Chatham_Well Abandonment_20230315

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 1
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
construction/abandonment,you can submit otie form.
A - 4252
.Y. . .•. ,.,r�' 7b.Approximate volume of water remaining in well(s): 2•5 (gal.)
NC Well Contractor Certification Number t. y,v,;i .m; 8 Tr:,,
GEOLOGIC EXPLORATION MAR n� FOR WATER SUPPLY WELLS ONLY:
t"t,AR � 3 5 U
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Una
List all applicable well construction permits(i.e.County,State,I4nrra;Qt eiC,tifiknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: O Bentonite Slurry El Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test 0 Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location: •
CIRCLE K- 2724660
Facility/Owner Name Facility iD#(if applicable) 8.Certification: ff •
1513 EAST 11TH STREET SILER CITY 27344 1 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM 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 lat/long is sufficient) 9.Site diagram or additional well details:
35o 44' 00.81" 79° 26 33.87" You may use the back of this page to provide additional well site details or well
NW 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 Iron-,rater 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
Ga.Well ID#:
MW-11 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
2 0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 10.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Injection Wells: In addition to sending the form to
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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 7a.Number of wells being abandonedl: 1
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
construction/abandonment,you can submit obe form.
A - 4252
i t a 7b.Approximate volume of water remaining in well(s): 2'S (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION Ma R 2CL� FOR WATER SUPPLY WELLS ONLY:
Company Name U 7c.Type of disinfectant used:
i ftiviia%3e( 11 3C%7'" Lt 7;"
2.Well Construction Permit#: —„•_._. .'
List all applicable well construction permits(i.e.County,StaleVai'd'rircl;4iP)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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4.0 GALLONS
[2 Aquifer Storage and Recovery ❑Sal inity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
01
4.Date well(s)abandoned: /1 6/23
5a.Well location:
I
CIRCLE K- 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1513 EAST 11TH STREET SILER CITY 27344 1.00.6 ``t' 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM 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 thew!!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:
35°44' 00.81" N 79° 26' 33.87" 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 nndtiple injection or non-water supply
wells ONLY with the sante construction/abandonment,you can submit one form. 1Oa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-12 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb. For Injection Wells: In addition to sending the form to the address in 10a
2 0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 10.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Injection Wells: In addition to sending the form to
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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor-Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personal) abandoning;welLontlus/Iter,Rrp.erty) For multiple injection or nor-water supply wells ONLY with the .saute
a construction/abandonment,you can submit one form.
A - 4252
7b.Approximate volume of water remaining in well(s): 2'S (gal.)
NC Well Contractor Certification Number MAR 1 5 2023
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name {fiiGir;+2is4 1 i ii"•? ., Util
t-A,; 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
O Monitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned: O 1/16/23
5a.Well location:
CIRCLE K - 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification: •
1513 EAST 11TH STREET SILER CITY 27344 igedD 0,40.44,4' 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM By signing this form, 1 hereby certi.61 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:
35°44' 00.81" N 79° 26' 33.87" �� 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 wilt-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
Ga.Well ID#: MW-1 3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 10.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& infection Wells: In addition to sending the fonn 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.
GE Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 1
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
construction/abandonment,you can submit one form.
A - 4252 I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'S
(gal.)
,.^ s^�
GEOLOGIC EXPLORATION '�' `:,.f .Y. „ s v,. FOR WATER SUPPLY WELLS ONLY:
Company Name MAR 1 5 2023 7e.Type of disinfectant used:
2.Well Construction Permit#:
List a//applicable well construction permits(i.e. wu
G , mte,-l�ariance;-•err if_ ifvlt(-pil
,�,•.y,+-S•-• :} 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 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: E Bentonite Slurry ❑ Other(explain under 7g)
EMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1513 EAST 11TH STREET SILER CITY 27344 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM By signing this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1SA 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:
35°44' 00.81" N 79° 26'.33.87" 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-crater 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#: M W-14 abandonment to the following:
Division of Water Quality,Information Processing Unit,
25.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Injection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this.form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 10.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10e.For Water Supply&Injection Wells: In addition to sending the form to
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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality. Revised March 2013

•
WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ,WELL ABANDONMENT DETAILS
JACOB MESSICK
7a.Number of wells being abando led: 1
Well Contractor Name(or well owner personally abandoning,well on his/her property) For multiple injection or non-wallet-1 supply wells ONLY with the same
-,. ;. construction/abandonment,you can submii one form.
