Wake_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
Lawrence D. Opper 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.
NC 3322-A
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
Regional Probing Services 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.)(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 ?. , '`:O>Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout .o Dry Clay
❑Industrial/Commercial [Residential Water Supply(shared) ❑ Concrete Grout MA R d 5 20611 Cuttings
❑Irrigation ❑ Specialty Grout in .-. ❑ Gravel•
Non-Water Supply Well: ❑ Bentonite Slurry r- G7 tlj r(explain under 7g)
• .:i;,)
Monitoring •
❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 64Ibs
❑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 Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 1/31/2023
•
5a.Well location: •
Starmount Family Fare#425
Facility/Owner Name Facility ID#(if applicable) S•Certification:
�o�.d�W 1ewucbm
3520 Capital Blvd., Raleigh - Lawrence Oppe,. �s, °"~ 2/21/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 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:
35.828360 78.584683 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 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#: MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth 40 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
well dia: 2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
approx 37 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
6E Inner casing/tubing length(if known): 15 (ft.) where abandoned.
•
6g.Screen length(if known): 25 (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
Scott Werley 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
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0501539
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)ifknoun
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 A Neat Cement:Grout- -� II Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout�,, 3^�-' ft3 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grouts,n D 0 Drill Cuttings
❑irrigation ❑ Specialty Grout 1 5 2023 ❑Gravel
Non-Water Supply Well: ❑ Bentonite-,S_ln ;l` C Other(explain under 7g)
FiM onitoring ❑RecoverY (, atrt � Uni
Injection Well: 7f.For each material seledted-atiove,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite — 10 lbs Neat Cement—30 lbs
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer
OGeothennal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed bentOnite chips to 5 ft bgs.
PVC riser was removed from bore hole.
4.Date well(s)abandoned: 02/24/23 Portland cement was poured from 5 ft bgs to sub-surface.
5a.Well location: Surface capped with hydraulic cement.
Old Dominion Freight Line Site
Facility/Owner Name Facility 1DI4(if applicable) 8 rtification:
150 International Drive, Morrisville, NC 27560 Z/2 8fzoz
Physical Address,City,and Zip Signature of Certifi W 1 Contractor or Well Owner Date
Wake 0755196073
By signing this form, /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.
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:
N 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)ifmmilable. 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 fonn within 30 days of completion of well
6a.Well ID#: TW-1 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 fonn to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this fonn within 30 days of completion of well
,1 abandonment to the following:
6d.Water level below ground surface: 1 1 '54 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) l Oc.For Water Supply&Injection Wells: In addition to sending the fonn 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): 7 (ft.) abandoned.
6g.Screen length(if known): 1 O (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
Scott Werley 7a.For Geoprobe/DPT or Closed-L lop 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
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
W M 0501539
List all applicable well construction permits 6.e.U/C,County,State,Variance,etc.)ifknovn
7d.Amount of disinfectant used:
3.Well use(check well use):
•
Water Supply Well: 7e.Sealing materials used(check all that apply):
0 Agricultural 0 Municipal/Public a Neat Cement 61--duf-- a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) El Sand Cement Grbt"d--- Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout A p l Drill Cuttings
❑lnigation ❑ Specialty Grout MA
5 2023 ❑Gravel
Non-Water Supply Well: ❑ Bentonitkiiiryt aj�; _., a Other(explain under 7g)
IMonitoring ❑Recovery v(;.;o,,,.;•;:4:3
Injection Well: 7f.For each material selected hl oVe,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite — 5 lbs Neat Cement— 15 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
•
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed bentonite chips to 5 ft bgs.
PVC riser was removed from bore hole.
4.Date well(s)abandoned: 02/24/23 Portland cement was poured from 5 ft bgs to sub-surface.
5a.Well location: Surface capped with hydraulic cement.
Old Dominion Freight Line Site
Facility/Owner Name Facility ID#(if applicable) rtification:
150 International Drive, Morrisville, NC 27560
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 0755196073 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:
N 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 vith 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#: TW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 9 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the fonn 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: 1 2.92 (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 fonn within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 9 (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
Scott Werley 7a.For Geoprobe/DPT or Closed-L lop 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
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'25 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0501539
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)if knoll??
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 III Neat Cement Grout II Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement iou�t 0 Dry Clay
❑Industrial/Commercial 0 Residential Water Supply(shared) 0 Concrete Grout '-'i -r'....,' ry r:ce...D'Drill Cuttings
�..i J .
❑Irrigation 0 Specialty Grout MAR j y I'`O Gravel
Non-Water Supply Well: ❑ Bentonite Slurry R 1 5 2023 C Other(explain under 7g)
(Monitoring ❑Recovery
Injection Well: 7f.For each materialsQlected above,,proqvideamount of materials used:
❑Aquifer Recharge ❑Groundwater Rernediation Bentonite "' 5`Ifisi fit-4 Neat Cement-- 15 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed bentonite chips to 5 ft bgs.
