Pender_Well Abandonment_20230104

r
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loll p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 his needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water re paining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTFi
7c.Type of disinfectant used: i
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.)ifknown 1/4,Ib
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all`that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or,Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout. ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug 50 Ibs
❑Aquifer Storage and Recovery ' ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pull drop pipe. Cut well-1 ft. below grade, fill with
Hole Plug, cap and cover.
11/3/22
4.Date well(s)abandoned:
Sa.Well location:
NC DOT jAN _ r
Facility/Owner Name Facility ID9(ifapplicable) 8.Certification:
2425 NC Hwy 210 Hampstead, NC �' ����� DrA' BOG 11/3/22
Physical Address,City,and Zip Signature ofCertified Wet Contractor or Well Owner Date
Pender(H)
By signing this form, I hereby certify that the ivell(s)was.(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.01 00'or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 22 768 N 77 44 931 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construciionlabandonment,you can submit one fonn.
10a. For All Wells: Submit this;form within 30 days of completion of well
6a.Well ID#: 2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 48 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of thi'form within 30 days of completion of well
abandonment to the following: '
6d.Water level below ground surface: 20 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county, health department of the county where
611 Inner casing/tubing length(if known): 30 ot.) abandoned. r
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY: j
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30}is heeded. Indicate TOTAL NUMBER of
2531-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name , HTH
7c.Type of disinfectant used. A
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)if known 1/4-1 b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ® Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry 1 ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
i
❑Aquifer Test ❑Stormwater Drainage
I
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pulled drop pipe with hoist. Cut well at ground
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
ground level, filled with Hole Plug, capped and
4.Date well()s abandoned: 1 1/1/22 covered. y U`5a.Well location:NC DOT I LC�3
i'
Facility/Owner Name Facility ID#(if applicable) 8.Certification: �f1iPwC+ri{v ,l?fCry^,� l�fr S
2350 Hwy 210, Hampstead, NC 11/1/22
Physical Address,City,and Zip Signature of Certified W611 Contractor or;ell Owner Date
Pender(H) By signing this form, I hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 22 785 N 77 44 804 �, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-nmtersupplywells
ONLY with.the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 42 (It.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I ,
6d.Water level below ground surface: 16 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 20 (ft.) abandoned.
6g.Screen length(if known): (ft.) j
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop'Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30l is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
I -
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,e1c.)ii known 1/4-lb
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ® Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,1provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Hole Plug 100 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control i
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
i
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well at ground level, fill with Hole Plug, cap and
cover.
1 <� F •.,
4.Date well 11/01/22 s)abandoned: nm. UZ+ vV 5Z L'
S e
Sa.Well location:
NC DOT I A NL - LG'
Facility/Owner Name Facility IDt#(ifapplicable) 8.Certification: s^_ �t?T^ �
#10 2131 Hwy 210, Hampstead, NC �/ GA�•t(a1s�% 11/01/22
Physical Address,City,and Zip Signature of Certified WcdYContractor or Well Owner Date
Pender By signing this form, I hereby certify that the ivell(s) was(1vere)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1.
(ifwell field,one lit/long is sufficient) 9.Site diagram or additional well details:
34 37 80 N 77 74 42 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
I
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one form. r
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 68 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
2 (in.) above,also submit one copy of this form within 30 days of completion of well
i
abandonment to the following: i
6d.Water level below ground surface: 13 (ft.) Division of Water Resources,Undetground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
f
6e.Outer casing length(if known): (2" GaIV) (ft.) 10c.For Water Sumaly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy;of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
e i

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
P
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
,.
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 Its needed. Indicate TOTAL NUMBER of
2531-A
wells abandoned:
{
NC Well Contractor Certification Number 7b.Approximate volume of water re i aining in well(s): (gal.)
I,
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#: i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 11.4 l b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Hole Plug 75 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well at ground level,,fill with Hole Plug, Cap
and cover.