•
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION MAR 1 5 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name i f1 3i 7:: _.3 n i.,_ Unli 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Stale,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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 6.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility 1D#(if applicable) 8.Certification: •
1513 EAST 11TH STREET SILER CITY 27344 4.6 qm° ' 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM 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 lat/long is sufficient) 9.Site diagram or additional well details:
35°44' 00.81" N 79° 26' 33.87" 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 sane construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: DW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
40.0 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Total well depth: (ft.)
10b. For Injection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Injection Wells: In addition to sending the fonn to
Ge.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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-saver supply wells ONLY with the same
construction/abandonment,you can submit one form.
A - 4252 � - ---: T
7b.Approximate volume of water remaining in well(s):_ (gal.)
NC Well Contractor Certification Number r ,, '•• I i
GEOLOGIC EXPLORATION 1 LU23 .ur FOR WATER SUPPLY WELLS ONLY:
MAR15n
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: rt' ""'":::i :>•i'• ^•7 I?I,.;
List all applicable well construction permits(i.e.County,State,VatikMi.e?/efc'.)i )rnovn 7d.Amount of disinfectant used:
J
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
•
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
EMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 10.0 GALLONS
DAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a:Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility 100(if applicable)
$•Certification:
1513 EAST 11TH STREET SILER CITY 27344 1,4rer6Oi10"44' 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM By signing this form, I hereby certif}'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:
35o �44' 00.81" 790 26' 33.87" You may use the back of this page to provide additional well site details or well
NW abandontnent 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-crater 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
DW-2 abandonment to the following:
6a.Well ID#:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 62.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: on.) abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunnly&Injection Wells: 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning welron his/her.property) For multiple injection or non-sraier; supply hells ONLY with the same
construction/abandonment,you can submit one form.
A - 4252
1.25
alb:
Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number MA
GEOLOGIC EXPLORATION AR.� 52023 FOR WATER SUPPLY WELLS ONLY:
- _.Company Name r i I 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
lMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility 1D#(if applicable) S•Certification:
•
1513 EAST 11TH STREET SILER CITY 27344 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM By signing this form, 1 hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has 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:
35°44' 00.81" N 79° 26' 33.87" You may use the back of this page to provide additional well site details or well
„
t abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recor (s)if available. For multiple injection or non-crater supply
we/Ls ONLY with the sane 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-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 18.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For injection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 10.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Injection Wells: In addition to sending the form to
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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
SR&R Environmental, Inc. 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
• Patrick Beccaria o wells abandoned:w
193 •
NC Well Contractor Certification Number + ? ' " '", ^, 7b.Approximate volume of water remaining in well(s): (gal.)
'^.�w,,c.
NC-4543 • MAR ` ' FOR WATER SUPPLY WELLS ONLY:
Company Name r 2102,E Calcium H ochiorite
7c.Type of disinfectant used: Yp
inic•;`roJ—;i pr, ;, is 1 i t 2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County!-Siat✓:;'1Varid,i6e,etc.)ifA1rown 4,5 ounces
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 IN Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
ElIndustrial/Commercial ❑Residential WatenSupply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery C.
Injection Well: 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage neat cement entire well a
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Disinfected well first.
❑Geothermal(Heating/Cooling Return) ['Other(explain under 7g)
Mixed neat cement mixture for entire well.
' 4.Date well(s)abandoned: 1/30/2023
5a.Well location:
VLH Enterprises, LLC
Facility/Owner Name • Facility lD#(if applicable) 8.Certificatio
10580 US Highway 64 East, Apex, NC / 1/30/2023
Physical Address,City,and Zip Signature of Certified ell Contractor or Well Owner Date
Chatham 0.702-00-02-0765
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:
35-44'.9.13 N 78-59'59.40 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
ONLY with the same construction/abandonment,you can submit one farm.
.�{./�. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:well #1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: ' 1 8 (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: 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 12 (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
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): n/a (ft.) abandoned.
