Bertie_Well Abandonment_20230213

lI
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned:
. NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1•03 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
• Company Name 7c.Type of disinfectant used:
A'
2.Well Construction Permit#: 'V/A
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)if known
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 m Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) El Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry I 0 Other(explain under 7g)
®Monitoring CRecovery
Injection Well: 7f.For each material selected abOve,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier j
0 Aquifer Test ❑StormwaterDrainage 10 lb concrete
❑Experimental Technology ❑Subsidence Control I:
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under.7g) Pour :' ,-a d 9 1.".",-",
LQ
4.Date well(s)abandoned: 12/14/2022 I' FEES I. { 2023
5a.Well location: p ���, y
CB Jones Texaco n/a m�V,===¢�,,, f,, ,. l'J L►,'..I
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 0Azipi '
NC Route 42 and SR 1321, Powellsville, NC 27967 ;. 12/21/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6910-07-0329
By signing this form, 1 hereby cert 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: 1 .
(if well field,one Iat/long is sufficient) 9.Site diagram or additional well details:
36.225643 N 76.932432 `,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 record(s)ifavailable. For multiple injection or non-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#: MW-A abandonment to the following: I'
Division of Water Res lurces,Information Processing Unit,
6b.Total well depth: 11.01 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
l
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
• abandonment to the following: j
6d.Water level below ground surface: 4.72 (ft.) Division of Water Resources,IUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Iniectil n 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 couniy health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 1 0 (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
Justin Radford 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
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of waterlremaining in well(s): 1.17 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLSIONLY:
Company Name
7c.Type of disinfectant used:
I
2.Well Construction Permit#: N/A I
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)if known
7d.Amount of disinfectant used:I.
1.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all'that apply):
❑Agricultural 0 Municipal/Public 0 Neat Cement Grout 11 , M Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout i' 0 Drill Cuttings
0 Irrigation 0 Specialty Grout !, 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
['Monitoring •Recovery f
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lb concrete I!
❑Experimental Technology ❑Subsidence Control I'
7g.Provide a brief description of the abandonment procedure:
0 Geothermal(Closed Loop) ❑Tracer
Pour
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
•
12/14/2022 i ,� '''' _ �
4.Date well(s)abandoned:5a.Well location: FED L ' 2023
CB Jones Texaco n/a Intrii-Frauzm HT,.ca.zsrg Usti
Facility/Owner Name Facility ID#(if applicable) 8.Certification: a`V Qt 3
NC Route 42 and SR 1321, Powellsville, NC 27967 946 I. 12/21/2022
I;
Physical Address,City,and Zip Signature of Certified Well Contractor o'ir Well Owner Date
Bertie 6910-07-0329 By signing this form, I hereby ceitifr 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: Ih
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.225643 N 76.932432 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 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#• M W-B abandonment to the following:
Division of Water Resources,Information Processing Unit,
1176 1617 Mail Service Center,Raleigh,NC 27699-1617
.
6b.Total well depth: (ft.)
I'
10b.For Infection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2 (in.)
,t
abandonment to the following: I: i
6d.Water level below ground surface:4.57 (ft) Division of Water Resources,(Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I; I
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Injecton Wells: In addition to sending the form to the
address(es)above,also submit one,copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 1 0 (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: I
I
I'
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1-12 (gal.)
Geological Resources, InC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
t�I
2.Well Construction Permit#: 'V/A 1.
. List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown I'
7d.Amount of disinfectant used',
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(checklall that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ! U Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) U Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: • 0 Bentonite Slurry 0 Other(explain under 7g)
['Monitoring URecovery '
Injection Well: : 7f.For each material selected above,provide amount of materials used:
❑AquiferRechoige ❑Groundwater Remediation 20 lbs of Bentonite.'