4.Date well(s)abandoned: 1 1/01/22
5a.Well location: —a V k--L a
NC DOT JAN 0 - 2023
Facility/Owner Name Facility lD#(ifapplicable) 8.Certification:
#11 2109 Hwy 210 Hampstead, NC 1MO 4 ' `"4 Ufl/01/22
Y� a i' EAPIOMOIC,
Physical Address,City,and Zip Signature ofCertified WO Contractor or Well Owner Date
Pender
By signing this form, I hereby certify'that the wells) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
34 37 77 N 77 74 30 W You may use the back of this page to;provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form. i
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft•) 1617 Mail Service Center,Raleigh,NC 27699-1617
il
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 2' (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 9 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (2" galV.) (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy bf this form within 30 days of completion
of well abandonment to the county, health department of the county where
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS,
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 his needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ij known , 1/4 I b
• 7d.Amount of disinfectant used.
3.Well use(check well use):
t
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout i ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
d
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of:materials used:
❑Aquifer Recharge ❑Groundwater Remediation Hole Plug 275 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well at ground level,j,fill with Hole Plug, cap
and cover. 1
4.Date well(s)abandoned: 1 1/01/22
5a.Well location: t V 01M
NC DOT
8.Certification: JAN 0 2023
Facility/Owner Name Facility ID#(if applicable) �
#12 2176 Hwy 210, Hampstead, NC �/ �'c ilt;B x �'� Pro,. ry---!;1)'10`1/22
Physical Address,City,and Zip Signature ofCertified W Contractor or Well Owner" Date
Pender I
By signing this form, 1 hereby certify ithat the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 37 91 N 77 74 41 w You may use the back of this page to'provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formuluple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: 11
Division of Water Resourcels,Information Processing Unit,
68 1617 Mail Service Center,,Raleigh,NC 27699-1617
66.Total well depth: (ft.)
10b.For Infection Wells: In additiot to sending the form to the address in 10a
6c.Borehole diameter: (in.)
4 above,also submit one copy of this form within 30 days of completion of well
�
abandonment to the following:
i
6 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Centr,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 44 (4" pyc) (ft) 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 I health department of the county where
611 Inner casing/tubing length(if known): (ft.) abandoned.
I
I
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
f
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sae
g 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30iis needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: !iII
NC Well Contractor Certification Number 7b.Approximate volume of water remalining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1/4 I b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout R Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Hole Plug 225 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of thelabandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well at ground level,j,fill with Hole Plug, cap
cover.
4.Date well(s)abandoned: 1 1/1/22 U,
C i
ltZ4 o'—U
Sa.Well location: 'JAN Q 4 2023
NC DOT
Facility/Owner Name Facility ID#(ifapplicable) 8.Certifieation: {tl.,y�itee$s:=� i ��•"^�'"�-v� a
#13 2212 Hwy 210, Hampstead, NC i' � ��lJ� 11/1/22
Physical Address,City,and Zip Signature of Certified W Contractor or Well Owner Date
Pender(H)
By signing this form; I hereby certifyl•that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beeniprovided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 37 94 N 77 74 44 `,lr You may use the back of this page toiprovide additional well site details or well
.abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)tfavailabte.For multiple injection or non-water supply wells
ONLY with the same constructtonlabandonment,you can submit one form.