6g.Screen length(if known): n/a (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
S R&R Environmental, Inc. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
• wells abandoned: I I
Patrick Beccaria - , lr, C:n
NC Well Contractor Certification Number `'W`r...,..4=••s" ..—a .' I`'^"9,..3 7b.Approximate volume of water remaining in well(s): 5 (gal.) .
NC-4543 MAR 'I 5 2023 • FOR WATER SUPPLY WELLS ONLY: .
Company Name
x^ p fi i�l;;j 7c.Type of disinfectant used:
2.Well Construction Permit#: "".- ,<''r.,,i751=n:-i
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
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ 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 ❑Groundwater Remediation betonite chips 1/2 bag
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage neat cement 6" plug
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer betonite chips up to 6" from top of well
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Mixed neat cement for 6" plug on top
4.Date well(s)abandoned: 1/30/2023
5a.Well location:
VLH Enterprises, LLC
Facility/Owner Name Facility ID#(if applicable) S.Cert 7
10580 US Highway 64 East, Apex, NC ( / , ( 1/30/2023
Physical Address,City,and Zip SignaLe of Certified Well Contractor or Well Owner Date
Chatham 0702-00-02-0765
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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35-44'.9.13 N 78-59'59.40 `,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
ONLY with the same construction/abandonment,you can submit one forts.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 6 R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 7 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
'2 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
r
6d.Water level below ground surface: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636 i
6e.Outer casing length(if known): 7 (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): n/a (ft.) abandoned.
t 1 ,
6g.Screen length(if known): 1 7 (ft.)
I
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
S R&R Environmental, Inc. 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 1s needed. Indicate TOTAL NUMBER of
Patrick Beccaria _ wells abandoned:
NC Well Contractor Certification Number : - v 1J 7b.Approximate volume of water remaining in well(s): 5 (gal.)
N C-4543 MAR 1 5 7023 FOR WATER SUPPLY WELLS ONLY:
Company Name
fR+=f t C rof `"� j 1'1-A 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,Countyntate,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 ❑MunicipaUPublic •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) ❑ 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:
❑Aquifer Recharge ❑Groundwater Remediation betonite chips 1/2 bag
El Aquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑StormwaterDrainage neat cement 6" plug
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer betonite chips up to 6" from top of well
0 Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
Mixed neat cement for 6" plug on top
4.Date well(s)abandoned: 1/30/2023
5a.Well location:
VLH Enterprises, LLC
Facility/Owner Name Facility ID#(if applicable) 8.Certificatio_:t✓_
10580 US Highway 64 East, Apex, NC � ' 1/30/2023
Physical Address,City,and ZipSignature of edified Well Contractor or Well Owner Date
Y Y g
Chatham 0702-00-02-0765 3 signing form, hereby certifywell(s) (were)
B y si nin this I certi that the wasabandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds.or decimal degrees:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
35-44'.9.13 N 78-59'59.40 M, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can subunit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 8 R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 17 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:
6d.Water level below ground surface: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
t
6e.Outer casing length(if known): 7 (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): n/a (ft.) abandoned.
6g.Screen length(if known): 17 (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
SR&R Environmental, Inc. 7a.ForGeoprobe/DPTorClosed-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 1is needed
Patrick Beccaria Indicate TOTAL NUMBER of
wells abandoned:
r+Prn g�, ,..yam.
NC Well Contractor Certification Number ,_. -__, i t^• 1) 7b.Approximate volume of water remaining in well(s): 5 (gal.)