O Aquifer Storage and Recovery 0 Salinity Barrier 1
❑Aquifer Test ❑StormwaterDrainage 10 lb concrete
,❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of'the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) i, _
4.Date well(s)abandoned: 12/14/2022
FEB 1 7Q23
5a.Well location: l'
CB Jones Texaco n/a `^__T"� „�.�t'rW I
L)WQiF-;°':
Facility/Owner Na rib Facility ID#(if applicable) 8.Certification: /)L�r i1,
NC Route 42 and SR 1321, Powellsville, NC 27967 `OJ���u ,. 12/21/2022
Physical Address,Pity,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6910-07-0329
By signing this form, I hereby certi&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 lat(long is sufficient) 9.Site diagram or additional well details:
36.225643 N 76.932432 `,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 record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. i'
W-^ 10a. For All Wells: Submit this form within 30 days of completion of well
Ik�
6a.Well ID#: 1 C abandonment to the following: , '
i
• Division of Water Resources,Information Processing Unit,
6b.Total well�gpth 11.48 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617 .
ii
lob.For Injection Wells: In addition to sending the form to the address in 10a
•
6c.Borehole digmeter: 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: 4.63 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Iniectibnl 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
1.
6f.Inner casing/tubing length(if known): 1 (ft.) abandoned. j
6g.Screen length(if known): 1 1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources : Revised 2-22-2016
1 :

WELL ABANDONMENT RECORD For Internal Use ONLY:
11
•
1.Well Contractor Information: WELL ABANDONMENT DETAII:S
Justin Radford 7a.For Geoprobe/DPT or Close4Loop 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
3270-A wells abandoned: I. I
. !;
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1•18 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
I,
CompanyName 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
•
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used::
3.Well use(check well use): j
•
Water Supply Well: 7e.Sealing materials used(checkall that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout U Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) U Concrete Grout • ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ; ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
UMonitoring (Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
DAquifer Storage and Recovery ❑Salinity Barrier •
DAquifer Test ❑StormwaterDrainage 10 lb concrete
•
❑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) Pour • !p' ,e�7 p? f
1
4.Date well(s)abandoned: 12/14/2022 , FLB i 2023
5a.Well location: Ici c.r; ;1?l('�; �.t ('t'l�
CB Jones Texaco n/a '�`�'°'`'
Facility/Owner Name Facility ID#(if applicable) 8.Certification: i
NC Route 42 and SR 1321, Powellsville, NC 27967 .
12/21/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6910-07-0329 By signing this form, I hereby cirtifr 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.225643 N 76.932432 `,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 record(s)ifavailable. For m ltiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. I,
It Il`tt' 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M V V-D abandonment to the following: 1,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 1•73 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
II
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
,t
abandonment to the following: 1
6d.Water level below ground surface: 4.49 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): n/a (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
6f.Inner casing/tubing length(if known): 1 (ft.) abandoned.
6g.Screen length(if known): 1 1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

f
WELL ABANDONMENT RECORD For Internal Use ONLY:
.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford
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
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3.43 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name I'
7c.Type of disinfectant used: P
2.Well Construction Permit#: N/A I;
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1,
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 0 Neat Cement Grout • e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout l, 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
MMonitoring ❑Recovery • 1
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge 0 Groundwater Remediation 25 lbs of Bentonite,
❑Aquifer Storage and Recovery ❑Salinity Barrier j
❑Aquifer Test ❑StormwaterDrainage 10 lb concrete 1
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Pour j�'^ ' f�-"(�°
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) c``r ._!s n`r,_ 4 4ti 4 G
4.Date wells)abandoned: 12/14/2022 r�-U '' 2023
Sa.Welllocation: Infzi-7,avan r'iC ,w,24:r:� i
Uin
Hoggard's Grocery 00-0-023897 FA°o``'0i.
Facility/Owner Name Facility ID#(if applicable) 8.Certificatio .
1235 Bull Hill Road, Windsor, NC l�Zl Zv
Physical Address,City,and Zip Signature of C fed Well Contractor r Well r Date
Bertie 6825-77-1145 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well'details:
36.086578 N 76.877521 W You may use the back of this page jto provide additional well site details or well
abandonment details. You may alsolattach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells ,
ONLY with the samenA construction/abandonment,you can submit one form. 10a. For All Wells: Submit this iform within 30 days of completion of well
V'6a.Well DV: ' W-D 13 abandonment to the following: I;
I.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24.30 (ft.) 1.