10a. For All Wells: Submit this foim within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth:
66 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
1 I
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the countyl,health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I
I

i '
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 its needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1/4 lb
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug 225 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer 7g,provide a brief description of the'abandonmentproeedure:
Cut well at ground level,.fill with Hole Plug, Cap
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
cover. j
4.Date well(s)abandoned: 1 1/1/22 j
Sa.Well location:
NC DOT JAr'
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
#14 2232 Hwy210 Hampstead
p ?ronaz-vng U �/1/22
N. sae 1 et?d�a� c
Physical Address,City,and Zip Signature o£Certified W Contractor or Well Owner Date
Pender(H) By signing this form, I hereby certify'that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been,provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 37 95 N 77 74 46 ,1, You may use the back of this page to,provide additional well site details or well
abandonment details. You may also ati ach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonmem,you can submit onefonn. 10a. For All Wells: Submit this folim within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 58 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In additi n to sending the form to the address in 10a
6c.Borehole diameter: 4 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cenier`Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For.Water Suoaly&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
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-301is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)tfknown 1 42 lb
7d.Amount of disinfectant used:
3.Well use(check well use):
i;
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout X Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug 360 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control �r
7g.Provide a brief description of the!abandonment procedure:
❑Geothetmal(Closed Loop) ❑Tracer Remove drop pipe.. Cutlwell at ground level,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
fill with Hole Plug, cap and cover.
4.Date well(s)abandoned: 11/2/22
5a.Well location: w°b"t=' __a V=1 Fes.*
NC DOT 'JAN Q 4- 2023
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
34 Hidden Bluff Hampstead, NC
c�t2�tZ ink crr4 ;a�n ?rr _04&22
Physical Address,City,and Zip Signature of Certified Welltontractor or Well Owner Date
Vender(H) By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelt field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 22 886 N 77 45 130 W You may use the back of this page t0 provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 16 abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 78 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
i
13 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center;Raleigh,NC 27699-1636
60 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the couQ'health department of the county where
6E Inner casing/tubing length(if known): 40 (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sae
g 7a.For Geoprobe/DPT or Closed-Loop(Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 jis needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
I
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
h
Company Name HTH
7c.Type of disinfectant used: i
2.Well Construction Permit#: j
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1/4:l b
7d.Amount of disinfectant used: I
3.Well use(check well use):
i'
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout I, ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout i ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ` ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug j 300 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Cut well at ground level.!; Fill with Hole Plug, Cap
and cover.
4.Date well(s)abandoned: 1 1/01/22
IJ
5a.Well location:
NC DOT
JIK,N U LUL
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
2624 NC Hwy 210 Hampstead, NC 1� ln,:,,�ta;�n ara fay Fya�'"
'• �� ��� '�j�ec�i�cxG �1/01/22
Physical Address,City,and Zip Signature ofCertified WIA Contractor or Well Owner Date
Pender By signing this form, I hereby cert6l,that the ivell(s)ivas(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 38 13 N 77 75 10 `l, You may use the back of this page to(provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
r
Division of Water Resource ls,Information Processing Unit,
6b.Total well depth: 70 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
4 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: �
i
6d.Water level below ground surface: 16 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cent;r,!Raleigh,NC 27699-1636
6e.Outer casing length(if known): (4" pVC) (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources j Revised 2-22-2016
I '

i
WELL"ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Lo`piGeothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-301is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: II
NC Well Contractor Certification Number 7b.Approximate volume of water re f alning in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used: i
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)tfknown 1/4 lb
7d.Amount of disinfectant used:
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry I ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
i
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug 350 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well at ground level,(fill with Hole Plug, cap and
cover.
4.Date well(s)abandoned: 1 1/1/22
Sa.Well location:
NC DOT jAN U _ Z023
Facility/Owner Name Facility lD#(ifapplicable) 8.Certifcation:
2540 Hwy 210, Hampstead, NC �' �" '` `r "''' 'a U 1'�I/1/22
i �ft3is,O%
Physical Address,City,and Zip Signature ofCertified WM Contractor or Weil Owner Date
Pender(H)
By signing this fonn, 1 hereby certify!that the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
9.Site diagram or additional well details:
34 22 866 N 77 45 011 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 18 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 70 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.)
above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface:
19 (ft.) Division of Water Resources,Underground Injection Control Program,
i
1636 Mail Service Center,)Raleigh,NC 27699-1636
� I
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.)
abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
I.

