Wake_Well Abandonment_20230127

,\ILL J �ll )PiM NT�RECORD iiYnsl( ttititeT: i •
.r-,..,•en Wqr,emeed f.s►e.!*II*e+Mt+s►i
Ee re..r..e.e.ew.M.r•
Q ��� L
15.
TL IlomMr drt+eN..eirlots ..�*w 1.a►w#,a{c.iiVIMAT'rerr!e? rip* r Oft .•a eim "..
. / ?Loll pm?P.Mort truce.
7k Apncttstt velum.f loner resented fe nA(fJe f 4)
ti AV, P0010 Wen 8 Pump Co. MR WATGA rnlrn r wicfu waxt
-T•, •.-. Ye.Type.fifordmrstnear lirli
•.•..ca+el etdos remll illiii..026.
S .ag-ZAMA. .)/9jee
.er ere•ee..eer.+.tr re r. w foe.re-ea-re. e^t) 7Z Ames,of Meidaet.n rut:
I.w r't n.(check end see):
A..t S.FpfT g elh It Sean tondos ens(deed o)t)ei sppi)ya
' v.1.icurs; Olinhipelrubil: 0 Nee!Cesar et(host 0Wpe or Mete
.'C�ra+rm itNe.¢Y�CO.Noiiyply) 0OreartediWe'?l':;pirrrin4ir) -it..ed �r - 0 Drya f
t i . :la. �r
aecialeCer omereroi CRealderd el Water 3;ply(dewed)` 5'L'Or�+!! O Dry Cr�a�
'Ott lere ,:l ay� 2023 Arsvd
tea-pK S.Pph Belk CI9eaAas11.71sij 0 Myr(espisb sailer 7pi
.I
i.n..;tlRatect. URecumv •apeman Vet: )tusk Bch aiaihe trig prerfie lieeerf of rpferlele en*
'_'As rRta:aegt 71Citmtndwa ter Rem:dieiien ..Ar Y � 0
(i 3faeir tad Recover;; ❑Sallnir/boric
= ;z /4�� _ _ �A -�2 �S
fe'rest Omua SleltrDrainage 1J
:2Evei totalTaimolsq OSubeidmca Ccnntl 7R..ji—' '3
oxide a brier doe (ttca of the ahaardsomtsf prned.rr.
. (Clleed Loop) ❑-r,-a.er ZP
4,4Ave ilv "Otherlad7g) /
610Jy
l��� ` II�v� '�
'.Datew-t:;I?abandaced: Fn , ��.np n - JQ i 1i9
�.ntuictat:ac; A j/41-4,4411,11,44 ",.... - /�71]d-a 1„JJ J �a�G�
�e:"•±c't�.ee?rYme Father I (Ify,plie.ble) • ,n'Boni ^ `��
/n ,� t
:11 Aetna. sod v f s et�,r ease e Ct,,:•g1/440a2(577 PA f
. Gina dr
N.)4 Dy efi^I^T tide j4 rm I/rera curt*Sad Mt WIN MI pun)skis t-rd,•
refcei Identlfleaden No.RN) occordsici xl;h 114 N AC G:C.OICC c-s2CSall rev Conmedst a E :r
and that a CTr7Y rf t.6lr recur/Fsr tern pro-Wale the era owner.
:f:Lerhds and longitude In degreedmintttalteconda or dtelosei degrta:
ttetidai.saaa hldmiita kRrelete) • 9.Blte dtagrtm or addtttuaal ee11 details:
35.76 fq"y IV __,g. C it3 Ycu may uri the back of this rag:la proeidsttiiifrsa!'ad site detail,er .•sc:
I W 3handarame:tt Math. Ycu may also attach sdilIoed papa Uie:men
WYSIlRi:C;14�� {]� l�jjz �� 6IJyQirrAL.Lr�I2IGCIIO.`{d
I•'-:•••::(,9riitrii61161 r r I i lilii fr d;Wryli rl f tlNcn or moo-wavy ngTlp
•"Nt.P�:'h r.44 tote eanrl-nerfmi)dieand can etonTrnr,iv*ca otir one from.
10e.Far All Welk:•Submit this fc:::: mils 30 his of taaaepietoem of raeD
Wag gbstt ahmdnnmenl to Die fcllava.irg
Dhlaton afl}'a ter.Re.tourw,Iararcafi-Pt: rir';;Usk.Total Beta dam& 556(EL) 1617 Mill Service Center,Rate:;:,7•C:':;:•;:;'
lob,Forlaltrilo2 Well: In addition to eeadias he rem he be adds.his Ida
- _• rhea di.asdrr: {pa,) e.tave,Ilea ild nut en:cep,cr LI:6 f r taiihin 30 days of cac:pieffaa of red
eL endowment Io the fui:msis,:
::.aer keel lelerarsasaimelon: e.;11--.__(f(.) Division of Water lieuoreu,l;adersraaadl.JachsCurrr)irotirns,
/ 1636 Mall Servks Cerier.Aalelg:,NC 27Hf-1Q5
:>.fer tuts*tenet(if h.tlAny: (Q / (Rl lte is shahs Is sorhea dae tans t�
tlr. addtaa(ea abort alto hosie coo copy of Oh fans within30 days e
�••••• completlea of well ehvIdcreeaet to dee comity hoid►immense of die COD*.
ryrccr teska�sika Ina tit(If Lmswe)t ____ ._((t.) n1:Ye eh,a::d ere!
.+rot:4:gth elf nnono)! (II.)
910.1 (ionhCttoilneslot•utmeutcr atituazeut kid t(i ailReratee-1 ,•ru:---+••

rr.>JLi, �y.11O ITT RDC0 ar �itr�esfj� ,f u
Tltie fomt can bo used for single or•rtttiltlpl'e tvellr "t� ""�U�ONLY,
1.Well Cuolraclor Io m
rorallont r
•
.. I'
Well Conuaclar\June(or wet wott en 7a,Number of*ells being abandoned: l----�_
p ooa3ty tbtndoning till trn der property) Fur multiple 1 rcllon or N nm o ripply udb tlNGr with file am;•
___ /_, ronrrruerron/vbondonmrn{}r,/cart submit one form.
ere Well canrr„e,`�etda�uon Number •.
7h.Approximate Tolume of/rater remaining In rrell(e): •
N.W. Poole Well & Pump C /1(3 cl
Company NameFOR WATER SUPPLY WELLS ONLY: •
•
2,Well Construction Penult H 7e Type of disinfectant ueedl
rerennpprrraarr>.•rrrprmtnt().r•�� ������+�--/
h•Sfarr,i mforrcr,I t/rcNon,rraJ(r6rvxn ysso.
g3,Well use(t heck well use): 7d.Amount of disinfectant need: i{"7 �
Water Supply well:
0Agrlculhunl 7e.Sealing material;cued(check all that apply):
OGcoutcnnal(Heating/Cooling Supply) 0Muniolpel/Publfo 0 Neat Cement Cut
a pp y) }t ealdentiai Water Supply(tingle) 0 Sand Cement Orvut 0De Clay
Chips or F'cllcLa
oludustrial/Commercial 0Realderttial Wales-SV I (shared) 0 Corte ,ctauauu T r C Dry Ciut
0[ni allot: _ 0 Drill CulUngs
Non-Witter Supply Well: 0 9px(dly Grout P(Qrevel
Ohfonllorittg 0 Ilrntonlle 8 2 7 2023 0 Other(explain under 7g)
Injection\Veit: ❑IZCCOY
0Aqulfcr Recharge7L F r vir.h./V, ,1_t101-11n!#sftesktr'p rride amount Of matertafs used:
❑OroundwalerRcmodlslitnr ` r�.��.;,
\:Aquifer Stange and Recovery' OSdbtif g�{a /�/�)
0Aquifer'I'eal Y tTy� )"{-�Cr' ``°
❑SlarrnwalcrDrahtago p` -t` "' ,G'i�.` �) . .,
I I:Experimental Technology c
175ubsldcnco Control
rJCeolJlenntd(Clonal Loop) OTracer 7g.Provide a brief description of the abandonment procedure:
DUcolhcrmal calin Coulin Return ❑Otter lain tlnder.•7 -
4,1)alc well(s)abandoned: 'J',p „41 t "/' P��f'��/i'�
6 "
3n.Well location:
a • s
' cflily/ptrner Name '—
- FtollltylDt(Ifappper6le) . g•Celli Mont,
• a
1'byrlcnl Address,Clly,and Zlp r ` � .�
` • / 8lsnthati of Cathie ell Conhiolor br Well O net 'Dole
tom.
Counly Uy:I8 n81htijam,Ilnnay ctq that the well(JJ war(:ea, abandoned irn
Patcel!batik:stilNa,t (PIN) accordance with JiA NC.4C 01C.0100 or1C.0100 Well Corulnrdton Standards
'b.Lalltudtand:longltuti eIn degreei/minutetheeondsor decimal degrees!
and dta(acopyofrlrlrrtrvniharbeenprarldedtolheuellonntr,
(irnellneld,'6ne IaVli ng ii tiiifielttttl) •
._._3 O L� 9,Bite dlagram:or a dltonal well details:
___.__-.,N g.rj— You may sii.tllo.6iec of this page to provide additional well site details or well
SY abandonment details; You may also attach additional pages If necessafy.
drle'dhIip j •
Trill aN ; )h ikN' ,,' et,„t erldral;kel dn•M,nr,idk p •retie r carr m I 5
,�:. f�l lilib on 6t•non-halm ngrlly
;n.Well IN: IDe,LrQL QI(:II!<Jj(r •Submit this finite within30 days of completion of well
•
abandordtn enl to tto folbwing•
b,Total well depth: Division of WaferReiourem,Information Processlug Volt,
(ff.) 1617 Mall Service Center,Iialelgb,NC 27699.1617
c.Ilvreholc diameter: �y IDb, laehy—_ a'SVen,r In eddlllon Iv sending the form to Ilia addrus in 10a
(In.) above,alao''subd{It bhb copy of this form wllfnlrt 30 days of completion of well
•
abandonment to the following:
`ri•Water lead bclliry grotinii iirrface:. .: •
(R) Division.of:}yilerltetuurcu,Underground Injection Control Program,
I
lSU-MiiiBervir.e Center,Raleigh,NC 27699-163G
r. Outer cueing length(i( 0Th)I
(R) 10c
t:o addn1>ilsliilyn We st In addition to sending the fort to
'it1d1'n, !dip submit ono copy of this form within 30 days of
•
m c l
H.,Inner easing/tubing•length(lf•iwbwn)r `"—� 'Mimeaib n of wall abandottinntl to the country health department of the cowtty
`---- �(iG) coo of sal.
:•Screen;',ienth(if kdtiwn)t
(R•)
.,,r1,1 CfW3D •
• ' North Ctmllnitteplrirnent b(Enetreemenl inrf N.i....t v.._:.: _. . .

r r liLd:tital ll UffiYIEIYT RF CORD 1�p�p
This rum cart be used for single ormn141u welly �� wml UaeONLY.
1.Well C n(rac(ar lorunnallunt •
Well Conuednr Munn(or w owner an 7a,Number of teeth being abandoned(
9h personally ebendanlnp*Wire his/her replay) For muhlp!, lrtlrellan or non•xaltr supply lull, ONLY trlrlr the eon,ram rrvcrlardnboedonmrn{yrou can rubmlt out form.
irC welt Counacl x Cetdicaden Number • 7b.Approalmale'folume of/rater remaining In nell(s): al.
N.W. Pools Well & Pump Co. '•5--(g
Coropnn}'Naive / fir. FOR WATER SUPPLY WELLS ONLY:
•2.Well CoustntclJon Penult !: �(,{J'� '
/ 7c.Type of disinfectant used,s,all appllcoblr e•rll prrntus(Lc Cowt7.Stair,i ariarrer•l'sc taq ire)rtnawn `¢�
3.Well use(check well use): 7d.Amoonl of disinfectant used:
Witter Supply Well:
f7A[;rlculltlrnl 7e.Sealing materials wed(check all that apply):
DAgriccnnal(I1caUng/Coolht Supply) ClMunlo(paJ/Pubilo 0 Neat Cement ut,�
B pP y) esldentlai Water Supply(single) 0 Send Cement u L,L.17 i 1.S ytClay onlle Chips or Pellets
Olndustritil/Contnlcrcltil PP Y( g1 ) rq�
Ones!dentin]Water Supply(shared) ❑ Conuzie oroul
171ni ellon -L1"17r111 Cuttings
Nun-Water Supply Well: C•Spxially Grout JAN 2 7 2023 X.Ornvel
C7Monhoring ❑flenton)le Slulty. 0 Other(explain raider 7g)
injection Well: Olttxov Insrrril+c� fafT
7L For each mafeHal s t,Jr,
L7Aq«IfcrRccllorgc ❑17ruundwalerRemallallon �prmide aminIllI/bf:us(crisis used:
I [7Ayuffcr Storage and Recovery °Gronll Berra ==— r•2'la'ir� y f .....;
❑Aquifer Test y _
❑SlotmwalaDnlruge 'W f �6 `7 $
I °ExperimentalTccimology �'� a�N 7 '/d� �/
❑Ccoot uicnl(Closed Loop) ❑Subscrdt�rcro Control
7g,Provide a brief description of the abandonwenl procedure:
I,DOeolhetmal(I-losting/Cooling Relum) ❑Other(cxplaln under•7 r `+ '
'.Dalewell(s)abandoned: EgiOnA. Az)i d�� '
fige
Ill N8 �L
gin.Well location' , g �7 711rWP
�cihly/n><ncr Neme FeelUly IN(If appUctblr)
,� )r 8.C. catonr 14-
l
I • ,
Physical Adttress,city,and zip / `
Z.i ` /4' Blsnstuni of Certified Well Contiao or Well Omer bale
Couury is for
11y signing thm,I lrrroily csrtry that the well(.)was(wee)abandoned In
Parcel ldeeilfea it No.(PP/) accordance Vilh f 1A NCB C 01C.0100 or 1C.0100 Well Construction Standards
'b.Lat(udb and:longitude in degeeei/minater/seeonde or decimal degrees; and lhaf a copy of this meant has been provided to the cell nanny.
Bernet(rleid:titu!sl/hing li)4161E60
J�S . �� Z2.(/ � 9.Site diagram or adr�ditional re11'Walls:
N c GC br 1Y You may 1W tile.'beck of tWs page to provide additional well site details or well
abandonment details; You may also attach additional pages Unecessary.
.4r1t1'0170 f ;,
well;(ifY }! � li a)tar' in' eblil •
`tdtlrti)' f lfi 4 Alai Oh fir neroratrr ripply
abolkldtilnihb j•dk tin,rubailt oar font
i Well Ibtt; IOa, Fur` II.W list .yubmit lies form within 30 days of completion of well
• abandodinant lb tic following:
•
b 'Total well depth;_____2&_____ Division oflYa ter lterourca,Informs(fun Processing full,
{fl.) 1617 Mill Service Center,Raleigh,NC 2709.1017
10b, •,•"
c.Ilorelrole diameter;______a________
IecU- on •
n'. u In,addhlon to sending the form to its address In IOa
(In.) ..above, slso'subii{iioiio copy of this fomi within 30 days of complcllon of well
abandonment id Zile following;
tt.Water level below grotlni}jlsrface:. . '
•
(ft.) PIvhsltrn ofWalerIiesourcea,Underground Injection Control Program,
16.it MIII Service Center,Raleigh,NC 27699-163G
•Outer eating lehglh(If kutgvh):
((l,) IOc
the ad b`. b : In addition to sending the fun::to
completion o }vblleb Joninn io submit
jo the co ry health departmcUilrnt Uf3Ute county
Inner easlrig/tubing length(If•known)h form
(ft.) where abandoned.
•Screen ieplh(lf lulurvp)I c,,
(It) •
!'betel OW-30 • •
. ' North Gtitilinabeptdmentbfnottrenmentsatwo,—ta_._ _, , .

