple wells I
1.Well Co actor Infor atior WELL ABANDONMENT DETAILS
Iar y 5e,1,L�- 7a.Number of wells being abandoned::
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water 'supply wells ONLY with the same
7 3 3g construction/abandonment,you can submit one'form.
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Con c Certi do Numb/ l
el
/�0) �1i��„ (C. A�sos-
N4-
Company FOR WATER SUPPLY WELLS ONLY:!((///"` ���lll `" L• 7c.Type of disinfectant used:Name `
64----
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known P A-
7d.Amount of disinfectant used: I
3.Well use(check well use):
Water Supply Well: •7 Sealing materials used(check all that tip )-
❑Agricultural °Municipal/Public
Neat Cement Grout 1 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) °Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Gravel
°irrigation _ J] ecialty Grout
n-Water Supply Well: a� o e ;`( �. ett)onite Slurry 0 Other(explain under 7g)
NUV 1 A`Z
Monitoring
❑Recovery
)� f.For each material selected above,provide amount of materials used:
Injection Well: I �/ [ r
❑Aquifer Recharge °Groundwater Remediation J lY S, 6 eft1�t}44 fro% /Lj /s/i S, rvc 4 had
❑Aquifer Storage and Recovery OSalinity Barlft u Q/3JG 2.f yell. wG�W /-4, /"Dwbfir0 ia'-O/Ir/C
❑Aquifer Test ❑Stormwater Drainage r
°Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the'abandonment procedure:
❑Geothermal(Closed Loop) OTracer � .Sia4e lowV ep.Irla , `g t, /J/N r( low,- / irCLl
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /
4.Date well(s)abandoned: l /3 AM-1 CP js'P.Kt" do tu' t1 tail All Irf Y ' A-
5a. 11 location: (� �� t/ l �" Su
I 6...„4 z, _4*i/a
Facility ID#(if applicable) pc
8•Certifi on:
Facility/Owner Name
2p b 1, rL/44 )4; d/U iCoi ' fib C. "2-17.01 ///ctb-�
Physical ddress,City,and Zip Signature of Cdrtified Well Contractor or Well Owner Date
O By signing this form, I hereby certi j that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: y Site diagram or additional well details:
(if well field,one lat/longis sufficient)
if,�633 You may use the back of this page to!provide additional well site details or well
3 �tj() N ©�g. W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/aabdonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
�/J�'1 Pt) abandonment to the following:
6a.Well ID#:
1
Division of Water Resources;Information Processing Unit,
1617 Mail Service Center;Raleigh,NC 27699-1617
6b.Total well depth: v (ft.) j
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
6c.Borehole diameter: IT (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: / l (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
/ tOe. For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): V �Cn o (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
`. where abandoned.
6f.Inner casing/tubing length(if known): (ft.) '
6g.Screen length(if known): V A. lCfry U1.41 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well ntroctor In rmatio WELL ABANDONMENT DETAILS
!� 7a.Number of wells being abandoned:'.
IVVS p,
me r ell owner personallyabandoningwell on his/herproperty) For multiple injection or non-water ,supply wells ONLY with the same
Well Contra (q�{ construction/abandonment,you can submit One form.
me,
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contra for Ce fic72 —
on bet
AI l- , 4�sc . FOR WATER SUPPLY WELLS ONLY:Company Name ✓✓ 7c.Type of disinfectant used: a
2.Well Construction Permit#:
List all applicable well permits(i.e.Cormry,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all kthat app y):
OMunici al/Public Neat Cement Grout ( Bentonite Chips or Pellets
❑Agricultural p
0 Sand Cement Grout 0 ry Clay
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Cuttings
❑Industrial/Commercial °Residential Wate1:S s er Crete Grout Drill❑❑Gravel
❑litigation ('❑• pEcialty Grout
No -Water Supply Well: Bentonite Slurry 0 Other(explain under 7g)
❑Recove NOV 2�1�
onitoring ry 71: or.each aterial selected above,provide amount of materials used:
Injection Well: �_.,._.a,y�, ,t FCt +/ / n
❑Aquifer Recharge ❑Groundwatekllre111 �c g.Q,•jr� t o 4, en/ ilil ti �/tt:(•L- / 4,1 ) , , l.,-s/�
❑Aquifer Storage and Recovery ❑Salinity Barrier / /, rty /' // ,/ lei ( l`, ifkle l vye/ O+
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abando ent procedure: �/
❑Geothermal(Closed Loop) OTracer
��SU( l'Q-�/W✓� /y�2 4 ��uy �Iy^ tic
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) 111111
r c +
Veil
4.Date well(s)abandoned: ` q �L �� !'s"" ,Pgrd 1<1 ec 1- ie-mei( Aur we/`
•
5a ell 1 cation: .H Lt ri/j )tl� 4,, it, t",,, 'v 4e,�krx tic
5ur4�
1/�✓�6y1, 6 8.Certift on:
Facility/Own Name Facility ID#(if applicable) l
o f. A God 5 DL, A L— a 1 11( `44Phy al Address,City,and Zip
Sig urc of�ed Well Contractor or Well Owner Date
By By signing this form, /hereby cert6,that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with l SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient)
� ZD Olt
g ci�(_J p You may use the back of this page to;provide additional well site details or well
3 S Q(� �' D N �`Q t v l I W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
r,J p-� abandonment to the following:
6a.Well ID#: /1 r/�V 11 ! ,
1 Division of Water Resources,Information Processing Unit,
�( (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: I " �
I
� 106.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 1 ja l Division of Water Resources,Underground Injection Control Program,
(ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
Y
10c. For Water Supply&Infection[Wells: In addition to sending the form to
6e.Outer casing length(if known): V Nkn(71!A"N (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): U n Cr‘0w14 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
1