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-L I op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-36 is needed. Indicate TOTAL NUMBER of
2531-A
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name H T I
7c.Type of disinfectant used: i
2.Well Construction Permit#: l 1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1/4 l b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all;that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout f e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) ❑ Sand Cement Grout ! ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout i' ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well:
❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: - 7E For each material selected above,i provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug ;, 75 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1
❑Geothermal(Closed Loop) []Tracer7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Taper tapped Drop Pipe'. Blew Well. Cut well flush
with slab, filled with Hole Plug, capped and
4.Date well(s)abandoned: 1 1/2/22 `
covered.
5a.Well location: Imo„�
NC DOT
Facility/Owner Name Facility lD#(ifapplicable) 8.Certifrcation: JA O �' 2023
471 Brickyard Rd. Hampstead, NC 1� ;X,,&Ul;,n Pr�c°in—i UNA
, 7e !2a ;�-- r-oun1noG 11/2/22
Physical Address,City,and Zip Signature of Certified Wel ontractor or Well Owner Date
Pender(h)
By signing this form, I hereby certo;that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and.that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 38 36 N 77 73 92 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also att 11 ach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• 19 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 42 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 16 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cent`r,lRaleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county!health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I.
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30,is`needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
i
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1/4 lb
7d.Amount of disinfectant used:
3.Well use(check well use):
r
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout I b Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I. ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout �' ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 1 ❑ Other(explain under%)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,6rovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug i 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the;abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Use taper tap to pull dro'p'pipe. Cut well, fill with
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Hole Plug, cap and cover.,
4.Date well(s)abandoned: 1 1/2/22 'J E� - "
.i IZc ice,�..�'E
5a.Well location: I A 70173
NC DOT
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: Iftiti+st43�s53a`Przcas :v:I� Unry
530 Brickyard Rd. Hampstead, NC runw'O'OG 11/2/22
Physical Address,City,and Zip Signature ofCertified We Contractor or Well Owner Date
Pender(H) By signing this form, I hereby certi that the wells 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:
(ifwell field,one ladlong is sufficient) 9.Site diagram or additional well details:
34 23 078 N 77 44 250 W You may use the back of this page to iprovide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 20 abandonment to the following:
Division of Water Resources,Information Processing Unit,
30 1617 Mail Service Center,6b.Total well depth: (ft) r,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: + i
6d.Water level below ground surface: 11 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cent'r,ERaleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I
t .

WELL ABANDONMENT RECORD For Internal Use ONLY: i1
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-L oop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-36 isf needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: !
NC Well Contractor Certification Number 7b.Approximate volume of water reL lining in well(s): (gal.)
I I
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH '
7c.Type of disinfectant used: !
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1/4 lb
7d.Amount of disinfectant used:
3.Well use(check well use): i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑'Neat Cement Grout ® Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above„provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
. 7g.Provide a brief description of the�abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Use taper tap'to pull drop pipe. Cut well at
ground level, fill with Hole Plug, cap and cover.
4.Date well 11/2/22s)abandoned: i'3�
5a.Well location:
I r1 Ai ,n ,f 9Pi4')
NC DOT
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
4 rlivirl:et>3C"1 i�i:':•'n'�':s`]l��i�
534 Brickyard Rd. Hampstead, NC 11/2/22
Physical Address,City,and Zip Signature of Certified We Contractor or Well Owner Date
Pender(H)
By signing this form, 1 hereby certifyjthat the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 23 091 N 77 44 276 W You may use the back of this page to(provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS I.
Attach well construction record(s)ifavadable.Formultiple it jection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. I
10a. For All Wells: Submit this form,within 30 days of completion of well
6a.Well ID#: 21 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: V
6d.Water level below ground surface: 1 1 (ft.) Division of Water Resources,Undler'round Injection Control Program,
1636 Mail Service Centi r,iRaleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suaaly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS 0NLY:
li
Company Name 7c.Type of disinfectant used: HTH
y,
2.Well Construction Permit#: I
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.)ifknoun 1!/4 lb
7d.Amount of disinfectant used:
r
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout i ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry I ❑Other(explain under 7g)
❑Monitoring ❑Recovery �•
Injection Well: 7E For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Rem_ediation Hole Plug ?: 75 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage I'
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well flush with slab. Use taper tap to pull drop
pipe. Fill with Hole Plug, cap and cover.