1617 Mail Service Center,Raleigh,NC 27699-1617
1,
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:
i
6d.Water level below ground surface: 3.24 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft.) l0c.For Water Supply&Injection I 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): 19 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1 ••
WELL ABANDONMENT RECORD For Internal Use ONLY: I
I '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: I I
I;
NC Well Contractor Certification Number 7b.Approximate volume of water Remaining in well(s): 1.34 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known '
7d.Amount of disinfectant used: 1'
3.Well use(check well use): 1,
1,
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout •Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout i' 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout I, 0 Drill Cuttings
❑Irrigation 0 Specialty Grout +` 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 15 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
10 lb concrete I: -
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I' '
❑Geothermal(Heating/Cooling Return) ElOther(explain under 7g) Pour
4.Date well(s)abandoned:
12/14/2022 •
1 A. �. . C�y 'V F fl
I FEB t , 2n?3
5a.Well location: I
Hoggard's Grocery 00-0-023897 itt; .;:_- "- " -"-,',�;,
Facility/Owner Name Facility ID//(if applicable) 8.Certification: I 7 l�p�7
1235 Bull Hill Road, Windsor, NC
Physical Address,City,and Zip Signature of Certified W 11 Contractor or. ell OA2,17AriQi5OG
Date
Bertie 6825-77-1145
By signing this form,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
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:
36.086578 N 76.877521 `,lr 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)iifavailable.For multiple injection or non-water supply wells
ONLY with the samenA construction/abandonment,you can submit one form. 10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well DNi: 'V'W-1 R abandonment to the following: I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 11.80 (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: 2 (m,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I I
II
6d.Water level below ground surface: 3.57 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
n/a . 10c.For Water Supply&Injection 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 county health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 1 0 (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:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'26 (gal.)
1,
Geological Resources, Inc. , FOR WATER SUPPLY WELLS ONLY:
Company Name !'
A' 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known i,
7d.Amount of disinfectant used: I'
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout •Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout I. 0 Drill Cuttings
_❑lrjation 0 Specialty Grout I' 0 Gravel -
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 15 lbs of Bentonite;
❑Aquifer Storage and Recovery 0 Salinity Barrier
•
❑Aquifer Test ❑Stormwater Drainage 10 lb concrete I.
❑Experimental Technology 0 Subsidence Control !'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) Pour If.7"l..R,a
j• i c 1,-a..h^V fl..;,'teri
ii
4.Date well(s) 12/14/2022 abandoned: FEB 1 2023
5a.Well location: I, �_ 31 ;� :y�^;r lrrjl
Hoggard's Grocery 00-0-023897 `"'v`"'''' _�
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1
1235 Bull Hill Road, Windsor, NC // ,` -'i iVZ,V2,0 2,7
Physical Address,City,and Zip Signature of Certifi:i Well Contractor,i ell 0• . Date
Berne 6825-77-1145 By signing this form,I hereby certify that thewell(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 lat/long is sufficient) 9.Site diagram or additional well'details:
36.086578 N 76.877521 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-water supply wells - I
ONLY with the same construction/abandonment,you can submit one form. II
nA 10a. For All Wells: Submit this;form within 30 days of completion of well
6a.Well EN: 'V'W 2 abandonment to the following: i'
il
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 11.61 (f.) 1617 Mail Service Center,Raleigh,NC 27699-1617
r
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 3.85 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ci nter,Raleigh,NC 27699-1636
n/a 10c.For Water Supply&Injection 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 county health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft,) abandoned.