1 biild:.ADAND UNIYIrIYT RF CORD • FB I Ug ONLY:
This form curs bo used for rinAle nr'mnitlpl'e welly
r
I.}Vdtj.-pntreclor Information:
•
- -if
Well Contractor Nuns( well comer personally rbendonlet*WDs blither property) ForNmmultipleof rertIon ogr
n -d o1errt supply ,relit ONLY with the Jame
eon rruetfon/abonelanmrn{you rare subrfi one form.
NC Wall onnectot Certification Number 7b.Approximate s•olume or eater remaining In ntll(e): el.)
N.W. Poole Well & Pump Co. (gal.)
Company NameFOR WATER SUPPLY WELLS ONLY:
2•Well Construction Permit H:[�kifr�C1.� ,.� ��7 7c Type of disinfectant need, �^'�
Usti all applicable well permits(1.e.Cmmfj,Starr,rmierrrrr,!leak'''.rt IrMaxn
( - ,
3.Well use(check well use): 7d.Amount of disinfectant used;
C
Water Supply Well;
OAgriculturnl 7e Sealing materials rued( heek that apply):
0Munloipa1iPubefc 13 N' o- t • i-�i �,
0Ocolhcnnel(Heating/Cooling Supply) ati t : _. k' Dry Clay Chips or Pellets
pp y) talderttlel Water Supply(single) 0 9RBdeCement drovt 0 Dry Cloy
Olndusllial/Comntcrcltil c�
❑Ra(dentlal Water Supply(shared) LI Conciti,� rt2 7 2023
C1[ni orlon O Drill Cuttings
iVon-Zlreler Supply Well: 1310
9pxWty Orout Oravcl
C3Monitoring Pr�:0a,�a-„3 Lr,:
{injection\1'tll
ORtxovery �C2i , CI Other(explain under 7g)
iJAqulfcr Recharge 7f.For each material selected above,provide amount Of materials eyed:
❑arouroundweterRemodWlvrt ` /yn �a
—51
❑Ayulfcr Storage and Recovery O CI (y Barrier '4
rAquifcr'I'esl OStormwatcrDra►nago • rf�G� 7 ��❑Experhncnlal Technology OSu 1 `Gs �r��G' 04 le
baldenco Control
�Gcothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
• 7Clentitcnnal fHcaling/Cooling Return OOlher(oxpittln undtr7g) �` tr 3 , ,JcI-/ oiiii-i
.Dale wells)abandoned; K-- --�. � � ©/�/j ��� �Il)� r
PI �0�
'p.Well loeallon;
,=_nifty/Owner Nente
Facility 11:4(If applicable . 8.Certlflutont
AO
i�'
Ihyeleel Address,Cify,end Zip q r.- '�""C a -14
/V #` I 81.r' .ofCer'c .WellContnotnror Well()ener De
Dale
our Patcol ldehrtf8tadohiNo. Fir Dy signing 1W form,I bere�y certify that the well(s)was(were)abandoned in
( ) accardmres With IJA NCAC 01C.0100 or 1C.0100 Well Cottstnidion Standards
c;i_J.Latitude andaoogitude In degreedrulnutes/seconds or decimal degrees; and rhafa of this record has beetprtnidedfo the well miner.
iif'*Nell field,one iel bug li iiiGcleal) ,
Ja(„QrD�� 9.611e diagram or additional trill details:
u/O N � ,7 f `3 YOU may Willi:bade of thle page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
alisnlfillammacimirlI(IN 1'tr{ )`t'ht'}din'' cbn'i)Rlrrlw►lobenddnnrtnf:%0.6.6' . lif Oar.Or n-wanr ripply
,.Well IDN: 10a, ForAll Well,; •Submit this formwititin 3t days of completion of well
ebandoitinenl to the following:
t1r Total n ell depth:,_„,52Qad.._____
of WaterResnurcu,informaflon Procuring Unit,
(IL) 1617 Mall Service Center,Raleigh,NC 27699.1617
'I • • IDb,Borehole diameter:_______62_____ 1L3Yg11t: In-addltjon to mending the form to the address In 10a
(In.) ..above, tlro"subtrllt'ono copy of this form within 30 days of completion of well
abandonment iri the following:
Water level below ground surface:. (n.) Drislbn obWtlerReronrcea,Underground Injection Control Prog
ram,
5} ill Service Center,Raleigh,NC 27699-1636
Outer caring leygtk(If kduivh);
_______Ki (rt.) _ loc. . .... .
the form to
the adtirtiiN`ebeni, lieu tubmlt one copy of ttishoform sending
30 days of
'niter cesing/tubing length(if knuwn): whereeetbtan of wall abandtnunrnl to the count health-��(fL) com abandoned, y department of the county
:.•ScreetTle6gth'(Il;ltdutyti)1
(tit)
,:,3(lW.30
' Nett Cartillna Dewitt:out bf CaTbbnment Ynd N.r,...t n------- _. , -

•
t I LUG irlDWIENT RECORDirogailliar.wt r+w.tom„te. nR tMb {
•
i!
t wok C.* it,.t.ra../Mtst
crivz. mop iv .
.t„t �M��� t p wtrtiAatAatrr) ►w 1111 yir i*eMr ew wwarr 1 way oar .nt, ✓., e,-•
• ....w.errai/aeaasaasaR�eamrw11a�6rwll�teaec �//7
'� 4 C' ""t` wNetstt,� 1L A�ple tnl�e tf••tell/neaiatas Is w-Ut1):' __'.t!.
N.W. Page wen&Ptmt
+-,.�„try P Co. t+wlwAtElt tturrteT wi►ta.1 an.Yc
1,\YerCetetlnHN ItTntddWehttaslseedt fr,7
:.Ae.q e#,q ..1,11....be A..Cow*311".t+twaa ee.Iy►•4e► //�=r'/
•
}•Weil sty(tkedi*el wee)• •�/I6t•a 7i Assent dilateewt"el:
i\Ystrr Svpy Wail:
i QA6tt�r teas; 7t 66111ag mahrlala t (dub WI Uat rq,p11)c
1 OGect ell y� t 0 lt�tyfr+a _ - �-,-_.' agoras
CbiDa v Mkt'
ole d eq 3,914) ultl V:ewhigIr ) C S idi �—t All. Qay
QRnlltnttc vie: Supvly(ebared) ❑Cmvre t... 7 n,3 Ci 0:01 C.:1.-3t
�iRlbttleaa ❑Specially t
Tiga-Wi r1 N 2 211E El On ve:
Citesoe t7 lie6calie g� n pm,: z.sir..)
k 0 C"el.ferla!i u .I'l
-, 1eI r» a.n CQro undwateaRemolltlar {©�tal Recovery CSillnl {a 7f Fn.aehmahrjg
/ st prorldeenasa' reterrfa�
FV
' S
• / m�(.i7M ❑SltrrmmlerDrainageIrr.Y.,a___lai amiololcgy ❑Subsidence Control 7•YrotIde a brief deecripI a at the abaadancent;racedort:
OQtd I ��Loop) ❑Tncae
7‘DOtaterrrtil iatla aoln• telum ❑Ouer itlnwrda7 (1R4r DAJ/
6.DC:ntli(s)abaadot ed _ 1 Z..,"
is WE;; 'catiuu! j•••�
Naee
Fie Litytp-((tt�gctyte) . 8.Certllindonl
':t:at Ad:stu,Clay.nad ZIXek. .e.l �O��/� ' `�/
/tf�j� 81 tic.tlC- ''d ^nennF7 / /Z.2
^ Dab
CcL _ Ily'liring rhir firm,I hers cr. Oa As id"Fete!IdeallaadenNo.(PUt) aernrttmrce utth ill NC4C OIC.0/00 at7C trrl�n igiaiAls ird:
5t.LaLLi3:and longitude In degreee/mlenteshecoada or decimal delreu: and that o i►6�f etidra�aa6wds cgryofrlrUrtcenfhubeeny,e1da My tteraar•
7 9.ffile diagram or addilloaal well delaW:
N �g q W You may Liao ttlo back of this page to;raeids
abandonment detail'. You my elm a;: WNW
WNW Ri Tall lie w tsil
W Fa3d If.�aury.�
aster v:;:Ei+iil R n+, fiF ���
Ala F1.�LYr1(e4�teems cbnr. emlare)`b•� �+ M1t•tNoa or wen-baler nTFtY• "ftkuk corm''Gmlt rnrf'"'
"-Wel11)16 IOC :'3ul:mi3'Lit rum within 31 dr.t of
tbardnnmrnt to Iba follantins: d aid
'IxT s tltlut Irlrplaaofl}weerIiu at
ourea,IaSo:� lca1'neadsg',;i.;' 16171lail Service Center,Italet
lab.For Lniet to a gi-r Lt aldillaa to at:editi the taw 1s le Minas Is 17s
'..Zereltela diameter:_- (In.) abate alto full rht cne cc W at Lit form*Ilia:*Ilia:37 da
ys�aadt arwd(
Wets,-teed hdor.grngnd*Watt: Division of lYalerlEetaurcne L'adergro'ad La
1*-106
r� 1f36 SIa115er.iee Center,Ratrt It,�(Cen ad Pura;
OCT,'nett!tail%(I!kte.t,n): (tt) IOt For}Yi1 r 9 n+
lr dt Inleerin���e;•t, s
t4 addrela(a)abort also subunit an or Ns ea le swift en Tatra o
aver tatter';r';:u t:each(it k'tona't J angle*i srteail a mular.raay le Os iy lea wMefs Sa dqa or
i ---_____(tt) ala•danal. �grMed d Gx were;.
,_trttt length Iltk tas•c}: ,__itt.)
n`;:X•', t cirh Catcltna ll rrmeut a(F -
tr atlassradal+e+..•._..

rrtiik:AilAINDVIVENT lit CORD �jp II This Enna can be used for single or mnitpl'e wells F al Uu ONLY: • •
1.wen tractor rnrormattour
•
•
wet]Cotpi., ,....lnctor Nuns(or well owner personally ebendonla iriU ba Alslhtt 7a,Number of hells being
.i property) For mule is t ecnon abandoned(
p N non•xolo supply wells ONLI
aennrvcnor✓abondonmrn{you eon fvbmrr one fork
u•rdr the sonar
NC Well Contractor Certll)eellon Number s
7b.Approximate rolorne of/rater remaining In nel(s): r/ al
N•W. Poole Well & Pump Co. (gal.)
Company Naute FOR WATER SUPPLY WELLS ONLY:
2.Well Construction Permit tit/�/.fl�g/��� 7c Type of disinfectant used:
!I,N oil applicable well prrmtr,t(T.r,CrVariance,
omrr, IghcNoq ere)Vbre»r+ } A
3.Well use(check well use): 7d.Amoont of disinfectant used: L/�/
Water Supply Well:
\ClAgrI
\'etc cultural 7e.Sealing materials and(check all that a
❑Munlolpal/Publlo 0 Neat Cement°rout apply);
Cl°caUtcrmal(Heating/Cooling Supply) gldeztNel Watceu I (single) 0 Sand Cam X3ctttonlle Chips orI'cllcls
t 00Q:th anal Hearin nl Supply( gl)
❑Realdrntnl WsltrSupply(shared) ❑CantxGe rod bt+.� ,r �.-� .. Clay
Olrti;allon xl Drill Cuttings
4
Non-Water Supply Well:
o Spxlahy°rout'
Non-°MoWater
BrnlottllaSltrrt) 2 7 2023 X°
Inf cation Well: �Recov. O Other(explain under 7g)
DAqulfcr Recharge 7f,For ea
❑Groundwater Remediallmt i; i9 ,ti de amount of ma(crlttls used:
❑Aquifer 8totage and Recovery ❑Salina Barrier �• • ' �' j��y �l
fy •.a �l�iW `• '
I7ngnircr Teat ,, ----_
I
°Experimental Technology ❑SlormwaterDtahlago d�l %/ / — �t0Ceothennal(Closccl Loop) DSubeldenco Control
�
❑Tracer 7 Prerride a brief description of the abandonment procedure:
I.❑Geothermal !coda: Coolin; Return ❑Other . 'lain under7:
'.Dote 1t'ell(s)ebaniloned; .�e. � L 1V1 iz, e j
3n.1Wg Io allon; -iF-��" _ L l.�' rya
v y 'fkr Yam#��'�_la ke-6 l 177) J/frit.eenily/0rvner Name
^/ PaclUtylDJl.(IftypUwblr) 8.C 1llcatont P _•
Pltyslcnl ddr a Clay, nil Zip ' 3�s `'
Li Li. 14, . 0.i:. . .r
c/O8lgnsttue of Cert(j1 WellCaulrsctor or WellOrrrter '
Dale
y sighting this
fora;
County
Parcel IdeatOeadtnh No.(PIN) D: I hers certify that the well(s)was()care)abandoned to
tt,Latitude and:longitude In degreeri/mJnoted1econde or decimal degree:(PIN) accordance With 1J,!NClC 01C,OIOl7 vr1C,0100 Well Construction Standards
and that a copy of this record has been prot'ided to the well owner.
(trn•elttie(d,one ial/Iong li►ii ielei,t)
•
W 9.She diagram or-Additional well details:
�'2, N 7 . S?j 3 (0 N You mry rids a beds of this pogo to provide additional pages
s If site tarsals or well
abandonmwt dciai(s. Yw ma) also attach additional pagrs If necessary.
tine leil3l f
ell,t711 $t;t))r ihi I,' eb,rr ''
crltho'ba i °^hraon-thatch ntnply M..lfrforintiht,)der Cerra rubiiir one firm
'is..\YellMY; • IOa,
lila, untebr .: •Submit Utis form within 30 days of completion of well
l,'fold n ell depth: Dlvlslon of vim ter llesaurces,Iuformatlop Praceulug Unit,
(fb) 1617 Mall Service Center,Raleigh,NC 17699.1617
Uor•'hole diameter: IDb,
(In.) .,above,tdso'dubiriif oho copy of this fomi witrilr g30 days of compl the form to the etion oft wIta
ellabandonment to the following.
`i.Water level belo'ry ground int-face:. .:
____,A5____
(!L) Division of YhttirResources,Underground Injection Control Program,
163ri Mall Service Center,Raleigh,NC 1769 9-1 63 6
Outer casing length(if knOrn)t
_„,„;_itiT,....:„...", (Il,) I Oc
On adrltrll(f�`.ib : In addition to sending the form to
`:ginner casing/lubing length(ifknown)( there ban of wohnb doninrnl�llo lho copy healt of h department witiln 30 days of
---�_(ft) completion
tion of abandoned,
partment of the county,
•Screett Idngtij(if knoivii)f .
(It)
trot OW-30 •
North Call n►Departneut of Pnrtrnh.,,..a .-