4.Date well(s)abandoned: 1 1/2/22
Sa.Well location: — V r a"
NC DOT 0 4 2023
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
496 Brickyard Rd Hampstead, NC �' `'`m iPrcc. `�.Q un511/2/22
b _1-:�4i
Physical Address,City,and Zip Signature ofCertified We Contractor or Well Owner Date
Pender(H) By signing this form, I hereby certifyI that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been'provided to the well owner.
�
(ifwell field,one latAong is sufficient) 9.Site diagram or additional well details:
34 23 038 N 77 44 268 `l You may use the back of this page to;provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
i�
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formultiple injection ornon-watersupplywells
ONLY with the same consiruciion/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• 22 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 58 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: d
6d.Water level below ground surface: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,(Raleigh,NC 27699-1636
(
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injectiou Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county;health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
l
I

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-36 is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water rem fining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
_Company Name HTH'
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1 iA I b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all!!that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout i ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well:
pP y -❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery '•
Injection Well: 7E For each material selected above,-provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug ;` 60 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Use taper tap to pull drop pipe. Cut at ground
level, fill with Hole Plug,!cap and cover.
4.Date well(s)abandoned: 1 1/3/22 I•
5a.Well location: y ti
a
NC DOT �� �j
Facility/Owner Name Facility IDff(ifapplicable) 8.Certification: JAW U 4 1GL3
293 One Mile Rd. Hampstead, NC II 11/3/22
Physical Address,City,and Zip Signature ofCertified Wel Contractor or �llt(�w"ner�L' Date
Pender(H)
By signing this form,I hereby certify'that the well(s)tvas(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been,provided to the ivell owner.
(ifwell field,one IaUlong is sufficient) 9.Site diagram or additional well details:
34 23 074 N 77 43 562 W You may,use the back of this page to;provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructionrecord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 25 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 60 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 13 (fk) -Division of Water Resources,UndIerground Injection Control Program,
1636 Mail Service enter,!Raleigb,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.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{h jalth department of the county where
6E Inner casing/tubing length(if known): 40 (ft.) abandoned. f
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-L op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only i GW-30 is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
I
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH'
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1"i2 l b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all1that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(HeatinglCooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hTi ation ❑ Specialty Grout 1 ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery i.
Injection Well: 7E For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Hole Plug ; 560 lbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed pump and drop pipe. Cut well flush with
slab, fill with Hole Plug, cap and cover.
4.Date well(s)abandoned: 1 1/3/22
Sa.Well location: R,
NC DOT F-)
/� �
Facility/Owner Name Facility ID#(if applicable) 8.Certification: JA fV V 2023
258 One Mile Rd Hampstead, NC �/ �' ]rl;r �:�ta;'?,.�, r ; �1J3/22
Physical Address,City,and Zip Signature of Certified We Contractor or Well Owner�t--"O = Date
Pender(H)
By signing this form, I hereby certifyi that the ivell(s) was (were)abandoned in
County Parcel Identification No.(PiN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been;provided to the ivell owner.
i
(if well field one ladlong is sufficient) 9.Site diagram or additional well details:
34 23 022 N 77 43 484 W You may use the back of this page to 1provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
ONLY with the sane co»struciion/abandonment,you can submit ate form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#- 26 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 81 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
4 above;also submit one copy of this fort within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: j
I
6d.Water level below ground surface: 13 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centl r,!Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county I health department of the county where
6E Inner casing/tubing length(if known): 42 (2°galv.)(ft) abandoned.