6g.Screen length(if known): 10 (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
Justin Radford
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
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water i emaining in well(s): 1'86 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: I
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 0 Neat Cement Grout @ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) @ Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
@Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 15 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier
10 lb concrete
❑Aquifer Test ❑Stormwater Drainage I'
❑Experimental Technology ❑Subsidence Control I'
I 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Ij
OGeothermal(Heating/Cooling Return) 0 Other(explain under 7g) II Pour
yy
ii'ti= r . a 11n..'d_„)
4.Date well(s)abandoned: 12/14/2022
1 ZQ23
5a.Well location: FEBI h J
Hoggard's Grocery 00-0-023897• i `"'-`" wD '�`' '�y ��`l
�� mom OG
Facility/Owner Name Facility ID#(if applicable) 8.Certification: II
1235 Bull Hill Road, Windsor, NC ZZ f Zll2,c»2,-i
Physical Address,City,and Zip Signature of nified Well Contra or or We caner Date
Bertie 6825-77-1145 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: ;I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.086578 N 76.877521 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 i
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#: MW-3 abandonment to the following: i
Division of Water Resoul ces,Information Processing Unit,
1617 Mail Service C nter,Raleigh,NC 27699-1617
6b.Total well depth: 12.10 (fL)
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (i) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i I
0.70 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: • (ft.)
1636 Mail Service Cfen ter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (fL) 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 count)) health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft,) abandoned.
6g.Screen length(if known): 1 0 (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:
i, �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned:
i' ,
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.49 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) .IN Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 15 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 10 lb concrete ,
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour ..- r-z.. ...-.�cTr-,.1 Frt‘o i..,xT,
4.Date well(s)abandoned: 12/14/2022 FEB 1 ' 2023
5a.Well location: �'`•"..---•:,n ?r.--:,�:,, 'no Unii
Hoggard's Grocery 00-0-023897 1 D O.I
Facility/Owner Name Facility ID#(if applicable) S.Certification:
1235 Bull Hill Road, Windsor, NC 12{2((2b27i
Physical Address,City,and Zip Signature of Certifie ell Contractor or ell O Date
Bertie 6825-77-1145 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.086578 N 76.877521 ,,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)if available.For multiple injection or non-water supply wells
I
ONLY with the same construction/abandonment,you can submit one form.
n A 10a. For All Wells: Submit this':form within 30 days of completion of well
V'6a.Well ID#: ' W 4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.20 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
I'1
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: i;
il' I
6d.Water level below ground surface: 3.05 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cenier,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft,) 10c.For Water Supply&Iniectiol 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): 2 (ft.) abandoned.
6g.Screen length(if known): 1 0 (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:
i;
1.Well Contractor Information: WELL ABANDONMENT DETAILS
• Justin Radford 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
3270-A wells abandoned:
i1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'46 (gal.)
• If !
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ft-known
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 0 Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout 0 Drill Cuttings
❑irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: • 0 Bentonite Slurry 1 0 Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 15 lbs of Bentonite'.
❑Aquifer Storage and Recovery ❑Salinity Barrier I
❑Aquifer Test ❑Stormwater Drainage 10 I b concrete _
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer ">. L,w L L.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour „rim,".." _i......... ttf E L.IUj
FEB I , 207-
4.Date well(s)abandoned: 12/14/2022
5a.Well location: �,• ;�Sy�:a '[j 1O V UPI
Hoggard's Grocery 00-0-023897
Facility/Owner Name Facility ID#(if applicable)
8.Certification:
1235 Bull Hill Road, Windsor, NC 1212((2-o2Z
Physical Address,City,and Zip Signature of Cert. ed Wel ontract r or We wne Date
Bertie 6825-77-1145 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: �•.