R-4w'it—,a ti, J.,9,a..�
N C-4543 3 FOR WATER SUPPLY WELLS ONLY:
Company Name MAR` 20 L
7c.Type of disinfectant used:
2.Well Construction Permit#: tnfr..:-,<:1:,L7,n 'err • f,',!E-j Un:
List all applicable well construction permits(i.e.UIC,County.04M,CIftzciade)etc.)if known
7d.Amount of disinfectant used:
3.Welll use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public I Neat Cement Grout I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
II Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation betonite chips 1/2 bag
0 Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage neat cement 6" plug
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure: •
❑Geothermal(Closed Loop) ❑Tracer betonite chips up to 6" from top of well
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Mixed neat cement for 6" plug on top
4.Date well(s)abandoned: 1/30/2023 ,
5a.Well location:
VLH Enterprises, LLC
Facility/Owner Name Facility ID#(if applicable) 8.Certificatio
10580 US Highway 64 East, Apex, NC (, 1/30/2023
Physical Address,City,and Zip Signature of tiertificd Wel' ontractor or Well Owner Date
Chatham 0702-00-02-0765
By signing this form, I hereby certiA,that the well(s) was(were)abandoned in
, County Parcel Identification No.(PIN) accordance with 1SA 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:
35-44'.9.13 N 78-59'59.40 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 veils
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 IDM ' W 5R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 17 (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: 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: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 7 (ft.) IOc.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): n/a (ft.) abandoned.
t
6g.Screen length(if known): 17' (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
SR&R Environmental, Inc. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30'is needed. Indicate TOTAL NUMBER of
Patrick Beccaria .�� : ` :, wells abandoned:
\; z
"" a..� ' 7b.Approximate volume of water remainin in well(s): 5 al.
NC Well Contractor Certification Number �y PP g (gal.)
NC-4543 MAR 1 5 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: CAVQIDOG
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflarown
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 M 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) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
IMMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge - ❑GroundwaterRemediation betonite chips 1/2 bag
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage neat cement 6" plug
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer betonite chips up to 6" from top of well
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Mixed neat cement for 6" plug on top
4.Date well(s)abandoned: 1/30/20.23
5a.Well location:
VLH Enterprises, LLC
Facility/Owner Name Facility ID#(if applicable) S.Certification%--—
10580 US Highway 64 East, Apex, NC C/ 1/30/2023
Physical Address,City,and Zip Signature of Certified Well ontractor or Well Owner' Date
Chatham 0702-00-02-0765
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I 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:
35-44'.9.13 N 78-59'59.40 , 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.
MW 15 IOa. 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: 17 (ft.)- 1617 Mail Service Center,Raleigh,NC 27699-1617
�� 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 7 (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): n/a (ft.) abandoned.
L_ 6g.Screen length Of known): 1 7 (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:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
SR&R Environmental, Inc. 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
Patrick Beccaria wells abandoned:
t _ 7-n n 'Y�0�T
NC Well Contractor Certification Number t a>•, (: ; \6a r r1 ) 7b.Approximate volume of water remaining in well(s): 5 (gal.)
NC-4543 FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#: Ifh,:+• „;~ 'i `f i_.
,•j t✓r,t 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State;Vuridnce,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 PI Neat Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout -' ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
®Monitoring • ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation betonite chips 1/2 bag
❑Aquifer Storage and Recovery CI Salinity Barrier `
❑Aquifer Test ❑StormwaterDrainage neat cement 6" plug
❑Experimental Technology I ❑Subsidence Control '
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer betonite chips up to 6" from top of well
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Mixed neat cement for 6" plug on top
4.Date well(s)abandoned: 1/30/2023
5a.Well location:
VLH Enterprises, LLC .
Facility/Owner Name Facility ID#(if applicable) 8.Certificationi
10580 US.Highway 64 East, Apex, NC ,� 1/30/2023
Physical Address,City,and Zip S natuth of Certified Well Contractor or Well Owner Date
Chatham 0702-00-02-0765
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:
35-44'.9.13 N 78-59'59.40 `,1t 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.-
IVIW 16 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: 1 7 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
2" 10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
•
6d.Water level below ground surface: 6 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&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): n/a (ft.) abandoned.
6g.Screen length(if known): 1 7 (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:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 7a.Number of wells being abandoned: 1
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
construction/abandonment,you can submit one form.