I
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

r
i�
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 i3 needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water r;mi fining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1/4 I b
7d.Amount of disinfectant used:
3.Well use(check well use): i
Water Supply Well: 7e.Sealing materials used(check all that apply):
i
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout R Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout 1 ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above,,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Cut well 1 ft. above grade. Fill with Hole Plug
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
and cap.
4.Date well(s)abandoned: 1 1/3/22
5a.Well location: iL
NC DOT
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: ,Jq N O ��n�
17585 Hwy 17 Hampstead, NC �/� c1� I [ 11/3/22
Physical Address,City,and Zip Signature of Certified VMI Contractor or l� 11' .ae`rxv�"'7l IR i Date
Pender(H) By signing this form, 1 hereby certify,that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
(ifwell field,one lat/long is sufficient) ii
9.Site diagram or additional well details:
34 23 786 N 77 4� 5�� W You may use the back of this page to'provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavai[able.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 29 abandonment to the following: '
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b:For Infection Wells: In additior to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I
6d.Water level below ground surface: 8 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centler,,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county';health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
I'
6g.Screen length(if known): (ft.) I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
i
WELL ABANDONMENT RECORD For Internal Use ONLY:
I �
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTFI
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ij'known 1,'/4 l b
7d.Amount of disinfectant used:
3.Well use(check well use): i
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above;provide amount of materials used:
❑Aquifer Recharge dGroundwaterRemediation Hole Plug 100 Ibs
❑Aquifer Storage and Recovery []Salinity Barrier
i;
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer j
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well at ground level.; Fill with Hole
Plug, cap and cover. f
4.Date well(s)abandoned: 10/31/22
5a.Well location: i4a.. Il,_7 1
i
DOT IAN-0 _ ZUB
Facility/Owner Name Facility ID#(ifapplicable)
8.Certification:
#1 2479 Hwy 210, Hampstead, NC l' �o`i ''' �r�` '"'�` 0'l31/22
I, DAN
Physical Address,City,and Zip Signature ofCertified W&d Contractor or Well Owner Date
Pender
By signing this form, I hereby certify that the ivell(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been'P rovided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1;
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
34 22 750 N 77 44 949 W You may use the back of this page tollprovide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS 1'
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction✓abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 69 (ft.) 1617 Mail Service Center,,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) ,
abandonment to the following: j
19 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface. (ft.) 1636 Mail Service Centr,'Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suanly&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 abandonmeni to the county;,health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned. ;
}
1
6g.Screen length(if known): (ft.) I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

r
I.
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAI ILS',
Michael Sage 7a.For Geoprobe/DPT or Closed-Lroop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: �I I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
If
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name , HTH
7c.Type of disinfectant used.
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1'/4 lb
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural ❑Municipal/Public ❑Neat Cement Grout H Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout �' ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout I ❑ Gravel
Non-Water Supply Well:
❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug 400 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage t
I
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer i
7g.Provide a brief description of the,abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well at ground level1.
: Fill with Hole
Plug, cap and cover.
-�
4.Date well 10/31/22 s)abandoned: !, • =`"I,. �, .1 011
Sa.Well location:
DOT 94223
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
2363 Hwy 210 Hampstead, NC I, ='�°r ' �C 0/31/22
Physical Address,City,and Zip Signature of Certified W01 Contractor or Well Owner Date -
Pender By signing this form, I hereby certr that the rvell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been'provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
34 37 86 N 77 74 75 W You may use the back of this page to"provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavatlable.For multiple injection ornan-watersupply rre!!s �
ONLY with the same construcdordabandonmeut,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resource,;s,Information Processing Unit,
6b.Total well depth: 78 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
4 (in.) above,also submit one copy of this fl rm within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 17 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centr,'Raleigh,NC 27699-1636
6e.Outer casing length(if known): 50 (ft) loc.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 f health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
i
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i �
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS,
Michael Sage 7a.For Geoprobe/DPT or Closed-Io p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): {gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
I '
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 1/4 l b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all,that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ; ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery i
Injection Well: 7E For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Hole Plug I 75 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier p
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under 7g) Cut well at ground level; Fill with Hole
Plug, cap and cover.