rr'dila iiillU, ENT RECORD • fa hail UR ONLY:
This form can be used for single or multiple weW
I.well Contractor Info (tone
I
Well Contractor N a(or ell owner personally abandoning*rill an h106er property) For Nu ulgolt [Infectiells balsa ab,non or -wa edi sic* well, ONLP with the some
y` construction/abandonment,you can submit one/arm.
NC Welt Contractor Certification Number 7b.Approximate volume of water remainingIn well(s):
N•W• Poole Well & Pump Co. I? � (gal.)
Company Name FOR WATER SUPPLY WELLS ONLY:
2.Well Construction Permit M:-I U 1 d J(-1• 7eVIT Type otdblafeehat used: V Hit
List all applicable well permits(1.e.Coto*Slott,f ortonee,Nation.ere)Ifknown L
3.Well use(cheek well use): 7d.Amount of disinfectant ased: f sl.f
Water Supply Well: • 7e.Baling materials used(check all that apply):
°Agricultural turioi al/Publle Nat Cement Orout &T/Brnlonile Chips or Pellets
OGeothermal(Fleeting/Cooling Supply) ❑Reside ndal Water supply(single)
0 Sand CemP�e Ste"°' �--p Dry❑lndustrial/Commercial ❑Residential Water Supply0 Concrete �.• '- Clay
l7[trl atlou (aid) ❑ Drill Cuttings
Non-Water Supply Well: ❑9pecialtyMcot:MN 2 % ?023 Gravel
°Monitoring CIBentotdte Slurry • Other(explain under 7g)
Infection Well: ❑Recov iffott art Pr:`C: •
7L For each materI 1 t j �� !o ;
❑Aquifer Recharge °GrvundwalerRemedialfon -7 ti prwide amount of materials used:
°Aquifer Storage and Recovery ❑Salinity Bonier r� �� � ' .141 �� �� �it r
DAquifer Test °Ste mwaterDrainage 25 s v ~h1,�, e/1
❑Experimental Technology °Subsidence Control
°Geo'thermal(Closed Loop) Cancer7g Provide a brief description of the abandonment procedure:
°Geothermal(Heettn Cooling Return) ❑Other(oxplain tmdtx7al 9�%� j,:� �r.��,
d.Date well(s)abandoned: • •
��
5a. Yeti location:
Fecill /Owner Nam. Facility ID/(if applicable) • 8.Certifi
cation:
radii
�'� �- ,��t r i,I IMF �G Z� 1-
Fhyeical!trees,City,and Zip � 4�S�
2 Signshae of Certified Well Contractor or Well Owner De\c,.." ,_. 1——------" Sill t
County ' � 6y:lining!h!t
Petal Identification No. W g�g form,I hereby cert(fy that the well(s)was(were)abandoned in
(PIN) accordretee with ISANC,AC 0.2C.0100 orTC.0200 Well Construction Standards
5b.Latitude andaoagitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifivell'field,one ial/iong it iuFgdeot) ,
, � � � 1� u , �, •, �� Y Site diagrams dlsgt or additional well details:
N 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.
Atiaeh':. '1 T r
tire ti chi'4)h`ili �rbrir ednihnetidi)e'betktotnnin you corm ntbmion r a -anti;up* EMILEDULEMILCLISM
6e,Well IDN: • • 10a,For Al kt •Submit this form within 30 days of completion of well
abandonment to the following:
66:Total well depth: S©� Division of WaterResourca,Information Processing Unit,
(f) 1617 Mall Service Center,Raleigh,NC 27699-1617
F • lob.FarLlecfloa-wen.; �
6c Borehole diameter: --iglisu..-..a In addition to sending the form to the address in IV,
_•(In.) ,above,also alibinit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water lewd below ground surface: Division of Wa{te�r� Besoarces,Underground Injection Control Program,
(�) 1636 Miii Service Center,Raleigh,NC 27699-163G
Ge.Outer casing length(If kfldWr ):
(B•) loc.
the addtedll(p`eboneb* : In addition to sending the form to
completion of well cb dsoninrnbt�to the county healthcopy of s form department of30the county
6f.Inner casing/tubing length(it known): �` •
{[t) where abandoned.
6g,Screen`length(If iteroivn)i —
(11j
Form CIW30 •
' North Ctuolina Department of Environment and Natural Resources-.Dishier:of Water Reim:nes „_.._ . . ----

TvEli : kilIDO 11E 'RECORD
77»s fonrrcnn Ue used for eingle or•molt),1 wells Fo (Uo ONLY:
i.well Co lr for lnronnntlout
' z . -.Ao
Well Conlnctor Nuns.(or well owoar penoailly ebmdvnhh trill tdtl6et 7e.Number of relb being abandonedt
-i property) For muhfple 1Nscllon or non-water srioply u,llr ONLY with the mn,r
cannrvenom/abandonment,you eon subhnrr one forat.
MC wdl onuxet Certification Number 7b.Approzlmate 1 olame of Haler remelning In neU(a): al•)
N.W. Poole Well 8� Pump Co. —/�(g
Company NAMFOR WATER SUPPLY WELLS ONLY: i
2.Well ConalrnctlonPertnll H: V�1V'� / �i1r,�1J 7c.Type of disinfectant need:
Lrsr o!!npplfcotirr will rrndrs p (1.e.Cam stare, i ey Xl.lisie
'
4 Variance,/ryrerron,ere)(/b+o,rn _-, '.
3.Weil use(aback well tire): 7d.Amount of dialect Lent used:
Water Supply Well:
OAgrleullurnl 7e.Selling Interleaf cued(check all(het e I• OMunlolpaUPtsbllo 0 Neat Cemen pp y)r
DOcoUccnnnl(Ilealing/Coolht Supply) Llfou't"y,-'•'F.:'' f"• .l3•.9cnlonhe Chips or Pellets
g Pp Y) RgldalUd Water Supply(single) 0 Send Cuernt Q�otrt^Z,.i Ca i to
❑indusuttil/Conuncrclal - ❑RcldrnUnlWalcr6v f shared) 0 Concrete JAN Clay
0[rrl:atlon •
PPP( c� OUriUCulUngs
Non-Water Supply Well: pwhdly Orout 4 �` 2�23
oring0 Gravel
Injection}Veil: 011sxov- 0 BcntunJl9ri .$:ran Pr^:giving Lff7:aptirer(expltin utndcr 7S)
OlvfonitDiA,QrnOil;
❑Aquifer Recharge 7f.For each materiel;elected a1B37y provide amount of meted:its used:
❑Aquifer5(otage and Recovery p allnliyBarriaem�lallon n j�/�/�,�/�j�/
❑Aquifer Test
y raW ` e` �`�� I�L jail- ,.
17Gxperimcnlal Teolutology CiSlormwa(crDralrcago e. © �
OGeothcnnal(Closlul hoop) ❑Subsldacro Control
OTraccr 7g.PProrlde a brief description of the abandonment procedure:
OOcodhcrtnal icelln: Coolln: Return °Other . 'lainunder.•7: -air fliV��c
tv
4,Dale well(s)abandoned: v • 1�`���t�/�- T
E4‘2,_,z-adj____ __12.322„) .
3r,.Well location;
J
Facility/Owner Nama.
Feolllty IDI(if,y,ptleeblr) • 8.CeHlfciUo
Physical A dress, Icy.end Zip / /„�
6laneluri of Ceriilled W• Contnolor or Well• er 7 •
,fl
Dale l
Dy Vining(h11 jvrm,1 hpr�y certify(Inn(!he well(s)war(were)abandoned In
Couu y
Patrol IdentifiationNo.(PIN) accorrkircaWWllhJSANCAC01C.0100or2C.0200WellColutructionStandards
1
St).LeUtude.and;tongl(ude In'degreeihnlcules/seconds or decimal degrees: and tits)a o
(Ira ell tleid.'one lal/Ibtta li iiikilerat) copy of Mir record has been provided to the well owner.
�� • 9.Bite liagrtm or 1ddlUohel well detais;
N f • l07�(,' You mty us tlie•b'eclr of tails pogo to provide additional well site dctaib or well
nbandottmwt details; You may also attach addJUonal pages If necessary.
•fri 5Arlahit/(rr1Ivo'i • ' /'bl 1 i o ena•rali np+ply •
nelli r inbarrtlfraardHtnhlo
otrissuballroarfoin,.
Well 1UH: • 10e. For: II:W'tli; Submit this fvrul within 30 days of completion of well
abandoritnen!to ll e,IbIJitwing:
Procuring
b,'fntal*ell depth: DDivisionof lYalerltarourcw,Informs:lion Unit,
2a_______.(f�) 1617 Mall Service Center,Raleigh,NC27G99-1617
-•Borehole dlamelert. • 10b• -
(In,) ,,above, tlao'sutinii py o f this foot withinsendingddition In 30 days of compl thc Than to the etion of r lUa
well
• abandonment ld.lile following;
,ri.Water lei•el beitirr grotlnil iirrface;.
(!t) Division ofilYilirResources,Underground Injection Control Program,
163t}4Y.l dervlce Center,Raleigh,NC 27699-163G
Outer eating length:,(If kndtrn):
________e912___.(R) 10e.Fit-d ;
lbo nd ab : In addhfon to sending the Conn to
Inner cesltig/lliUing length(if knotrn)t •
°0 submit ono copy of Lids form within 30 days of
compleilohi of well:abandonment to am county health dcpar(rncrtt of the county
--�_(ft.) %limeebandoned.
3crcelt',IfndiH,(If;l4ojvti)l'.
tnJ
"inmi OW30
• ' NenhtartillnabeprttaentofEnrlrr.n......, r.,.. •-

l IJ wt lWVI �YIENT RCORD - i��g�ajlqi ONLY'.
This form-can bo used for single or•muWpl'e wells � "" I�u O�U1.
1.welt Cun actor Information:
416
��'cll ConUactor)June(or well owner en 7a Number distils being ebandoaedt
�/ � personally ebandouipa*ill tin hhlher property) For mule le I anon or
cenrrveno�obo error norr•Moftr rt¢rply Will: ONLY' wall the �amr
NC Well Contractor Certification Number ^{yO1 can'Won't our form,
7b.Approximate'plume of water remaining In well(s): ,��' ''
N.W. Poole Well & Pump Co. tgal.)
Company NameFOR WATER SUPPLY WELLS ONLY:
2.Well Construction Penult H 7r Type of disinfectant needs ��
L4r all applicable teal permit" ... / 1
P (I.e.cowry:Stair,i'erforrer, ryrCRon.ere)ifknown
3.Well 115E(check well use); 7d.Amount of d4lnfeclant used:
1YatcrSupply t
tiYell:
O'oter lhtrnl 7e.Sealing materials used(check ell that apply):
f70eol)tcnnal(Ileeling/Coolin Supply) DMuniolpal/publlo 0 Neal Coop�,, PP Y)
g pP y) ,esident1al Water Supply(single) 0 Sand Cemer t "^,�r z 3 y Clay
Chips or Pellets
171udustr(lil/Corrtntcrclnl PPY( g1) (ltdot•�•.�'L;• S,; �',
❑Reeldentlel Water Su "DrY Cley
Cl[ni;ntlon Supply(shafted) ❑Conta-tte OtOut JAN ❑ Drill Cuttings
Non-Water Supply Weil: ❑9peclalty Grout
2Q23
[JMonhnting ❑Idrntmill X`Oravel
Injection ❑Rccov. 9tWtn ta;i�n r�r::: ,g l�libdter(eaplaln under 7g)
❑Aquifc Well:Recharge rJi►fQr9 OG
71.For each material seise bores provide amount Of metu ads used;
C]Ayulfer5totageandRccovcry 0OroundwelerRemxdlallon
OAquifcr Test
C75dfnily Bella � "
DExperimmini Technology ❑SlorrrtwataDralrtago • © s'
DGeolhertnal(Closed Loop) DSubsidence Control "
❑Tracer 7g• odds a brief
fdtsc iptlon of the abendonment procedure:
fir
C1dcothennel letitln. Coolln: Return ❑other • Anent under:7: ;/� �"
•
'•stile neli(s)abandoned: " !!/G - Pr
•
3n.Well location:
' n^ •
tt--ff ' - fcC/�d at.';
I r7Lwr/wll.19
Pecillty/owner Name
///} Feolllty II)iV(,I/f�arrpperblr) 8•Cert!llcailaol
P ry"eice Addr as,City,and Zip/
6i,.5-81 'ofC dWe1 ontnolnror Well Owner Dete p ^+
•
�ouuty •By signing;hit I here�y curtly Oaf the well(i)was(were)abandoned In
Parcel Identification Na.(PIN) aceordaruia'atrh litNC1C 0.IC.0100 orTC.01001i'tll Construction Standards
b.Lalltudb and longitude in-degreeshnlcniet/secands or dedmal degrees; find that
(iftvell field,tine Id/Iong it iuR}ciwt) �}ojl$lr recortf has been provided to the well owner.
�-�� r Y.Bite diagramor addlllonal well details:
N / W You may ii tdet bec'C of Oda pogo to provide tonal nag well site ideals or well
.(rt6100.i f
t •_
abandonment:detains. You may also attach additional pages Ifnceessary.
rella(jfyI a'
i'f�i 3m' cEflit rdNri)o'badhhtihl,)blrap .7. -eh'Or •iratrr'nyfply 8
`a,WellLIM: • 10a,
rabandonmen o�g8 ubt this )until within 30 days of completion of well
•'br'folel n ell depth: Division of Wafer Resources,Information Processing Unit,
"_______4;________H .
(IL) 1617*IV ill Service Center,Relelgh,NC 27695.1517
.r.Borehole diameter: • 10h,
(In.) .Above,llao uih�py of Otls fount withtiig the form to the 30 days of completion oflw la
water Tsui below grouna iurface: a .✓ abandonment to thefollowing: p I
((L) D•ivision ofWaticResources,Underground Infection Control Program,
1634 Miilt Service Center,Raleigh,NC 27699-163G
c. Outer casing length(I!kndnh);
gt.) the edulr .A•e•l•u
,.1b. --ot� In addition to sending the fonts to
Inner casing/Itibing-length(IC'known)1 • where completion o evohnb doninrnlalio �lo the countyt an of this Corm within 30 days of
� (IL) colaoeion Of al. health department of the county
Screen Itnilti;(Ilknnivli)l r
(R) •
;,nut OW30 •
' North CuullnibepulrnomofFh.lrn",—.r._J._. •-