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well details:
36.086578 N 76.877521 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
Attach well construction record(s)ijavailable.For multiple injection or non-water supply wells _
ONLY with the same construction/abandonment,you can submit one form.
p A 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 'V'W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 1 .1 7 (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: 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: 2.20 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
addresses)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.)
abandoned. I
6g.Screen length(if known): 1 0 (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: I' •
,' ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Justin Radford 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
3270-A wells abandoned: i
NC Well Contractor Certification Number • 7b.Approximate volume of water remaining in well(s): 1.08 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ''
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: 1'
3.Well use(check well use): 1,
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout " Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) PI Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
"Monitoring ❑Recovery '
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 15 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test 0 Stormwater Drainage 10 lb concrete ,
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer ^:77-7: F 31d °,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour 7. , ve y.a, V: @w -�'
4.Date well(s)abandoned:
12/14/2022 FEB I ' 7(193
5a.Well location: 1 J�i�a`id;=+OC�
Hoggard's Grocery 00-0-023897
Facility/Owner Name Facility ID#(if applicable) 8.Certificati
1235 Bull Hill Road, Windsor, NC 11/21 /2_oz�_
Physical Address,City,and Zip Signature of ified ell Co tractor ell r;�;N :�
Owner Date
Bertie 6825-77-1145 By signing this form,I hereby certj 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.086578 N 76.877521 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 j'
Attach well construction record(s)((available.For muluple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.n A10a. For All Wells: Submit this 1foim within 30 days of completion of well
6a.Well ID# V'• ' W 6 abandonment to the following: i!
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 0.02 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1
lOb.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: I r
1
3.37 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
n/a 10c.For Water Supply&Injection 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 county health department of the county where
6f.Inner casing/tubing length(if known): 1 (ft.) abandoned.
6g.Screen length(if known): 1 0 (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
Justin Radford 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
3270—A wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water I remaining in well(s): 1.53 (gam)
b ,
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name i'
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)tjknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural ❑Municipal/Public 0 Neat Cement Grout U Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout j 0 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 15 lbs of Benton ite
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 10 lb concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour -- — _ _
4.Date well(s)abandoned: 12/14/2022
FEB 1 S 2023
5a.Well location: Is
Hoggard's Grocery 00-0-023897 1" .a:,y es "3'�`. Ur l f ""
y /30(3
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1235 Bull Hill Road, Windsor, NC l Z z,j 002ti-
Physical Address,City,and Zip Signature of Certifie ell Contractor or ell Ow Date
Bertie 6825-77-1145 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.
Sb.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:
36.086578 N 76.877521 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 I!
Attach we0 construction record(s)ijavailable.For multiple injection or non-water supply wells
ONLY with the samenA construction/abandonment,you can submit one form. 10a. For All Wells: Submit this:'form within 30 days of completion of well
V'6a.Well ID#: ' W-7 abandonment to the following: 1
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.05 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
lOb.For Infection Wells: In addition to sending the form to the address in l0a
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: 2.67 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Injectioln 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): 2 (ft.) abandoned. I' j
6g.Screen length(if known): 1 0 (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
Justin Radford 7a.For Geoprobe/DPT or Closed-Loy 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
3270-A wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining I in well(s): 1•51 (gal)
I
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
I
Company Name
7c.Type of disinfectant used: I,
2.Well Construction Permit#: N/A 11
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: II
3.Well use(check well use):
11
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout j; a Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout " 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ' 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
Monitoring ❑Recoveryil
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 15 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test 0 Stormwater Drainage 10 lb concrete
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer Pour
OGeothermal(Heating/Cooling Return) 0 Other(explain under 7g) _ A ?
4.Date well(s)abandoned: 12/14/2022
:, FEB y S. 2023
5a.Well location: ,
II
Hoggard's Grocery 00-0-023897 i iricTh.:.. �., . ..... . .;
Facility/Owner Name Facility ID#(if applicable)
1235 Bull Hill Road, Windsor, NC t7iU70VO.
Physical Address,City,and Zip Signature o ertified ell Con or or Well er Date
Bertie _6825-77-1145 By signing this form,I hereby certj 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: II
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.086578 76.877521 You may use the back of this page to provide additional well site details or well
N ��' abandonment details. You may also attach additional pages if necessary.
ii
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supply wells l
ONLY with the same construction/abandonment,you can submit one form.
n A 10a. For All Wells: Submit this form within 30 days of completion of well
ID V'6a.Well #: ' W-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 11 .70 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For r Injection Wells: In addition to sending the form to the address in l0a
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: 2.42 (ft.) Di of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,r,Raleigh,NC 27699-1636
n/a 10c.For Water Supply&Iniectioi 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 county health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 1 0 (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: I 1
1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: 1 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1-62 (gal.)