A - 4252
NC Well Contractor Certification Number (t � , 7b.Approximate volume of water,remaining in well(s): 3'0 (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
/,{ I. nnnn
Company Name iVi�tFC IL it LULJ 7c.Type of disinfectant used:
2.Well Construction Permit#: ..e :r:; :1 1 i _n::^1 •7!.n)
List all applicable well construction permits(i.e.County,State. d,ji. es;e7oJ 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 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El 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 4.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location: i
CIRCLE K- 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification: pp •
1513 EAST 11TH STREET SILER CITY 27344 ° °" 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM 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:
35°44' 00.81" N 79° 26' 33.87" 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#:
MW-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 28.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Injection Wells: In addition to sending the fonn to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
1 0.0 Division of Water Quality,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
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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information: WELL ABANDONMENT DETAILS
JACOB MESSICK 1
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 sante
construction/abandonment,you can submit one form.
A - 4252
7b.Approximate volume of water remaining in well(s): 2'S (gal.)
NC Well Contractor Certification Number c GEOLOGIC EXPLORATION a s FOR WATER SUPPLY WELLS ONLY:
Company Name IVINR I a LUL3
7c.Type of disinfectant used:
2.Well Construction Permit#: r; :; ^; .7 ! r:i
List all applicable well construction permits(i.e.Cotiitty,-State,lFar/ance;erc){i/iknosru 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g)
ll Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑AquiferRecharge ❑Groundwater Remediation 4.0 GALLONS
CI Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility iD#(if applicable) 8•CCrtificati0n:
•
1513 EAST 11TH STREET SILER CITY 27344 4'.24" 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel identification No.(PIN). accordance with i5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long in sufficient) 9.Site diagram or additional well details:
35°44' 00.81" N, 79° 26' 33.87" W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-seater 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#:
M W-3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
24.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Injection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
10.0 Division of Water Quality,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
Ge.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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 7a.Number of wells being abandoned: 1
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
construction/abandonment,you can submit one form.
A - 4252
7b.Approximate volume of water remaining in well(s): 2'S (gal.)
NC Well Contractor Certification Number ? •
GEOLOGIC EXPLORATION Iv�t/ j(r'�'?R !FOR WATER SUPPLY WELLS ONLY:
Company Name MAK 1 ZVLJ
7c.Type of disinfectant used:
2.Well Construction Permit#: ';: 1 t 11 •�
List all applicable well construction permits(i.e.C}Aiitty'.Sole,=l(ariance,iete '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 ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ 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)
OMonitoring ❑Recovery
Injection Well: If.For each material selected above,provide amount of materials used:
0 Aquifer Recharge ❑GroundwaterRernediatiort 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage
['Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility IDO(if applicable) 8.Certification:
1513 EAST 11TH STREET SILER CITY 27344 °"" 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM 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:
35°44' 00.81" N 79° 26' 33.87" 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(%)if available. For multiple injection or non-water supply
wells ONLY with the some construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MVV-4 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above, also submit one copy of this fonn within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
1 0.0 Division of Water Quality,Underground Injection Control Program,
Gd.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
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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
'
1.Well Contractor information: WELL ABANDONMENT DETAILS
JACOB MESSICK 1
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 hells ONLY with the same
construction/abandonment,you can submit one form.
A - 4252 _ 771,
75
NC Well Contractor Certification Number ` k...^N _ �" `t—'°'" 7b.Approximate volume of water remaining in well(s): (gal.)
L�.�r
GEOLOGIC EXPLORATION 1 7n73 FOR WATER SUPPLY WELLS ONLY:
Company Name ���� y
7c.Type of disinfectant used:
OVA
2.Well Construction Permit#:
List al/applicable well construction permits(.e.Count/-Stdte;'l'F.H ,ici,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: RI Bentonite Slurry ❑ Other(explain under 7g)
IAMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier •
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification: •
1513 EAST 11TH STREET SILER CITY 27344 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM By signing this form, 1 hereby certif}'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:
35°44' 00.81" 79° 26' 33.87" 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)if available. For multiple injection or non-crater 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/4: M W-5 abandonment to the following:
Division of Water Quality,Information Processing Unit,
20.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
IOb. For Injection Wells: In addition to sending the form to the address in l0a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
10.0 Division of Water Quality,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
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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning-Will,6ii hiVlier:p'ropgriy), ,�S n i'or multiple injection or non-water supply wells ONLY with the same
A 4252 q.,,„ construction/abandonment,you can submit one form.