T r DIAISMII)llVISOLEIT11 RDGQ1110 • lJ
This farm can be used for single or mnitlpl'e wets jg I"N Hi'.
t•We oInformation'clor Information' •
Well Conueelo N � 7t.Number of hells beingabandons H (or well owner peneaal(y ebendo trill On h1slhKptoP n7) D Abandoned: /
s'� nips s For multiple Iniretton or non-water rupply :verb ONLY arrh the Jame
rem rrvcnor✓abandonmrn4 yroa con sobmrl ant form.
NC Welt Conesclor Certification Number
b.Approximate volume of Hater remaining In wtU(s):
N.W.. Poole Well & Pump Co. tcel,)
Company Nante FOR WATER SUPPLY WELLS ONLY:
2.Well Construction Permit l: �• .'0 4.S g 6/�lLc Type of d[s[afeetant used:
Lis all appUccl,wrllrrrmits(1.e.County,.}Tarr,rorla„ee b/,rrfor etc)tfbroxn l'ALA6
3.Well use(check well tile): 7d.Amount of disinfectant used;
Water Supply Well:
f7Agticulttu al 7e.Sealing materials used(check all that apply):
OMuniolpal/Publfo ❑Neat Ceuten4 0rvut 00eoUrermal(Heating/Cooling Supply) ,esidental Water Supply(single) O Send Ce erfl@tgu� +'?� cntonlle Chips or Pellets
a iudusUfal/cnmtn,etnlnl
❑Refdental Water Supply0 Commie 0evut ��+ �: Dry Clay
(shared) --�.i
O[tti etlou ��//�� 0 Drill Cuttngs
Non-Water Supply Well:
C Spxlilty 0tuut '�v 2 ? 2023 �[0revcl
f7Monitnring ❑gentDnl �u�,, ICI Other(explain under 78)
infection Well: ❑Rceov i sr:,,1 C?„rn^tea
7f.For Er"-naterl� emFld�ibor��ri
OAqulfcr Jlccltarge OOroundwater Remafiativn ti provide amount of materials used:
❑Aquifer Storage and Recovery OSaltnl Battler `'
OAquifer Test � L�`l/;,^� p.
❑SlnrrnwalcrlhtLugc ���� �' `/� i 6 4��4-oZ �-st.sC
OExpearnental Technology OSubsldence Control
II OGeolJtermal(Closed Loop) OTraCa 7g.Fronde a brief deectiptlon of the abandonment procedure:
I,00cothcrmal Qictiting/Cnoling Return) ❑Other(cl[pleln undo 7g) 121,,itr" � (j trL1 . - r",,,,„ B,,,,,,,,,,j�f �,
-7-3 4c‘)
Date well(s)abandoned: ...
,
5A.1Velllocation: ' ' '_ ' if ;‘)
FacitlylDwnerNeme 1 �f,
® Q AA Facility ID•�(If IIce61e) • 8.Certlttullon: � ,T6
J /l d0�i i
Physical Ad es Chy,and Zlp f/ Al et- g'�. �, c
/V`% ,a+' / 81Ar,---x
f Cd Ws Conlreelor or Well�mter Date -✓—
uu y Pe[tel ldeDUAeadotl No.(pW) aecol� ,ei miry tat form,Imirythat the well(s)war(were)abandoned if!
Si).Latitude and.ionattuue in degreee/mtnafet/tecondt or decimal degreul1:9 +t rlct Will/1�NCAC OIC.0100 or 1C.0100 Well Construction Standardsand that a copy of MI:neon/has been provided to the well miller,
(tCnell field,one laVlbng li liifileleot) .
g(�Q 9.Site dlagrun or additional well details:
r r� _N 7g,jo G(„IOI You may tsb:t$e itte gilds page to provide additional well site details or wellt
---_W abandonmeat details. You may also attach additional pages Unecessary.
4rfeeh41li
roll}ON 'i h t I.
m' e n1 t��� 6 bit Or nen•irarrr applyfilailmilammalt S
er1OrtAil ciii bits,j4k;cart rvbrnll one Atm.
Well Ihll: 10a, For! it. 1►.t •Submit this form within 30 days of completion of well
abandon[nent IV the following:
�11r Total Well depth: blvislon or Water Information Procuring Uult,
(fL) 1617 M‘II Service Center,Raleigh,NC27699.1617
• 10b,iiorehole diameter: �leC- thou ttr In,addltlon to sending the form to Ilse addrras In 10a
(In.) ..above,sho submit ono copy of Utis form within 30 days of completion of well
• abandonment to.the following:
'n•Water)ci'cl besot:grotnd surface;. .
(lt) Dlvielon ofWtiterlterourcee,Underground Injection Control Program,
163t Mill Barnes Center,Raleigh,NC 27699-1636
Outer teeing length(If knuiTn)t 32
((b) _ lot, • .
the ad t In addition to sending the form to
inner casIng/tubIng length(Ifknbwn)t completl o ee jl nb donmmlio �lo the county healtht Erne copy of department form llof3Ut0a county
(ft) cohere abandoned.
-r,..Bet acu length(If kupwh)I:; •.
(IL)
''trrw(3W.30 •
' thrib Can:lintbeperttuent otEnTlonuuset end Natural a ,:,,rrr- , --

u+a141.4 Will f,u1/1 dial/ �W) • .71»s fomr can bo used for single ar mulUplb�eUa ��itaI it oa?,
•
•
Welt Cvntrseiar None(or well o mime*abmdo 7L Namber of ireih being abandoned:-� Iir" bnhl✓ ttprvperty) For multiple
2, .r V lrtlydlon or non•xorer reply trrflr ONL) ,rlrh d,c J;
romrruerren/abondonmrn{)vu roar rubmrr orrr form,
NC Well onnector Certification Numbs o ,
N.W. Poole WellPu 7b.Approximate tolom °Nailer remaining In relit* C. (g
Pump Co. FUR WATER S F'
Company Name
SUPPLY WELLS ONLY;
2.Well cons trnetlon_.permlt H: , —0,�'�a e1-,,,/�, lc.Type of disinfectant used, `'�°
Liar on oppricoble will puma,,(I.E.County Srorr,Var{grata,INrrtlorl etc)V Ir a
bro*n
3.Well use(deck well use): 7d.Amount of dulrtfrclant used; '"�
Water Supply}Yell.
Wale cultural 7e_Sealbsg material,sued(check ill that apply):
tlAgrit7AeoUtermal °Munlatpel/publfo ❑Neat Cem
(Heat ng/Cooilug Supply) Testis dial Water Supply(single) U Sand CemeilfT ra -� .
dindusWal/Co • � /""' enlonhe Chips or Pellets
mmerclal ❑Residential Water Su ► ' Clay
.01M:allot;
Supply("hued) CI (trout n °Drill Cuttings
Non-Water Supply Wells "peclalty Orovt�A V 2 ? 2023 g
°Monitoring • °Otani
n ec on ell: °Itecov. U 13entanile 9lttrt
In yr a;i:-i Pr-::.5,,.v-sr:3 1. : er(explain under 70
°AqulforRecharge 7f..For each material atll t�{Mibo�' pruride amount
❑QroundwelerRetnadlatlrnt ti bfmateriels treed:
°Aquifer Storage and Recovery ❑Sallnii Dania
°Aquifer Test Y -.
f]t;xpirirnenW Technology °SlorrttKalaDralnagv ci,.•.f_
°Cicollt sien (Closed bap) DSubaldonro Control❑Tear a rma
7k ides brief description of the abandonment procedure:
OCicoUtcrntel cafln. Cnolin; Return 00ther • 'lainunder,7:
i.Dale stall(:)abandoned �': " — 1,�. `
3n.Well location:
< �,n�,,
FeciblP/pnner Na e
t-— 1 aclUtylf) (Irappbcable) S.CertlflcaUonl
physical Address,City,and Zip �J
//� ' !� �/Sign of Ccttille a Contnolor or ell()Amer Dine `
Dine
Comity
•Dy!lining this
Passel Ideni{tlsxtfon Na.(ppr) deco fora;I hfr1f ctrf(fy that list well(s)war(were)abandoned iii
3b,Lailtudb and,lungltuue In degreei/minute/seconds or decimal degree; r(cI ' /1,I NCfC 01C,0100 ar1C,D11701Yr11 Construction Standard,
(Irreelf iield,rone IsVltirtg li iiiigcle6t) and that d copy ofr),Lr recvltf has been provided to the well owner.
�c-�(� N - �G t I`f 9,Slle diagrxw or a d(tional xell detail':
4 1,50LN �Y You mky tifatiie beek of his papa to provide additional well site details or well
• abandonment detnlh; You may also attach additional pages Ifnecessary.
ifr1E! •
h r
wallbh''
i'''". tit "erirte d' tiINomRirir',j•dr Carr rub iilr oneform„0"r"j1y •
is.Weil Wilt . 10a
r• abendotifn eh!ICI lira fkwi :
olg81t this avant within 30 days of completion of well
=6''Tnfal Well depth;
,
(fL) Division of Wafer Resource',Inform lion?roaming!Alf,
______45::_
161781111 Strvire Center,Riddell NC17,699.1617
u lloreholc diameter; IOb, se
______g_Y____.(In,) r Imadditivn In sanding Use(nun In Um address in l0a
.Above,tdso"subiiflt'oho copy of this fbtm Within 30 days of completion of well
,d•Water level baldly grnuni surface:• abutdonmenl fd'Iho�llowing:
WtUerRettiurcea,Underground Inaction Control Program,
• 1r, M..tJ SeMce Center:Raleigh,NC 27699-1636
Outer easing lehglh(If IcutiSra)l
—..i.Z.C ________.- (R.) _. ioe. • .
um aII>11eeU_on Walt : In addition to sending
the form la
•`' whore tleri of evoll'eband copy of this form witdn 30 days of
((L) whore abandoned.
w. went to the county health department of the county
g•Screed Ieniii (Ifkdii'.ilk( ''. - .�"
•
itintOW.30 • ,i •
Neal}lbh
artillniDepluttenlbfEmiromototIndNaturalRernh:si.iAiLr_. .. --

r Uu�: fll7llVllEYInT' CORD • fMp .
Ihie form•can be Used for aingle or•mulllplewelJr •
f�rwroIU�CO�Y, •
r.wen Co°iractor tale .l
ttnatlont
•
_=._._Z___
\fell Contractor None(o all own penoeul(v ebmdenla ���� h.Number of*ells being abandoned:
a ►/her property) For multiple laltrflon or nest'-wafer supply milt ONLk wish Me sours
3 � [OM nrcrrnr✓abandonmrn4 you can rvbmit one!ann.
Pump Co.
NC Well Contractor Certification Number •
7b.Approslmale:atoms of remaining
nng In rell(s): r teal.)
N.W.W. Poole Well 8rI ' to )
FOR WATER SUPPLY WELI 9 t71YI,�';
Conynny Nanre ,t
2•Well Cons tructlon.Permgt 11: a 3�s 7c Type of dbinfeetanf used: /� /.f
th,all applicable well prrmru(t r.C h, Srarr, rrarfoner,lyre/fort.ref ifkn , ! ` / '
3.Well use(Check well use): 7d.Amonnt of ti4lnfeclant need: +LB
Water Supply Well:
DASrlcuihuai 7L Saling material;rued(check all that apply):
DAgrlDMnnlolpaUPublio ❑Na Cement Chou
: T �pale Chips or Perks
cnnal p{cat[ng/CoollrB Supply) Xesldent1al Water Supply(*Ingle) ❑Sand Cement Gro \;...�r I,_ k-' tay❑fudustrial/Conncrcln
❑Reildential Water Supply(share!) 0 Conutte Grout
.01n1 allot' JA N 2 7 �fr7 brill Cuttings
Non-Water Supply Well; ❑9peolallyGrovt Z ravel
°Monitoring ❑13rn1°ttlla 91�y
Infection Well: ORxoY 1t1�Cirt4e7Y.1O1 r�r.^ „g,7JollpFRt(explain under 7g)
0Aqufi r Recharge 7f.For act material;declea i} ti
ClOmundwalerRemedlalltnt preside amount bf mafcrlals used:
l7Atlulfer 5lorage and Recovery pSallnll Barrierr 4 �j©ed .r►
OAquifcr'fest y { LfC�
I 0l xperirncnW Technology
OSlorrttwa ter Drainage A iti . . �5 „' Ag O5ubtldatco Control
'
t�Ceolhcnnril(Closes!Loop) [7Traeer 7g.Prerlde a brief description of the abandonment procedure:
DCcnlh (Nees
crmal Oath). Oling Return ❑Olttorfcxnint under7a)
lr ,�.
.,r ]Jolt well(s)abandoned;,//2___A44 �� ! - - '
tin.Well location;
"��►►��-- r J7 j
i ecilityl0rrncr Neme•
' .116
i ! FsollitylDC(Ifapplicebir) • g•CettllfcaUonr
•
Pbyelcel Address,-City,and Zip „: t,
r ,r Bl6arluri of Cert(fled Well Conhaolnr or Well tiwner bole
7��j`� _
nuuty By►(Suing 1h4 furs{I htneS;me afar the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accortfdnct'*Ith l5ANC4C 02C.0100 or2C.0200 Will Corutrudlon Standards
5b.L,alltudb and:lonaltuiitt In degrcei talcutetlteeond;or decimal degree;; and that a
(if well ileid,�one lsVlbng li iiiiiieleot) copyof this rervrsd has been provided to the cell owner.
CJ. ply—1 3g _ 9,Bile diagram or adduutn al well detail,:
N �$. �J12 t 3 3 You inky iitd tifo bea atolls page to provido additional well site details or well
IY
abandonment deWla:'You may also attach addlNontrl pages If necessary.
.4rlaihi4Di 1
s •
:silt ON ,.\ S
t'i Oki"
m soot ` erlrir►loAelldd fN lift U all 6r non-ball:nelply
nmrnl,j4ii rtrtr airbntlr enriota•
e.Well 1bN; • 10s,Per r .Submit this faro, within 30 days of completion of well
abandodtnenl Io U,o following:
br'fatal n ell depth: blvLioti of Waferltesourca,Infurma flu n Procuring Volt,
_9.V_(ff)1 1617 Mall Service Center,Raleigh,NC 27691.1617
IDb,jy s"
-•Borehole diameter: IDJi,iy'.: 5 In,addhlon Iv sending the font' to the addrtss In IOa
(In) aboYC,tl;o'euBii{lc'biio copy of this fount within 30 days of completion of well
abandonment to lilt following:
'ry•Water teed beloiy gradnil iurface:. L •
(n) Division oflYalerBerourcea,Underground Injection Control Program,
`,
163-MM!Jterrtce Center,Raleigh,NC 27699-163G
',: .Outer eating length:(if kntl(vn);
(R) IOc Lq
: on tothe addrrdii((a'."ibdyy,'alio submit ono copyLn of Odist formswithiendinn 30 daysthe ,to
of
.Inner casing/tubing length(If•kndren): completion of abendonincnl to the countyhcalUt do� (fl) oroofabandoned. partrnent of Ole cowrty
;q."Screen itn11fh(1fltdrii4h)r
;,.r,,OW-30 •
• ' North Co llorbep►rtmeetbfSa,kroaa,enl►MsN.,,..ra..-: _. , .