1,
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
il
Company Name l'
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 0 Neat Cement Grout •Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout • 0 Gravel
Non-Water Supply Well: 0 Bentonite Slu
rry j 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 15 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier
10 lb concrete
❑Aquifer Test ❑Stormwater Drainage 1
❑Experimental Technology 0 Subsidence Control r :
7g.Provide a brief description of the abandon ent proce4ure: R...fl
OGeothermal(Closed Loop) ❑Tracer Pour I' l'..}-,_" "r I-.0 t (Y r ram•
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
FEB i LUL3
12/14/2022 �;��>;r„z
y�
5a.Well location: t�l , _ ie,�dtn;>+t;;u .
Hoggard's Grocery 00-0-023897
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1235 Bull Hill Road, Windsor, NC iqu(002z.„
Physical Address,City,and Zip Signature of Certifie ell Contras r or; ell Owner Date
Bertie 6825-77-1145 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.086578 N 76.877521 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 I
Attach well construction record(s)if available.For multiple injection ornon-watersupplywells
ONLY with the samenA construction/abandonment,you can submit one form. 10a. For All Wells: Submit thist,form within 30 days of completion of well
V'6a.Well lD#: I W-10 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.45 (ft) 1617 Mail Service C nter,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
1
2.54 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
I' 1
6e.Outer casing length(if known): n/a (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): 2 (ft,) abandoned.
6g.Screen length(if known): 1 0 (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:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned:
is
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'39 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A i
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): •
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout •Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 15 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 10 lb concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour - ' . ' - l K q l
sc.a. . T. 's - T. ._
4.Date well(s)abandoned: 12/14/2022 F Eb 1 ;, 2023
5a.Well location: ;I114.; ;:3,'-"1 PIT.::r.,. .`:]Una
Hoggard's Grocery 00-0-023897 ` `r)'-' '"1
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1235 Bull Hill Road, Windsor, NC l77Z 02)7.i
Physical Address,City,and Zip Signature of Cert. ed Well Contractor or ell Owner Date
Bertie 6825-77-1145 By signing this form,I hereby certl&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 lat/long is sufficient) 9.Site diagram or additional well details:
36.086578 N 76.877521 W You may use the back of this page,to provide additional well site details or well
abandonment details. You may alsoiattach additional pages if necessary.i
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
Ii
ONLY with the same construction/abandonment,you can submit one form.
n A 10a. For All Wells: Submit this form within 30 days of completion of well
V'6a.Well ID#: ' W-1 1 abandonment to the following:
. Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 1'68 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1
10b.For Injection Wells: In addition to sending the form to the address in l0a
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 I
I.
6d.Water level below ground surface: 3.15 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Injectio I (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): 1'5 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD Forinternal Use ONLY:
! '
1.Well Contractor Information: WELL ABANDONMENT DETAILS,
Justin Radford 7a.For Geoprobe/DPT or Closed-to Ip 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
3270-A wells abandoned: 1 1
NC Well Contractor Certification Number 7b.Approximate volume of water Remaining in well(s): 1.52 (gal.)
ii
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known l'
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 0 Neat Cement Grout IR Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 15 Ibs of Bentonite:,
:•
❑Aquifer Storage and Recovery ❑Salinity Barrier -
❑Aquifer Test ❑Stormwater Drainage 10 lb concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer R
Pour ,,, ', '.)