NC Well Contractor Certification Number MAR 1 5 2023 7b.Approximate volume of water remaining in well(s): 2.5 (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name ir1;Gr;q<:- -:
Dt'n a. '. 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Stale,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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1513 EAST 11TH STREET SILER CITY 27344 " 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM 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:
35°44' 00.81" N 79° 26' 33.87" 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-crater supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this fonn within 30 days of completion of well
6a.Well ID# M W-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth 24.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 10.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Infection Wells: In addition to sending the form to
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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Fonn GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 1
7a.Number of wells being abandoned:
t
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-hater supply wells ONLY with the same
A -4252 construction/abandonment,you can submit one form.
2.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION MAR 1 5 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name r l_t
7c.Type of disinfectant used:
2.Well Construction Permit#:
List al/applicable well construction permits(i.e.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 0 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) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry 0 Other(explain under 7g)
1EMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonmwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification: pp� •
1513 EAST 11TH STREET SILER CITY 27344 he6 °y44`4, 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM By signing this form, I hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0i00 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:
35°44' 00.81" N 79° 26' 33.87" �� 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 saute construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: MW-7 abandonment to the following:
Division of Water Quality,Information Processing Unit,
24.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
lOb. For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 10.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to
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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK � 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally a vtdoq ng;well on his/h�r;pr'opeRy)..` For multiple injection or non-water supply wells ONLY with the same
�°\" construction/abandonment,you can submit one form.
A -4252
NC Well Contractor Certification Number MAR 11 5 2023 7b.Approximate volume of water remaining in well(s): 2.5 (gal.)
GEOLOGIC EXPLORATION g tit,`, FOR WATER SUPPLY WELLS ONLY:
Company Name t" t-.�' ;;r•-%�;
v a 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Stale,(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 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
0Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑AquiferRecharge ❑GroundwaterRemediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storm water Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K - 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification: •
1513 EAST 11TH STREET SILER CITY 27344 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM By signing this form, I hereby certify that the we//(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 tat/long is sufficient) 9.Site diagram or additional well details:
35°44' 00.81" N 79° 26' 33.87" 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-waier 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
Ga.Well ID#: M W-8 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 24.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb. For Injection Wells: In addition to sending the form to the address in 10a
2.0 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
10.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
IOc. For Water Supply& Injection Wells: 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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JACOB MESSICK 1
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
construction/abandonment,you can submit one form.
A - 4252
1, •-- ;^„F,_, , �' 7b.Approximate volume of water remaining in well(s): 2•5 (gal.)
NC Well Contractor Certification Number +
GEOLOGIC EXPLORATION MO 1 5 20�3 FOR WATER SUPPLY WELLS ONLY:
Company Name tj;: 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,I'arianletc.)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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
"'Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: RI Bentonite Slurry ❑ Other(explain under 7g)
RJMonitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
U Aquifer Recharge ❑GroundwaterRemediation 4.0 GALLONS
[Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
['Geothermal(Closed Loop) "'Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification: •
1513 EAST 11TH STREET SILER CITY 27344 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM 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 lat/long is sufficient) 9.Site diagram or additional well details:
35°44' 00.81" 79° 26' 33.87" 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)if available. For multiple injection or non-water supply
wells ONLY with the sane construction/abandonment,you can submit one Orin. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: MW-9 abandonment to the following:
Division of Water Quality,information Processing Unit,
25.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
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: (in.) abandonment to the following:
10•0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
IOc. For Water Supply& Injection Wells: In addition to sending the form to
Ge.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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): .(ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information: WELL ABANDONMENT DETAILS
JACOB MESSICK 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-crater supply wells ONLY with the .cane
construction/abandonment,you can submit one form.
A - 4252 -
• a F P. L.. __. 7b.Approximate volume of water remaining in well(s): 2'S (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION MAR 1 S 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.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 0 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) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
Monitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage - - - -
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/16/23
5a.Well location:
CIRCLE K- 2724660
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1513 EAST 11TH STREET SILER CITY 27344 `'' 01/20/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CHATHAM 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 t/te well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 9.Site diagram or additional well details:
35°44' 00.81" N, 79° 26' 33.87" IV abandonment
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#: MW-10 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in l0a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in,) abandonment to the following:
1 0.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Infection Wells: 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 casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013