i'iliL1ll: f�(y1JQjYrj' CQRD NIUicONLY:
7lils font,can be tired for alngle or•mnitlpl'e Sven,
I
1.Well C >tclor lurormallpn,
•
Well Contractor 1� a(or well owner en 7a Number of*ells being abandoned; /
/ f p oo.11y.bmdo°Inajii11Dp61ilbttpr°prt(y). For mvlflplr fn/rcllon or nan-xoRr reply will ONLY anh the aonr
Amp eonrtr,rerror✓abondonmrrrt,rots eon submit one form,
•
7b.Approximate tolume of-rater remaining In nel1(s): ` (gal.)
NC Well Coouac:or Certification Number
N.W. Poole Well & Pump Co.
FOR WATER BUPPLYIYELL9 ONLY;
Company Nautc
2.Well Coastructlou Penult (: 7e Type ofdtrlafeef>rnt tired,
N
, is
L(.rl oil oppllca&fr,rrll panel,.,(t.a Co,a,h,,Stair,Variance%lytenen,etc)((known
/
3.Well use(check well use): 7 'ti°DOnI of disinfectant Hied;
Water Supply Well:
OAgrluullurnl 7e.Sealing materials used(check allthat apply):
ClMunlolpal/Pttbllo 0 Neat Cement Crow 0 Benlonite Chips or Pellets
OacoUtcrnial(Heating/Cooling Supply) AeeldetiUd Water Supply(single) 0 Sand C t„Qipu
❑lnduslried/Comntercinl oRaldeaUal Nihau-Supply shred) t I,'�,,.,,` f'�"'-`'t0 �Clay
.Curti anon PP Y l t7 COn�, � ln"`,,�� �� �-� ,•l7 brill Cuttings
B
Non-t}'aler Supply Well: �peolally Omit 0 Ornvcl
Non
-W o ❑9entonlle 91ur{}N 2 2023 (� Other(explain under 9g)
CIMonlInfection Well: ❑RecoY
maZ.
❑AqulfcrRechargc 7f.Aor gq� f j
❑OrvuttdwalerRemodlatlmt ��fbMlde amount ajerieis used:
P✓ ��
t7Aqulfer 5lvrage and Recovery ❑Sallnll Bards �► ••
I .
DAquifcr'Test Y
❑Slormwalcr Drainage
011xperbnenlal Technology
OSubsldcrtco Control
DGeothcnnld(Clonal Loop) ❑Tracer 7g.Fronde a brief description of the abandonment procedure:
1 DOeothctntal(Hcating/Cooling Return) D01h n under7
er(mcnlai ,� �l � jyjf� ��'
a) •
4,Dale well(s)abandoned:a-l_tlia._ 1'
3n.Well location:
Facility/Owner Namo ail) p luty 11) (Itapplleabb) • .
�j 8,CerUllctrU
Pbyelcel A_ ddretr,.Clfy anti Zip i .� f4/44,E
f�,/}i11�](/f�l('� ; -- i 8)aar of Crnitle C �a or}Ve Own r Dee /
County •ay signing this form,I htredy certry that the welt(s))vas(were)abandoned hi
Parcel IdeMlSeadod Na.(PW) dccoiddr(ct f#j(h J5A NCAO 02C,0100 or 2C,0200 Well Construction Standards
ab,Latitude and:longltude in degreei/minntesheconds or deetmal degrees; and that d copy°f iirLrrtcor>f has been provided to the well owner.
(irtxelf neld:one IaVI6ng li tiillilei,r) ,
O' 9,Bile disgrnm or additional well details:
N 1R. 351+31,1 'Ant miry tied t11o•b�tck of tins page to provide additional well silo details or well
W abandonment delnlle, You may also attach additional pages if necessary.
.driedh'fiD t ;t
gall.f)iitl t�f)rili ire' ebnf ''erloriWriidanment,j4ii elmir°crir xarrr r,grpiy
",WO HjS: •
•• IOa,I yr r 'Submit lids farm widest 30 days of completion of well
abandonnienl to(hifollerwing:
`;b‘Total well depth:_______(),()).__ Division of Water liuources,Information Proeerriug Uull,
(f t) 1617 Mall Sandra Center,Raleigh,NC 27699.1617
IDb,
c•Borehole diameter:_____IY___
—�iac thauAg!;t 1n addl(j°n Iv sending the form to Via address In Ills
(In.) ..above,tilao'lubirilt bhb t;opy of this fomr within 30 days of completion of well
�.9 , ebandorutient id the following:
?el.Water level Won:gran-nil tttrfaie:ar •/ !
_^(R.) Division°flWtilirlieruurces,Underground Infection Control Program,
Its ii,lill Service Center,Raleigh,NC 27699-163G
r• Outer caiing length(If kdU •b):
,________9a___((I,) -
IOC, -It h•Inlerl(on\Vella;
the a In addition to sending the font:10
b1`.ibdi%is, also submit ono copy of this form widiln 30 days of
comInner casing/lubing•leng(b(tf•kndwn)f :��.., •
v.i:c b ii o will abandotvnenl to the county health department of the county
. _((b) comae then of wi
_,Screen 1tilH(lf kdoivh)I
•
North Gatdilna beplrttnetd'of Environment and try,,..,e-._..:.. •_. , .

rrElilli D1111110MENT RECORD ,(
11ris form can ba rind for single or mnlUpl'e weW �� I U�ONLY,
•
1.Won untrectur 1nrorwetlonr
•
we I Contractor Narnr or Nell 0 h.Number o(ire1L being abandoned:
r_7 a prnooally ebmdonlnQ hill be Wdyerptoperty) For multiple /rtrrellon or non-wafer ripply wall ONLY aril, the aom
.r eonrrruerton/ebondomarta,"au can rubm1t one form.
NC Well Coon-nom Certification Number 7b.Approximate 1'flume of eater remaining In well(s); /5"-. ( al.'
N.W. Poole Well & Pump Co. g
Company Name FOR WATER SUPPLY WELLS ONLY:, •
77-
2.WellCongtrucUon Penult f:•
'� 7c Type ofd6fehetaat needs
Liston eppllcobfr wilt pe rolls(r.r.Counry,Starr,Yarlerrer,lrtlrolon.etc)I(anoFri 3,Well use(beck well tire); 7d.Amount of dlslde-dant need: f i^Wale•Supply}yell: /4".
i:Agricultural 7e.Sealing materials wed(cheek all that a ly);
OMunlolpal/Publfo 0 Neal Cemenf��'''n't+vW,. .. x:. . y OOcoUrcnnal(l-ealing/Coolbrg Supply) )4esldenUa Water Supply(single) ❑Sand Cement Qrou`: �"P g e �Dry Clay Chips or Pellets
OlrsJiutrial/Cornntcrclril PP Y( g1)
❑Realdentia Wax Su I strand o Conine Grout ❑ Clay
C]tni atloft PPY( ) JAN 2 7 2023 ObriUCulUngs
Non-Water Supply Well: • ❑Specialty Grout ravel
❑Monitoring ❑tie:limito� ra:i�n Paws i'g ,
CiRecoY ry+tr•�!O��V-� 1ef(explain under 7g)
In)action Weil:
D WOJG
OAqulfcr Recharge
7f.For each material selected alwnq provide a cant of materials used:
C7Agulfer Storage and Recovery' OSallrtit°groundwater Barrier ldlmt ` Vf7
OAquifer Test y �,� ' `� �
❑5larmwalcrDraLtage � �44/1T �4
I 013xperbncntal Tccltnology
ClSubsldenco Control j f,��
OCeotllennol(Closed Loop) El Tracer • 7g rorlde II�brief dte pf►oo of the abandonment procedur : �"'r ^R
L OCleothcrntal ictilln Cook' Rclw11 DOuter lain Undcr:.7
g ) (gyp /Oi /Arrd l4
,Dale well(s)abandoned: t^ " '� Cann �
y )f'� /��)
3n 'ell locatioiat
n;
r ,6 A7L4^�ei
•
Facility/Owner Namo 7.---y I.."---ppllee--
e.cerUnr,llo1 ..
A
Physical A dress,.Cily and Zip 6,A76i�
AK, 8lantluri o[CttilD onlnotvr or Well Qn tier Dale
ed W Contractor
Coo y Parcel ldenilQoadrnl Na.(FM •Dy:timing Ih form,1 here cerf(�y that the well(s)nut(were)abandoned In
b.Latllud6 and:longitude in degreei/msnnlechteonds or decimal d f rees; aciordaricr trlrh 11,{NC1G�01C.0/00 or1C.D100 Well airlift-tic-flanStandardsrind that a copy of this record has been pruvlded to the well owner.
nrnenitold,'ond LVlbnl li iiiiielobo , e$
S`4 '�' • e 9.Bite dlagnun or addigotial well tleUlle:
PiYou miry li;iiie;biek of this page to pruvido additional well site details or well
W abandonment detalla. tourney also attach additional pages If necessary.
.dritiON f
Drellf(jfQ 14Vi)riki'. ifs' cbnt ''erltin1iikatidarinrenf,j•dkeoneirAUoneform, Ii
r4 F an 6r non-segue rrgrply
ill,1i'ell IbN: as, r •Submit this :wart within 30 days of completion of well
ebandorlthent to llto following:
b 'total n ett depth:____14Z/_. Divlslori of Wafer Ruources,Infurma tin n Processing Unit,
(IL) 1617 Mill Service Center,Raleigh,NC27699-1G17
IDb, .4•
Borehole diameter:_______h_____
tigg etc In-addltlort to sending the form to the add;r s In IUa
• (In.) .,above,ttbo 3ut>vilt"ohb copy of this form witltfn 30 days of completion of well
• abandonment id lie following:
ri•Water tenet beloir gentian aurfeee:. . '
(fi.)._____679,45......_
Divislen.orayxterRelourcu,Underground Injection Control Program,
1634•i4 h Service Center,Raleigh,NC 27699-163G
Outer casing ieilgtli(If liilOvh);.._____tAL__Art.) - lot, • ..:. .. • •
the ad r In addition to sending the form to
4,_ill ' 'alio submit one copy of this form within 30 days of
completion of well nbandoninntt to the county health do partment of the county
casing/Itibing•length(Itknown)t •- (fL) iiere abandoned.
. nz.Screeti tin tl (If 1ldpivh)I r;'.••, '—..''
(p,) •
i)rot OW-30 • '
Nerih Gattitlna bepirtteenl brEntbonment and t.,i...,a-._:.:._ _. . .