E"' i A „ ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) •
a.Date well(s)abandoned: 12/14/2022 FEB I 2023
5a.Well location: :., 3� i'r4 C.•ny V i u.i
tlliui of
Hoggard's Grocery 00-0-023897 r1yy`''2o`y
Facility/Owner Name Facility ID#(if applicable) 8.Certificatio . i
1235 Bull Hill Road, Windsor, NC G24/710
Physical Address,City,and Zip Signature of rtified Well Con ctor or1W er Date
Bertie 6825-77-1145 _ •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: 1'
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details'
36.086578 76.877521 You may use the back of this page:to provide additional well site details or well
N W abandonment details. You may also'attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells I'
ONLY with the same construction/obandonment,you can submit one form. 10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#: M W-12 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 11 .92 (ft.)
jl
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in) above,also submit one copy of this form.within 30 days of completion of well
abandonment to the following: 1
2.62 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft) 10c.For Water Supply&Iniectiol 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): 1'5 (ft.) abandoned.
6g.Screen length(if known): 10 (ft)
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:
• l
I '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 7a.For Geoprobe/DPT or Closed-to Ip 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
3270-A wells abandoned: -
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'91 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) U Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
• Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
UMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
•
❑Aquifer Recharge 0 Groundwater Remediation 15 lbs of Bentonite''
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 10 lb concrete
❑Experimental Technology 0 Subsidence Control I
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour
F^^ ;^:'...11. (i 9 r.:'''',,',
4.Date well 12/14/2022 s)abandoned: F t B 1 i Z023
5a.Well location: I ;;;,2-N7 i)i. ?�y,r: 3 Una
Hoggard's Grocery 00-0-023897 "'v'"'
Facility/Owner Name FacilityID#(ifapplicable) 8.Certification: i'
1235 Bull Hill Road, Windsor, NC E iz,ll20ze
Physical Address,City,and Zip Signature of Certified Il Contractor o Well O er Date
Bertie 6825-77-1145 By signing this form,I hereby certt&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: i;
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.086578 N 76.877521 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
Attach well construction record(s)if available.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonment,you can submit one form. j:
n A 10a. For All Wells: Submit thisI..form within 30 days of completion of well
6a.Well ID#: 'V'W-16 abandonment to the following: I; :
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.80 (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:
1.07 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (fL) 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): unknown (ft) abandoned.
6g.Screen length(if known): unknown (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources: Revised 2-22-2016

1I
WELL ABANDONMENT RECORD For Internal Use ONLY: , I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water i remaining in well(s): 0.95 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A ,'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 0 Neat Cement Grout IN Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
(Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 10 lbs of Bentonite"
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lb concrete
❑Experimental Technology ❑Subsidence Control 11
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour
12/14/2022 1 ., : ``%, r
4.Date well(s)abandoned: _ It
5a.Well location: rE3 & 2023
Hoggard's Grocery 00-0-023897 ,In;,o.;N,a,=7,s:, :afi:,,.. ti..:j
Facility/Owner Name Facility ID#(if applicable) 8.Certification: I `%e:C 313L'
1235 Bull Hill Road, Windsor, NC /47IZoo-
Physical Address,City,and Zip Signature of Certi ed Well Contractor or;Wel weer Date
Berrie 6825-77-1145 By signing this form,I hereby ceriii51 that the well(s) was(were)abandoned in
County Parcel Identification No.(PINT) 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.086578 N 76.877521 W You may use the back of this pagei 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 muluple injection or non-water supply wells
ONLY with the same construction/abandonment you can submit one form.
n A 10a. For All Wells: Submit this;form within 30 days of completion of well
V'6a.Well ID#: ' W-1 7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9.98 (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: 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:
4.15 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service denier,Raleigh,NC 27699-1636
n/a 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) n
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): unknown (ft.) abandoned.