4.Date well(s)abandoned: 10/31/22
5a.Well location:
DOT i14 Al
- r 3
1nrt:PFiiswd,3U A-^^^'
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
s
#4 2505 Hwy 210, Hampstead, NC / ��'Ql Ot= 131/22
Physical Address,City,and Zip Signature of Certified W Contractor or Well Owner Date
Pender By signing this form, I hereby certify'!that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been I provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 22 801 N 77 44 949 M, You may use the back of this page to;provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructionrecord(s)ifavailable.Formultiple injection ornon-water supply wells I
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 58 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: 20 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i '
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy,of this form within 30 days of completion
of well abandonment to the county}health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
I
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sage 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknmvn 1/4 l b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout I, Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery.
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug 200 IbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage +
❑Experimental Technology ❑Subsidence Control {
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer !'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Cut well at ground level. Fill with Hole
r
Plug, cap and cover. +
_
4.Date well 10/31/22s)abandoned: r l °
5a.Well location:
nn
DOT _
Facility/Owner Name Facility ID#(if applicable) S.Certification:
#8 2280 Hwy210, Hampstead, NC Info` ``Vn Pro-^-5,MWng Unt
p yl!7 j U;01BOG 10/31/22
Physical Address,City,and Zip Signature of Certified We Contractor or Well Owner Date
Pender By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beeii provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34 37 97 N 77 74 56 `1 You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells i
ONLY with the same construction/abandonment,you can submit onejorm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: 1.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 42 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 11 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned. +I
i
6g.Screen length(if known): A)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
li
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sae I I
g 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30lis needed. Indicate TOTAL NUMBER of
wells abandoned:
2531-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if knoim -1/4 lb
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑'Neat Cement Grout a Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring DRecovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Hole Plug 75 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain.under 7g) Cut well at ground level. Fill with Hole
Plug, cap and cover.
4.Date well(s)abandoned: 1 0/31/22
Sa.Well location:
Galv. casing j
DOT 1, IN 0 _
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: I' ,
#9 2195 Hwy210 Hampstead, NC in(�. Sri .� Qi51:�h �r��
p : � �� DV,�� 10/31/22
Physical Address,City,and Zip Signature ofCertified WAI Contractor or Well Owner Date
I:
Pender By signing this form, I hereby certify that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.378365 N 77.744512 �, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)ifavailable.For multiple ityection or non-water supply wells
ONLY with the same construction/abandonmem,you can submit one form. I'
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 78 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of thisl form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 13 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) loc.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
611 Inner casing/tubing length(if known): 20 (1 1/4) (ft) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
1

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Sae
g 7a.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW 130'is needed. Indicate TOTAL NUMBER of
2531-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water i e i aining in well(s): (gal.)
Craigs Well Drilling, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1/4 l b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel.
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Hole Plug 80 Ibs
❑Aquifer Storage and Recovery EiSalinity Barrier
❑Aquifer Test CStormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Cut well at ground level. Removed 20 ft of Drop
Pipe, Plug well, cap and cover.
4.Date well(s)abandoned: 10/31/22 �
5a.Well location: ' a
DOT l ; _
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
#15 2715 Hwy 210 Hampstead, NC :n,c„� S= 10/31/22
Physical Address,City,and Zip Signature of Certified W61 Contractor or Well Owner Date
Pender ;
By signing this form, I hereby certify.that the tvell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1'
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
34.381020 N 77.752843 �, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: ,
Division of Water Resour I.ces,Information Processing Unit,
6b.Total well depth: 78 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 12 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I• ,
6e.Outer casing length(if known): (ft.) 10c.For Water SunDIV&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
6E Inner casing/tubing length(if known): 20 (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1