rrULk:• /11yDp IZCp
- Fo4•Iaittl Uac Off[,Y:
This form con be used for eingle el-multiple well:
•
_ VS---
1.well Con rnclor tororwelloot
• r
Well Contractor Nun i(or well owner pomposity abando 7a.Number of:retie being Abandonedt
g iti11lire Nsh,tt ptopsrty) For mulflplr !rtlretlon or non-water supply wilt ONLI with the Jame
' �� cons rrverlor✓abandonmrnr,you con submit one faun,
tic ell CooUxclar Certification Number • 7b.Approximate volume of Hater remaining In rrellts): (eel.I
N.W. Poole Well & Pump Co,
F011 WATER SIMPLY WELLS ONLY:
Contpnn)'Name •
N:Vl�1/'(J�// v
2.\Yell Construction Penult 7a Type of dtrinfeetant used:
_____741.h_q
DJ/an nppltco5fr will perm((,(r.e,County,Starr,i arfanee,bthefon,CIO)tfbtor n !
3,}}ell use(Check well use); 7d•Amount of dle(nfectent used;
\Valet•Supply}Yell;
❑Agticultu al 7t Soling materials used(cheek all that apply):
ClMtmlolpal/Publio ❑Neat Cenen s4•:'.... '-- ' ,S c,tonhe Chi s or Pellets
❑OcuUtcnnal(Healing/Cooling Supply) aldrnU Supply(tingle)Water e(n e 0 Send Cement Omit t"'f`'�* �' P
❑lndusUial/Comntcrclnl � ) Uy Clay
❑Reeldentid Water Supply(sltarekl) d Concrete(rout JAN 2 7
2023 O brill Cuttings
❑inn ellon
Non-Water Supply Weill • ❑Spevlalty(rout 0 Gravel
❑on-Wa�er ❑Benlatdt�a4Z71 fPmcee. ,g UM Other(explain under 78)
injection!Yell: ❑Rxov f3t�e't/�,0G`
❑AqulfcrRcchorgo 7f.For uch material selected abore provide amonn waterlaf used:
❑Otaundwaler Remedlnllwi Agfiag )
❑Aqulfcr Storage and Recovery ❑Sell Barr►cr j�
Y f ' f'
❑Agwfcr'resl ❑S(ormwattrDrainagc ._._.___
❑Experi ental Technology ❑Subsidence Control
❑Ceolhennal(Closed Loop) ❑Tracer 7 Prorlde a brief description of the abandonment procedure:
l DC)cagtcrmel(Hctiting/Cooling Rclurrl) ❑011lor(trxpleln under?
.I,Dale well(s)abandoned: "" '•,1/2_6/1 ., r
a�. n.Well location;
` 01�� ILL •Y -ii0
(,entity/p,rner Nemo S.Certification: r
• / Facility ,,,(Ifapppcablrj •
Physical Addrera,Clry,ett i Zt /�j r,_, • 77"...............a... 0•— ? y�� � t+'� /gi� �� ntl06d onhaolor or IYeU aae�— bete
County
Patcel Identification No. PIN lly ri ng ilt horny I here certify that the wells)war(were)abandoned In
(PIN) rridnce lffth ISA'NCACi 01C.0100 or 1C.0100 Well Corulructiun Standards
'b.Latitude andaonyllude In de rcer/minntef/eecoadt or dedmaldegrees; cind that a Hoffal'record has been provided to the well onner,
tirwell tleld,'onti IaVlb-ng(i iiihideot) ,
9.Site dlaglxm ur at¢dltional well details;
N • You may nub tbo black of ilds page to provido additional_
onal well site details or well W
.
abandonmevt•dtiinlla:..You may also attach additional pages ifnccessary.
•
rPrlT dN iti h lh� .m ebnt "crltnflabdiiildnhtrtil,jdk rCrr sirballraeriefoirr, iraffr namh. 5
io,Well Ibll; • 10a I •Submit this form within30 days of completionof well
abandonment to the tollowing:
h,'total Well depth; Di iiIon af Wafer Resourca,Information Processing Vol!,
(f1-) 161711!ell&nice Center,Raleigh,NC 27699.1617
se
• IDb,Uoreholc diameter:___4....._____. FIlt1IIL>ithort'1Y let ln.addltion Iv sending the fonn to ilia address in IDa
On.) ..above,tdso'subitilt'oho ropy of this form within 30 days of completion of well
abandonment In.the following:
tt•Waler level beloirgrotlriil iurfaee:
(n.) blrlsfon.ofslYetfrIleeourcea,Underground Infection Control Program,
163.E M1ti gal.-rice Center,Raleigh,NC 27699-163G
Puler easing(length(if kdti(rp):._____15___
(p,) - loc.
the ad : In addition to sending the font:to
.fib. -alao submit ono copy of this form within 30 days of
eomplinner casing/friblug length(If•knuwo)1 where tlan of ed, abandonincnt to Um county health department of the county
: (fL) where abandoned.
. ;,Screen iamb(lf kdtitvn)1
(R) •
bill-N OWZD •
' Nort6 Chitin,bepttlmetrt'of Paolreenmenl Ynd r1.1...1 n_._:., . _. —.

WELL ABANDONMENT RECORD Far Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
_...--
1 O WI. 1 ✓.1 i t t :i dl 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
< L / construction/abandonment,you can submit one form.
'1`� ! l 7b.Approximate volume of water remaining in well(s): (gaL)
NC Well Contactor Certification Number
I VW kill �� �Q {' ��i) i4C FOR WATER SUPPLY WELLS ONLY:
Company Name ►�`' 7c.Type of disinfectant used: c,>LA/4
2.Well Construction Permit#: /
List all applicable well permits(i.e.County,State,Variance,injection,etc)if known 7d.Amount of disinfectant used: / </X
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
ClAgrieultural ❑ >ctpa fPublic CI Neat Cement Grout. . - 0 Bentonite Chips or Pellets
°Geothermal(Heating/Cooling Supply) idcntial Water Supply(single) OiSaW Cement Grout .A..r C_ir y,� to Dry Clay
°Industrial/Commercial °Residential Water Supply(shared) le Concrete Grout A N 2 a Drill Cuttings
°irrigation CISpecialty Grout 1 2023o Gravel
Non-Water Supply Well: 0 Bentonite Slurry „a;,ion rprr: :r 0 Other(explain under 7g)
°Monitoring '�' },��,'++,;�.
Injection Well: °Recovery 7f.For each material seteeE?edi }trovide amount of materials used:
°Aquifer Recharge ❑Groundwater Remediation ^ :3 26, 0 2 (i syyi)-
oAquifer Storage and Recovery -6Salinity Barrier j
°Aquifer Test °Stormwater Drainage
❑Experimental Twilit °Subsidence Control 7g.Provide a brief description oft e abandonment procedure:
OGeothennal( Loop) °Tracer r� n -edure:
° (Heating/Cooling Return) ❑Other(explain under 7g) i-LIYYi
4.Date well(s)abandoned:...2741:____•2 --
5a.Well location:
ie P D 1 • 8.Certification:
Facility/Owner Name Facility (if applicable)
9 I2, /)/I Y e A Z ---2,..3
Physical Address,City,and Zip S. ormnctor or Well O�wnerr e
e/ G=e,_ By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accorlmtce with/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:
(if well field,one lat./long is sufficient) 9.Site diagram or additional well details:
/ °yL / y You may use the back of this page to provide additional well site details or well
3S 3 �. � 3?�t!N ��� . O 1 (0 / W abandonment details. You may also atach additional pages if necrosary.
CONSTRUCTION DETAILS OF WELL(SI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recur(*)(f Mailable. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All jig& Submit this hail within 30 days of completion of well
abandonment to the following.
6a.Well ID#: /
Division of Water Resources,Information Processing Unit,
/ l 1617 Mall Service Center,Raleigh,NC 27699-1617
/
6b.Total well depth: C (ft.)
10b.For Iuiecilon Wells: In additicn 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:
) Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: C� (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
10e.For Water Supply&Injectior : In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6f.Inner casinfftinbing length(if known): (ft.)
6g.Screen length(if lnown): r (ft.) SIMMONS WELL
1844 CUDE RD.
Form OW-30 North Carolina Department of Environn*l gytit$F 1;ptWeees Nition2ftoskmources Revised August 2013

�!J W�u 'flLY tf1 11tCp1D if aj� II
This form can be used for single or•mnitiplb wells ��" "I atom:
].Well lrgctor Inrortnanom . .
Wellivf
•
Contractor None(orowner e %Number of wells
P nvoally abandonleg itilI to hh/6a For multiple lyecIfon orabandoned:- fr [ry,Ply tr l([ ONL)' with the property)
renrrrveHonlabortdanmtn{you ran submit
one form, some
NC Well Contractor Certification Number
W Tb.Approximate volume of water remaining N• • Poole WeII & Pump Co. alnng In well(s):�(cal.)
Company Marne FOR WATER SUPPLY WELLS ONLY:
•
2.Well Construction Permit l:
`, /�, y/�{� ��A t� 7e.Type of db(efeettot!seed: '
List oil applfcoblr a•rfrprrmrra(i.e.Cowry Stole,York:rem IllrcMon irk)
((ban,,
3.Well use(check well use): 7d.Amount of disinfectant used:
Water Supply Well:
❑Agricultural 7e.Sealing materials axed(check all that apply);
❑OeoUtermal riteallttg/Coalln Su I °Muniolpal/Publlo 0 Neat Cement
g pP y) esidenUel Water Supply(tingle) 0 Sand Cement 63tdittio••Le LI'. ' lonlle Chips or Pellets
r7[udusUial/Conmaercial '-Cl'17ry Clay
°Raldendal Wales Supply(shared) ❑Conrxc(e Chout
Nln--ate JAN 2 7 2023 °Drill Cuttings
Non-Water Supply Well:
°Specialty Orovt
Non- luring �b(prrrvd
°Recov. ❑BeMonite 9urrr ,
Injection Well: �n�+i7 a:iC 1 ?r^ 38oi!StJtlLQiher(expinln under 7g)
CiMp❑Aquifer Recharge 7f,For ash material Wetted shovel ti provide amonn(bf materials used:
°Aquifer Stange �s
8 and Recovery' OSallnity Battler '1�'7.:> i44 t/a,4
1 OAquifer Test , ---—
l7stormxala Drainage
4__ B J 71�1'
j DExpertmental Technology �rf
❑Subaldrnco Control
l❑QeoUtertnal(Closed Loop) ❑Tracer 7 Provide a brief description of the abandonment procedure:
OOcothcmtel satin. Coolln: Return . ❑Other • rlelnunder7: ?
i,Daie weil(s)abandoned: •"" "'
•
i
3a,Well location:
"�"2 ` , �-f e
eciUty%Droner Name /14,.
s"fr „.v.e.,FscII1tY II?11,4tftPPllc[61[) • A•C Uoill
•
C 5
Physical Addre e,City,and Zip Avn.
rZ,.r�Itpshud of Certified Contrteor Or Well tinter l
�J���55 I7sle
Couoty 11y alining pall janm I inert cent Pmel ldeadlAadoo No. W (6,that the well(s)was(were)abandoned in
(P ) accordance With IS A•NCAC 0.2C.0100 or 2C.0200 Well Construction Standards
.gib.Latitude andiongttude In degreei/minuter<Jseconds or decimal degrees: meal that a
(if well held,one!rating ii IuE&elei,t) copy of ll;Lr rremtf has been provided to the itchl miner,
'12�•7 O Z 9.Slle dlgrttm or a dlfitnal well details:
N ��.Of0 `I �'f' You may wage bide of this page to provide additional well site deails or well
W abandonment details. You may also attach additional pages if necessary.
Arkiehlli
"ill nW )h Ilfi' rr rrl db3Ad.„.:1 n%y 1,car,ruMiilr Oh Be 'irorrrnypiy (?�S
;n,Well MTh10i, _ .Submit this form within 30 days of completion of well
abandontn en(to tin follifwing:
br Total fuel►depth: Division ofWaferfesources,Information Processing Unit,
(fl) 1617 Mall Service Center,Raleigh,NC I7699.16I7
Borehole diameter; t lOb, s,
(In.) .above,ilea lubint(oho Copy of this form viUl�in 30 days f completion ofg the form lo the address �well
• abandonment to the following:
=i•Water level below grotina Surface:.
(rt.) Division ofiViterResources,Underground Infection Control Program,
• "...,,,,,30______
� 163t WI Service Center,Raleigh,NC 27699-163G
n. Outer easing'length'(If kndiru);
(R) lOr.
•
the addnitt( also submit one 1n addition to sending the form to
;r.inner casing/tubing length(If•knbwn)l abandoned.
completion of 1vo11 nbandotunrnl Io Ute cowry hea td}t denn wtUtln 30 days of
•-� (fL) court lof We parirttenl of Uu county
Screen ten th(If kaatvti)I ^-
' North CuatbuPeper(meutbfFarironmeatSod Ritual Rewtaves.bivirtnhterm.,__"-----

rrbLid:m llIDO111YENT RCORD ��
71tia form can he uaee►for eingle nr mnWplb wells F "•�f�^"'I Ufc ONLY: '
].\Yell Ira clue Information: �yp� ' '
eubmlr one/ark
well Contractor None(or well owner penoaal(y tbmdvaln iRill>m Ws/Improperly) 7L Number of hells beta
.t Property) For multiple ! rrllon tf abandwatir
/� ...warriors/abandonment, er non• alrr rrgrply vr16
et,you eon m. ONLY with the acme
NC Well Contractor Certltle don Number
•
N W P0018 7b.Approximate-volume of water remaln►ng In oetl(e);
Well Pump Co. (gat.;
Company Name FOR WATER SUPPLY WELLS ONLY:
2.Well Constrnctlon Pertnit If:�1 . '•r �1 214}� ��Type°f eIhI feetauf used:
List or/epnllco8lr will prrmns(i.r,cow 2
o Stair,i m re ree,t tctloq tic)(/!Hoar �y
3.Well use(check well use):
7d.Amount of dlalnfrclant used: 141
Water Supply}yell;
•
r—� r
OAgricullurnl 7e Sealing malerjala "l
❑Muniol tatd,(che,c�akil.jbl•t+P f
DAgrl rcnnal(I{caling/Coolht Supply) pal/Publlo 0 Neat Cement Orout. '''''
g pP y) ealdentlal Water Supply(tingle) 0 Sand Cement Grout ../4 N 2 7 ? ry!Clete Chips or Pellets
diuduM /Cornnrerclnl ORdldptdrdWaiaSu i
Oltr1;ation Supply(shared) 0 Concrete°rout . Y
Supply Well: 111RiclYr ^l fit.^ Q Drill Collings
0 Spevlalty Grout r,
to Non-Water 0 9enlordlo Slurry
CV.1)/3. Gravel
Injection Well: ORecov. ❑ Other(explain under 7g)
❑Aqutfcr Recharge
❑°roundwtler Remedirdlat 7f.For each material selected aboti
ti provide amount bf rue(trials wed:
fJAyulfer Storage and Recovery °Sdinit a,•
I tJAquifer Test
Y Barrier ail = _j ��L�
❑Slormwala
I OSubaldence Control
OCxperiniental Technology Dr�naga s,�1 %1 IAP
—�`
r`
OGeotlrcnnal(Closet Loop) • 7 Prorlde a brief description of the abandonment procedure:
OOcotllcrrnal {cello: Coolie; ReturnOTtaocr
❑Olhor . 'lain under7. Jy„
',Dale well(s)abandoned:.4.-..,112.....X.A72
}- +�e—_ r'i7T 4� r
•
ecilil}/Owner erneFadillyII)p,(I(applicabte) • 8.0 liicadoor '
phyrleat ddr a Clty, dZip
f�.' t.�.l!V 'ft
�'"_
CI, o[CertlD ` /�• L� 1/'.e
ww I Well Cootnol°r or Well Owner bete 4,
County pY:lining lhfJ c
Neel ldeuilOeadod Na.(pW) fyac: from,I hrrvoy certify Ala(the well(s)-par(were)abandoned in
b.Latltudr;and:longitude In degreei/rnlfntea/aecond,or decimal degrees; rdmict With
III.NClG'OIC.0100 orIC.01001i'ell Caufnrdlon Standards
flrn•ell flair!,one IeVlbng It iiiiiieleo!} and Mal a copy ojrldt rrcar-ilrar been provided to Are well owner,
Jlf/ 9,She diagrymor additional well details:
pi
__70 . 53j 3 (o e E W You may ued:(�e"bee of ihla page to provide additional well site details or well
abandonment dlEtdla; You may also attach additional pages(f necessary.
rirlda 1.
relli WV }t 1+1 i AV' ire' chn) r.
rdr eibah citimint ydli era wb ell!ones•lrn/ir .„grpry
r,Well IDN. • lDa,For': it,.''1t,t •Submit thus form widen 30 days of completion of well
abandoeincrrl lei the following:
'h''folal Hell depth: Division oflYaterResources,Informs lion Processing Unll,
(f�) 1617 Mall Service Center,Raleigh,NC 27699.1617
•
Borehole diameter: lib.EyCL(In.) ,,above,tlad$ubailt bho copy of tis fglititaziat ont sending
days of completion ofi well
Water level beloir ground iirrface:. .: abandonment to the following:
(R) Division ofaYlitirResources,Underground Injection Control Program,
l at Mall Service Center,Raleigh,NC 27699-163G
Outer easing length(If linUhn)t
((i) 1Dr
the ad t In addition to sending the Corm to
Inner eesing/tdbing ten Ih If h...ebb alto submit ooe copy of Lids g ( known)1 where ban a tool abnndortinent Io due coon health department within 30 days of
�._(fL) completion
Lion Of
t partment of the county
Screen;:ienglb;(lf gnOivti)1'
' North Gtivlbu Depirimeut of lrsrirnet....1 .r.i.. .-