g unknown 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
h1

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS`
Justin Radford 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- 0 4is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'55 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A '
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 0 Neat Cement Grout •Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ; 0 Other(explain under 7g)
U Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 15 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lb concrete j
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer _ ,-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour G.,° --- ^ , 31
�.+ ,, .,.. th.-a )rn: 4..,,,'.sJ
4.Date well(s)abandoned: 12/14/2022 I-L t d 1 3 ZO23
5a.Well location: i{1f4,rF,-.1.,f3:1 Pl:`_'c:^ 3 Unit
Hoggard's Grocery 00-0-023897 'n`
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1235 Bull Hill Road, Windsor, NC i / //2-6Z,
Physical Address,City,and Zip Signature of Certified W l ontractor or Well Date
•
Bertie 6825-77-1145 By signing this form,I hereby cert(i 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 ben 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:
36.086578 N 76.877521 `,I, You may use the back of this page to provide additional well site details or well
abandonment details. You may alai'attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS 11
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells I'
ONLY with the same construction/abandonment,you can submit one form.V' 10a. For All Wells: Submit this,' daysform within 30 of completion of well
nA
6a.Well ID#: ' W-19 abandonment to the following: ;
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.01 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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: Om) 1
abandonment to the following: 1
6d.Water level below ground surface: 2.48 (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (fx) 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): 2 (ft,) abandoned.
6g.Screen length(if known): 10 (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:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford
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
3270-A wells abandoned: I 1
I 16.98
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
I•
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name ' I tr
t�' 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A / / I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known / 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 0 Neat Cement Grout II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
•
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
PIMonitoring 0 Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑GroundwaterRemediation 250 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier 40 lbs Concrete
❑Aquifer Test ❑Stormwater Drainage
DExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer �:�,r ��4 � r;�,..#.,,,
Pour k -Li, : 4,1 ;
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) --
4.Date well(s)abandoned:
12/14/2022 FFR 1 ' 2023
5a.Well location: r-tor�RI.J %
j Ot"I
. V b ` L
Todd's Service Station and Bowen's Grocery 0-0022807&0-0022804
Facility/Owner Name Facility ID/1(if applicable) 8.Certification:
US Highway 17 & RN Route 45, Merry Hill, NC 1, /212-j 62Z
1 / 12
Physical Address,City,and Zip Signature ofCerti/'Well Contractor o•, ell Ow Date
Bertie 6853-48-7302 By signing this form, I hereby cert fy 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 lat/long is sufficient) 9.Site diagram or additional well details:
36.0337037 N 76.7853227 `,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 record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the saraeWSW—
con`srrAu/ction/abandonnrent,you can submit one form. 10a. For All Wells: Submit this 1 form within 30 days of completion of well
r
6a.Well ID#: V V S v . abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 68-00 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 4 (in.)
abandonment to the following: 1
4200 Division of Water Resources,Underground Injection Control Program,
.
6d.Water level below ground surface: (ft)
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): n/a (ft)
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): Unknown(ft) abandoned.
6g.Screen length(if known): Unknown (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
I

WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1i
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Justin Radford 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
3270-A wells abandoned: ! I p
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.00 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 1-rr If
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: '
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
:Agricultural ❑Municipal/Public ❑Neat Cement Grout C Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
(Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 15 lbs of Bentonite •
❑Aquifer Storage and Recovery ❑Salinity Barrier
:Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Pour❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) Y 6:y r�.--li--, _
M 9
4.Date well(s)abandoned: 12/14/2022 FEB 1 ' 2023
5a.Well location: - --- P
Todd's Service Station and Bowen's Grocery 0-0022807&0-0022804 d e td Jul..;
Facility/Owner Name Facility1D#(if applicable) 8.Certification:
US Highway 17 & RN Route 45, Merry Hill, NC .6(\) /Z-AI 4oZZ
Physical Address,City,and Zip Signature of Certifie ell Contractor or Well er Date
Bettie 6853-48-7302 By signing this form,I hereby certfy 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: j, ,
(if well field,one latilong is sufficient) 9.Site diagram or additional well details:
36.0337037 N 76.7853227 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 1
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.
�+,n, 10a. For All Wells: Submit this form within 30 days of completion of well
n,
6a.Well DO: V V J y V-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
30.93 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
,
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 1.25 (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: 1 1 '37 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
6e.Outer casing length(if known): n/a (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): Unknown(ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource 1 Revised 2-22-2016 -