►►iJLw r�ruW thigL ffI RlCORD far
This form can be used for tingle or multiple,eW I UW OY.
1.Well Contractor Info Hon:
IWell Contractor a(or ell owner personally abandoning itirllan Mutter property) For multiple
of ells being abandoned:r ,lioPiy etlr ONLP with the same
l •
eonstrucnon/abandonmm you can submit one form.
NC Well Contractor Certification Number 7b.Approximate♦gists of water remainingin well(s):
N.W. Poole Well & Pump Co. O I? � (gal.)
Company Name FOR WATER SUPPLY WELLS ONLY:
2.Well Construction Permit N:4t'J '' . , d 0 ! •- jL 7e.Tnie of disinfectant axed:
�/�►(��6✓ ��
List all applicable well permits tr.e.Cowl%Start,Versant,Newton,etc)(/•4ne>.n rJ 3,Well use(check well use): 7d.Amount of dialnfectaat paed; f L
-J.
Water Supply Well: J
OAgrlcultural 7e Baling materials used(cheek all that a I
lunioipaYPublic Pleat Cement Grout PP Y)
❑Geothermal(Heating/Cooling Supply) ❑Realdentid Water Supply(single) 0 Sand Cement ci i0Brnntto Chips or Pellets
❑IndusWal/Commercla! PP y �-.'' '�,�^^.., p e, Clay
❑Rdldatdel Wales Supply(shared)
❑Concrete Grout' ``�-{•.9�;, `4•r.� -
❑Irri align q t•' Cuttings
Non-Water Supply Well: O SpecWry Grout Gravel
❑Monitoring ❑Bentordte Slurry J A N 2 2�23
CIRecov Other(explain under 7g)
Injection We1L In;-;,l saeh�tuf.771 Pr
❑Aquifer Recharge 7f.For each material sela ,e 5• it
pOtvundweterRemefiatltm rltd><a't►rohnnt of materials used:
❑Aquifer Storage and Recovery ❑Salini Banta • ' G+�` ' •� '� I L �L
❑Aquifer Test ❑Slormwatrt a • ll� • {: `
°Experimental Technology �5 S v[ Al;I,� j c t
❑Subsldalco Control
OGeo'tltermal(Closed Loop) OTracer 7g.Provide a brief description of the abandonment procedure:
ELel
OGeothefmal(Heating/Cooling Return) ❑Other(explain under7el i%� ryj�,,t_ •. s y,.
4.Date well(s)abandoned:_212_47.2e______
5e. Velllocation:/
i ` 0110 •
Fecili /(honer Neme! / Facility lD%`(If applicabllee) w�Ld.Certification:
. �2� VC r/I'7t. P 1 `i Z7c T 2 .1i,f oerr
Physical A dress,City.and Zip rat f
f Signature of Certified Well Contactor or Well Owner Ds •�
County
IC{ Zi ��Z$' By signing rhr,
Palest Identification__:_No.(PIN) f° I here certify that the well(s)war(were)abandoned in
accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
rind
t
5b.Latitude and:longitude in degrees/minutes/seconds or decimal degrees: a copy of this record has been provided to the well tuner.
Orwell field,one IsItong Is SURIelect)
7C
'3—J ��'C� !�S` 3� tr ' �� Y S e li dlagntui or additional well details:
N ,,3,1� Wmay use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
e► , el t,A,r
3L y� s : .It a ai, s
Ache', "try 4f i tt , 7 r �l;% 7. f v, q t+ nrli
trend°Atli A the j �n Mi4l A4ibiWildntnrnf pi!
it • {!dmiton or troe-irettr trgrply ar,1(j(
yor can submit one form,
6a.Well IbN: • 10a. W: •Submit this form within 30 days of completion of well
•
�•',c� abandonment to the Mowing:
6b:Total well depth: ��V� Division of WaterResourca,Information Processing Unit,
(IL) 1617 Mall Service Center,Raleigh,NC 27699-1617
F • 1D6, r Le►ecHen W it. �
Gc.Borehole diameter: a t In addition to sending the form to the address in 10a
(In,) ,above,also submit ono copy of this form within 30 days of completion of well
•
abandonment to the following:
6d.Water level below ground surface: Division oil•WaterResources,Underground Injection Control Program,
1636111aii Service Confer,Raleigh,NC 27699-163G
6e.Outer casing length(If kntiwn):
_____12±______(R) IOC
the ad = : In addition to sending the form to
•
completion of well aba dtrnunrntty the county submit one healtof h department of the county
6f.Inner casing/tubing length(If katten)t �'''—�
({t) where abandoned.
Gg,Screen';length;Slflrnoiyti)t, •
Form OW-30 •
Notch Outline beputmeut of Environment and Natural Resources.Division of Water Reaeurc.e - . . -

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Co clot Information: WELL ABANDONMENT DETAILS
wAidgiAitg426 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-3p is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): e) (gal.)
N.W. Poole Well and Pump Company FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
G W-081446-2022 7c.Type of disinfectant used:
2.Well Construction Permit#: 1�2 lb.
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing matelalf s sedi(ctie i,k all tha iy).:
❑Agricultural ❑MunicipalPublic 0 Neat Cement Grout .. " 6 entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) 0 Sand Cement Grout)AN 2 7 207 1 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) El Concrete Grout l� 0 Drill Cuttings
❑Irrigation 0 Specialty cOmmotion Pr;C 9C9sq tavei
Non-Water Supply Well: 0 Bentonite Slurry ►fir*.Q/3OG El Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.Foo each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /(rf®0 165 2 /� 4 6'
❑Aquifer Storage and Recovery ❑Salinity Barrier / jf//�� r�Ll,j�/'����Lj�h���j
❑Aquifer Test ❑Stormwater Drainage f-G�� !k�/�r (/ /F�l
❑Experimental Technology ❑Subsidence Control 7 .Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) 0 Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ti1 r " lie/7f'7VCt iiNI'M iA'e`r et0 °t
() � '�- � g*e,`�, m � 50 Fr FP .T22,�
4.Date wells abandoned: A i�y r, �+ M /I/_`
5a.Well location: �"� 40
r /���'1 /V ' p
A Squared LLC Well #1
Facility/Owner Name Facility ID#(if applicable) 8. 'fication:
235 Grand Avenue, Raleigh NC 27606 •
5.-A ""r `
Physical Address,City,and Zip Signature of Certified ontractor or Well Owner Date
Wake
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:
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well details:
35.793819 N -78.717315 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)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
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: 5 (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&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): ,aa/opi. (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 1-,.r Internal UscONLY:
This form can he used for single or multiple%sells
I.Well Contractor Information: W F.LL ABA\Il(1NMENT DET AILS
Brian Ewing 7a.Number of wells being abandoned: 1
Well('orataewt Name(or well owner p:noauil)abandoning w.'SI in,his het propols I t`,., .volt.,plc rnleat,<ut ,r erve-w..trr 'wpt�, wrl. 1 LI . Ai, the .t,
.witctrw(r.km ah,okionme'nt►r,n tan+ituntt one Erna
4240-B
NC Wcl1Coraractnr Certification Nnnbcr 7b.Approximate volume of water remaining in well(%): (seal.)
SAEDACCO Inc FOR W Al ER SUPPI.I'WELLS ONLY:
I onipaII Name . I six of disinfectant used:
2.Wdi Coestr eases Polak I:t ,
ull tipplkCUf*IV well ltrmII%tier('wnty,State.I;trt.urce•.Intettereee eke.,tot ktetwro 'II. \tnuutlt of disinfectant used:
3.Wdl ase(ciredc well use):
Water Supply Wee: 7e.1ealing materials used(check all that apply):
Aarnultural Dtllimichpail'Rihlic X \cat(.cmcut(i c>,1l M "s i l j;J Rentonite Chips or Pellets
❑(icothemul(Hcanng;('oolin_Swiph) ❑Reside meal Water Supph-(ctn_Ici LI Sand Cement(41341'`L t:..r V.' hi n CLn
DhduslnalCommeresal DResldedtal Water Supph I.Icin.1 0 Concrete Omit JA N 2 �l'`
j D Dnll('utthngs
❑Irrlr:itu,n
0 Specialty Gtottl a O GM%el
Non-Water Supply Well: 17 Bentonite S1ti1iG(r7,B:ian �fr.^g;�, IG1.9ther(explain under 7g)
rots.
QD!stumwnne DRctusen Qi3 )(
Injection Well: -I. For each material srketcd Arise.pro{-ide amount of materials used:
❑.Aquifer Recharge ❑(iroundwatcr Renediation Neat Cem. :471b ,Wtr:3gaJ.. Sand Cem. :lb ,Wtr:gal.
D.Aquifer Storage and Recovers DSalmts flamer
oAquifer Test DStonnwater Drainage
DEs4lerimental Tahnologs DSubstdencc C'otrtal 72.Provide*brief description of the abandonment pnwelur:
CJGeothernhal(ated Loop) LlTracer
OGeothermal 1Heatia8r'Cooline Return) f!Otherle'plain Mkt 7g) TREMI GROUT FROM THE BOTTOM TO SURFACE
4.Date wcllts)ahand :Id: 12-27-22
Sa.Well location:
Hardee'a
al..
lhaciTal*arm Name Facile.Itw(if aipphcabiv 8000 Fayetteville Rd. Raleigh, NC 27603 Brian Ewing 1/12/2023
PM steal Address.Ciq.and Zip Sift.i. . . .,i Well('omm.:t• 7 ,'.:11(kiar I
Wake Ht•signing this pens. 1 hereby eernjv that the welbsi was(werel abandoned an
Conan U.-u;fe.eaatnn No.(PIN) an-toralan a with ISA MAC 02('.0100 or 2t7 0200 Well(imstra(-tiori Standk,nI.
and that a cps,of this record has bear proved to the well ow rear.
,h.I Ariustk and longitude in akgrres:niimrtcs:seennds nr decimal degrees:
.'ir. Li! t u:,..,,n,.;_„ 9.Site diagram or additional well details:
You mar{ (ne the bact,of this page to proside dditiotial well site details or well
W abandonment details You etas also attach anlduaonal pages if necessary
(YY.SiRI(TIO\ DETAILS OFWELIASI R1l\(: ABANDONED SUBAIMAL1NSTRITCT(ON5
.U(.a i, »elf.'urelrui h:.rr n•n.r.ha• .;at wha":e .„r na1:I!i ryasn,'c,r rr•r.-....ter *�,�ri;
%elle ONL1 Meth the i.WN(toltstrtik teem athernetweeeweet wee eon a.h.n,t.wre Nsrm Ina. For All Wells: Submit this foam within 10 elms of completion of well
N.Well ID*:TP-1 abandonment to the following
Division of W Ater Resources.Information Proeessing I nit.
1617 WA Seri ice(enter,Raleigh.SC 27n9'l-1617
tits total,sell depute: 30 (ft.)
Iuk fur lalcelhtr Wes: in:K1,11110,1I, "•t(dnig the toms to the address in Ida
abuse. also submit one coin et "hi, I,'Iii within AO days of completion of well
or.Rr,rctadr diameter:1 I in.I abandonment to the following
bd.W atcr level below ground surface: Ifs.) Dhision of Water Resources,Cndergniund Injection Coetrul Program.
1636 Hail tier%ice('enter,Raleigh.l('2:699 Iti36
10c.for Water Sunnis eS Injection Wells: In addition to sending the form to
lie.Outer casing length lif known): aft.) the addresstesi abuse. also s..lhrinr ouc cups of This form within 111 days of
completion of%sell aharkionnscau to the counts health department of the counts
where alsitdoned
Of.Inner casingimbiig length!if known): 20 (D.l
6g.Screen length(if knuwn):10 01.1
Form GW-in Ninth C'm,lnsh Dep nines of Ein imonlen and Natural Resoute% -Die lion of Water Resouxs s Reseed August 2011

VV E.L L ABANDONNIEN.I. It u':( •()It l) For Internal Use ONLY
This!(role Can be used ton sno,.1c ui in,rlii 'l..shells
I.Well Contractor Information: \\E I.1. ABANDONMENT DETAILS
Brian Ewing -e. Number of oats being abandoned: 1
Well('c.tgra:to►Name tot%ellossi►Y pasnriatls stun omit,NcJ on he,Inc,pr. r.:ti • apl4fd, ,n;<,r,...i .0. ow-more, nopi) *WI( O.\I,) .nth the UV,.
.NtOrrrc NMI(,hawb.nm,nt t.,r lain whom Wks fionos
4240-B
7b.Approximate solaria'.of water remaining in well(s): (gal.'
NC N'clt Connarctor C.'nifRatron Nun#xr
SAEDACCO Inc FOR WATER SUPPLY V.'TIN ONLY:
Converts Name 7c.T,pe of disinfectant used:_
2.Well Construction Permit 0:,
1i., • Sane,)'urnaree.I recw»e ea.(ifhwinrr _d. \mount of disinfcvtant used;
3.Well use(che'. 'n ell use):
'Water Supph Pied: Te.Sealing materials used Scheel.All that Apply):
❑Agncultur:d ClMimictpil Ptthlic IR Neat Cement Grout Li Bentonite('hips or Pellets
❑(icothcrnul(Hearing('occhmi SuppIs I ❑Residential Water Supply isingle) 0 Sand tensely nt►t�' r I /,...A ' C'L•n
❑hidustrial.•Comnrrclal ❑Residential Water Supph (shared) CI Concrete Grain`{""'L i t t,�1 DnII Cuttings
�Irngat►oil ❑ *craft) Grtutt JAN 2 7 2023 D Gras el
Non-N ater Supph V,clI: 11 Bento ite Sloan D Other(explain under 7g)
Xt.tuntionne ❑Rctosen IritkrRitUi::1
Injection Well: 7L For each material gligtrkykbies.ifrio% tlt'aurriunt of material.used:
❑Aquifer Recharge ❑Gtcumd%taterRemcduanou Neat Cam. :47lb ,Wtr:3gal. Sand Cam. :lb ,Wtr:gal.
❑Aquifer Storage and Recos crt ❑Sahuns [tamer
DAquifrr Test ❑Sionm'ater Dratnuge
DEsperimet tal To hiwk►g► DSubsntkn a Control 7g.Provide a brief description of the abandonment procedure:
OGeothemtal(Closed I.00pr f_ITracer
TREMI GROUT FROM THE BOTTOM TO SURFACE
DGeothermtl IHe:ating'Cooling Return' ()Other(explain under 7g)
4.Date welhst abandoned: 12-27-22
51.Well location:
Hardee's
t:isrlrb.klusrr~.fork t o ihi. MN(if utpplicables
X.(ct'tiftealinn:
8000 Fayetteville Rd. Raleigh, NC 27603 Brian Ewing 1/12/2023
i•I..F-el 1J3ir+.(th.and Zip Slimmer of(c ! '.!hence l�
flake B1'signing this)inn, I hereby certify that else wellon was Iwerei nth nik fed in
t•osini P:nccl Identification No(PIN) ocavr►laner With/A MAC 0:('.0100 or 2e 0?00 ft'ell C'anstrjc•Aon Standards
and that a ceps'of'this regard has been provided to the well owner.
5b.Latitude and kangitude in rkgrcrsminutesrseeondaor decimal degrees:
tit nc f ii ld tires I L long is su(Ir:ant I 9.Site diagram or additional well details:
Von ous me the back of thus page to pros ide additional nell site details or%sell
W abandonment details You tics also attach additional pages if necessan
(ONSiKI CTION DI:TAII.S OF\\E:I.IAS) BI:I\G \H 1NDONFD SUBMITTAL INSTRUCTIONS
.((Lxrr NCll a'ur.tlra.,r+et n•it r,ira,N uaruhe�:a• t.v-�c,,:cws ry.,Not:,v rH.n-01.,711 wprh•
wr(txONLY with the M w.eucttir.hoPt Jaw.drmrite for"in shine rule lorrn Ina. For All Wells: Submit this form within ?0 days ofcompletion of well
6s.Weft IDa:B-2 abandonment to die following
Division of‘1 Ater RCYrtrrces,Information Processing Unit.
1617 Mail Se+%ice I:'enter,Raleigh.Is('27699-1617
ilk huts'%+ell(kWh: 30 tit.)
lob.For Irlectiur Wells: In addition to sending the form to the address in lua
abuse. also submit one cop) of this font within 10 dash of completion of%sell
1,c.Riin hide di.irnetcr:1 (in.) abandonment to the folios;mg
Division of Water Resources,Underground Injection Control Program.
bit.IA ester les el below ground surface: (ft.) 1636 Nisi!Scrsice('enter.Raleigh.N('27699-1636
Inc.Fur Water Surmis & Infection Weill: In addition to sending the form to
be.Outer casing length ill{non n is (ft.) the addresses) abio e. also submit one cops of this form within 10 dal s of
completion of nell at):rnd,inns:ni to the :mints health department of the count)
Dixie abandoned6f.Inner casing:'tulring length tit Lines n r: 20 (ft.)
lox.Screen length(it'Linos n I:10 (ft.)
F,tin GW-30 Nonh Carolina Depannrrf of Ens ironmcnt and Natural Rcwin:ca - Dos Donn of%tw i It,sott rhos Res rsed Auguti 201

WELL ABA\i)O\\I ENT RECORD F,IT Internal UteONLY:
This form can be used for sitt::k of intiku far wells
1.Well Contractor Information: WEI.I.ABANDONMENT DETAILS
Brian Ewing 7a.Number of wells being abandoned: 1
Wctl t:otatacse1 same for 14CI1 o In prrso ail%:busikuung eeil on ter+WI piopem r i.a mklnpfr rtt}etoott it ,pHt•Nietrr ,urri:kit Will ONl.) +rttl the sane
cam<rrw new nh,r*fi,nm a f.tau me wham one was
4240-B
NC Well Coeetart(1r(Cntt}tllMl4 ttrltn}KT lb.Approslmatc stibu w of water remaining in went%I: (gal.t
SAEDACCO Inc FOR W'ATF.R SFPPLI"WELLS ONLY:
Coupuau Name 7c.•I'pe of di'tdectant used:_
2.Well Construction Permit I:, ,
Lim all orr.(tt.thie Neil;e^rmrtr,e.e.a-vainly.Vale, I drt.Utte trgrertntt elt.I ei
-(1. %mount of disinfeetant used:
3.Well use(check wen use):
Water Supply Well: "r.Seating materiak until u•hexk all that apply):
DAgricuhunal QMunicipat•Rtblic X \C3t Cement(moat C) Bertonute Chips or Pellets
DGc+othenul tHeatii tt,C'ooling Suppls l °Resdettial Water Supply noel.`!.I Li Sand Cement( ip_�_t-�,,:., i CIa►
Oladustnal:Commttial DResidetatat Water Supplyishan.l CI Concrete Grout `�-LT L e 19' i 11 Cuttings
°Irrigation 0 Spectalt) CROW BAN 2 7 2023 to (inn el
Non-Water Supply Well: C]Bentonite Slurry d Other(explain under 7g)
Rhbnattonng DRecoscn In;`,. -..:atian Pr(.g , . t �Y
Injection Well: 7f.For each matt. al.etme 1 intpj 5in.um of materials used:
OAgutter Recharge O(irotuTdw:atcr Rcmcdt:atem Neat Cem. :47lb ,Wtr:3ga1. Sand Cem. :lb ,Wtr:gal.
°Agwfer Storage and Recovery ❑Salnnt) Darner
°Aquifer Test ❑Stonmater Drainage
°Experimental Technology OSubsuknceControl Pros ide a brief description of the abandonment prwrediire:
t30eothetn)a1(Closed Loop) °Tracer
OGoothermaal(NeatiugCooling Return) ()Otherteeplatn under 7g) TREMI GROUT FROM THE BOTTOM TO SURFACE
4.Date weR(s)abandoned: 12-27-22
Se.Well location:
Hardee'a
Pacil vOsincr a r..:.ttr, into tir;rpplicabtei R.Certification:
Physical
Fayetteville Rd. Raleigh, NC 27603 • Brian Ewing }1/12/2023
Physical Addicts.City.and ZipSaar t'I .r Din
Wake 13j'Signing the.fr,c n, 1 heftily certify that the wellts) was(were)dten dk ned in
Conas ',erect 1d:eatt0.atinn No.(PIN) urtortfamr with 1 EI AC4C 02C.0100 or 2C 0200 Well Construction Stcawka ds
and that a act of this record hue been provided to die well owner.
Sh.Latitude and longitude in degrces:ntinutes:ste 1s or decimal dtj reee:
Td nel:field oar tri lung es.sullawat! 9.Site diagram or additional well details:
You mat use the back of this page to pros tee additional well she details or well
K _ 11 abandonment details You ma) also mach additional pages if necessary.
('ONSTRI (TION DI:TAILS OF WELLe.si nil l\C. ttl+`DONED SI EMIITTAi.iNSTRUCTIONS
.tr t,x tt ., , ••:trite tenet n•i t,rdo,et,n iat.tt+•k. 7•.tr,e;t,!r!;q.';,yr.u.,.;„r non.II tat?'%apply
W rth 0..1t.) .Oh the Atme eonstr t tam ahauk.nlaenl.new Loco a,1Nnrt(Pre rintTIT. Ina. For AU Wens: Submit this form within .0 dass of completion of well
64.‘1 e91 I Ian:C-2 abandonment to the following
Disision of later Room rem Information Pnacessing Unit.
1617 %tail Sirs ice Center,Raleigh.N('27699-1617
ob. Iotat well depth: 30
lob.Fur Infection Hells: In addition to sending the font to the address in 10a
abuse. also submit one copy of tins form within 3C)dass of completion of well
s.. Borehole diameter:1 tin.) abandonment to the following
Division of Water Rouen-es,Underground Injection Control Program.
lid.Water level brim ground suriaee:_ (ft.) 1636 Mail!knife Center.Raleigh.NC 27699-1636
10e.For Water Sunni & Injection Wells: in addition to sending the form to
be.()titer casing length nit'known): (ft)
the addresstest abuse. also submit one copy of this form within 10 days of
completion of well abandonment to the county health department of the county
where ahnsndoncd.
4f.tunercasing'tubing Length'itlarossni: 20
6g.Screen length(if know n):10 (ft.)
Form GW-ter Noah Carotins t)epmuncta of Eats ironment sad Natural Resources-Dis ision of Water Ri.semrns Res ised August?ii 1

WELL ABANDONMENT REC'ORI-) For!wool Use ONI't
This form can be used for single or nwltipLL�r ila
1.Well Contractor Information: WELL ABANIH)NNIF:NT DETAILS
Brian Ewing 7a.Number of wells being,abandoned: 1
Well Contractor Nance tot welt owLai personalh abank,nrng w.Sl an ha her propene t For maw,- ,Non-$ars .uprv, *MS 11tYLT war ilk 4.4
44)411,16(000 nl,.tnclrAnsa,ytr,i0 eat-whew one&mu
4240-B
7b.Approximate volume of water ramainmc in scctlsi
NC 11'e1 Corxrklnr(cnifrwlinn Nuwiser
SAEDACCO Inc FOR W 4TF.R SUPPI.i'WEI.I.S O's 1 1:
Conn+Nana
7c.1 spy of disinfect/Hi usavl:
2.Well Construction Permit I:i ,
L.r ah Lositary.Spite.litrtarKCN,hWetfirla,at.;i(Ma'ix
`d. lrnuunt of disinfectant used
3.Well use(cheek w ell use):
Water Suppiy Well: sealing materials used(check all that apply):
OA nenhural (]Mimic l'Pubhe X \i1t C'cn (ar*R....,:. 0 Bentonite Chips or Pellets
OCicothcnuai(Heating/Cooling Suppls t ORestdential Water Supply.min t:1 J Sated( i .i V D Dry Clay
Oh dustriaf.•Commcrcial °Ref idential Water Supply(shared 0 Concrete Grou'�p O Dn11 Cuttitri
❑imgttnun
t7 Specialty Gton 2 f ? ZOZ3 O Grasel
Non-Water Supply Well: Hen*Oi> r Pro.;" c;r Utz 0 Other 4exPlain nisi,I 'k)
GDMonitonng ❑kecosen D Q, Os
Injection Well: .For each material selected whose.prositle amount of Mitt' used:
OAywtterRecharge OGround uerkentedtau•ii Neat Cern. :471b ,Wtr:3gal. Sand Cem. :lb ,Wtr:gal.
OAquifer Storage and Recover ❑Saluuty Darner
❑Aquiler Test OStonmsater Drainage ----
DExperimenlal Technology OSubsidem a Control ^e.Preside a brief description of the abandonment procedure:
OGeothemtal(Closed Loop) °Tr cer
TREMI GROUT FROM THE BOTTOM TO SURFACE
OGeolbermal(Heatins,'(ooling Return) °Ottter(explain under 7gi
4.Date wes(s)abandoned: 12-27-22
Sa.Well location:
Hardee's
r:,tho (hutrName r tptxabk) , ,ilu.tlinn
.,int, try
8000 Fayetteville Rd. Raleigh, NC 27603 Brian Ewing 1/12/2023
sgat-> ss.(in.and lip 5t.: ll(srmrsr • ... ()ow Date
Wake By swung this form. !he aw hereby certify that the wet si was Iwer :4 ahtAMIOlfed nt
It i, Parcel kienhtleation No(PINO tneexirdonce witlr hi.'ii AC 02('.C110O or ( .O2tM)ff CH(onstrucn to Standards
and that a cop-of this reran/has been prtnw rd to the well owner.
5h.l.atittulc•:end longitude in degrees,mimues:seconds or decimal degrees:
(it nen nekt nru la long,is stiff 6:r,f i 9.Site diagram or additional well details:
You ttttts use the back of this pclge to pros ide additional sell site details or tell
W abandonment details You may also attach additional pages if accessary
CONSTRI(T1ON DETAILS OF WELIASI BEING ABANDONED SUBMITTAL INSTRUCTIONS
.irks*.rrIl CORM rU..to»a rrc.,r<t:a,it.nwi.a,,k. l•.v wutt.pie uyetcoos,sr a.,,-Nater.,uprie
welk OtiLI warn the aunty ce nsorc•rxm aumtsnieuu al.row cite.<ylMrit nue,tunoi 10a. For All Wells: Sitltnui this C(mtt within 7,0 days of completion of well
abandomttciw to ttic(ollosstn)
6a Well DROP-2
Division of 11ater Ke.taarccs,Information Processing Unit.
1617.1ait Service Center,Ralcieh.'s('27699-1617
nor. total.sell depth: 30 (fl.)
ittb.For lltkeetion Welgt: In addition to sending the form to the address in lira
oc.BtinMtk diameter:1 tin.) abuse. also submit one copy of tits tonic within :n days of completion of sett
abandonment to the lollosstng
Disision of Water Resources,Underground Injection Control Program.
bd.Water ksc9 helms ground surface: (D-) 1636 Mail Sersire Center.Raleigh.NC 27699-1636
tile.for Water .unuls , I,lkg fun 11 ells: in addition to sending the form to
tic.(utter rasing,,tenth i it know n is tft.► the address(ea1 ate%c. also submit one copy of this form within i(n days of
compktuon of nett ab:ndonmeni to the county. health department of the county
wFetc abandoned
t.f.toner casinj(itu hint Icngali tit kiwisnt: 20 (ft.)
O .Screen length(if I.nunnt:10 (ft.1
Conn OW-io North Canstsm lkp anineta of Ens ironrncnt and Natural Resources -nil mon of Water Rstioam.s R.s tied August 24,1 s