PVC riser was removed from bore hole.
4.Date well(s)abandoned: 02/24/23 Portland cement was poured from 5 ft bgs to sub-surface.
5a.Well location: Surface capped with asphalt.
Old Dominion Freight Line Site
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
150 International Drive, Morrisville, NC 27560 2 /8/��,Z3
Physical Address,City,and Zip Sigma re of Certifie W Contractor or Well Owner Date
Wake 0755196073
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 ladlong is sufficient) 9.Site diagram or additional well details:
N W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructionrecord(s)ifavailable.For multiple injection or non-water supply tiells
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#: TW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (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 fonn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 1 2.45 (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 fonn 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 0 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Fonn 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
Scott Werle
Y 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
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
•
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0501539
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ij'knoun
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 IR Neat Cement Grout a Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement ff{fout 1 _D-Dry Clay
❑Industrial/Commercial ID Residential Water Supply(shared) ❑Concrete Grout ° -O Drill Cuttings
❑Irrigation ❑ Specialty Grout MAR 1 5 2023 ❑Gravel
Non-Water Supply Well: ID Slurry II Other(explain under 7g)
(Monitoring ❑Recovery in»++ :i1 ,_,..
Injection Well: 7f.For each material sele'cled.;a,6yc,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Retnediation Bentonite - 5 lbs Neat Cement— 15 lbs
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed Bentonite chips to 5 ft bgs.
PVC riser was removed from bore hole.
4.Date well(s)abandoned: 02/24/23 Portland cement was poured from 5 ft bgs to sub-surface.
5a.Well location: Surface capped with hydraulic cement.
Old Dominion Freight Line Site
Facility/Owner Name Facility lD#(if applicable) tifrcation:
150 International Drive, Morrisville, NC 27560 2/2eZo23
Physical Address,City,and Zip Signature of Certified I Contractor or Well Owner Datete`
Wake 0755196073 By signing this form, I hereby certi/y 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:
N 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 ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Inflection Wells: In addition to sending the fonn 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: 2.92 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 1 Oc.For Water Supply&Injection Wells: In addition to sending the fonn 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): 5 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
•
Fonn 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
Scott Werley 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
3344-A wells abandoned:
•
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
W M 0501539
List all applicable well construction permits(i.e.U!C,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 IN Neat Cement Giput II Bentonite Chips or Pellets
['Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ❑ Sand Cement Grout '• r;'C1 tDty Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 'l--L•7 Urill Cuttings
❑Irrigation 0 Specialty Grout MAR 1 5 2023 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry I Other(explain under 7g)
eMonitoring ❑Recovery 5'=tl '�;• ;`:�.,v.1
Injection Well: 7f.For each material selecterl;abON i prP ide amount of materials used:
❑Aquifer Recharge ❑Groundwater Rernediation Bentonite — 10 lbs Neat Cement•-30 lbs
0 Aquifer Storage and Recovery 0 Salinity Barrier
['Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer PVC screen was removed from borehole.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Gravity feed bentonite chips to 5 ft bgs.
4.Date well(s)abandoned: 02/24/23 Portland cement was poured from 5 ft bgs to sub-surface.
5a.Well location: Surface capped with asphalt.
Old Dominion Freight Line Site
Facility/Owner Name Facility IDI(if applicable) cmofertifledWonctororWellOwne
tification:
150 International Drive, Morrisville, NC 27560 ZA)7/2ez3
Physical Address,City,and Zip r Date
Wake 0755196073 Bysigning thisform, I herebycerti that the wells was were abandoned in
S S lY () (were)
County Parcel Identification No.(PIN) accordance with 1SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy pl.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:
N W You may use the back of this page tolprovide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 8.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection 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 V (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&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this fonn within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 8.5 (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
Scott Werle
Y 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
3344—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
WM0501539 7c.Type of disinfectant used:
2.Well Construction Permit#: .
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if know?
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 a Neat Cement Grout '"` _ !IF/Bentonite Chips or Pellets
11,
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout MAR 1 5 2lrill Cuttings
❑irrigation _ ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: in;ti•f i ;,t,a i't, ;r, ,
Pp y El Bentonite Slurry ,,_, �OtherZexplain under 7g)
▪Monitoring ❑Recovery `° 01"."
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite — 10 lbs Neat Cement—30 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
CI Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer PVC screen was removed from borehole.
❑Geothennal(Fleating/Cooling Return) ❑Other(explain under 7g)
Gravity feed bentonite chips to 5 ft bgs.
4.Date well(s)abandoned: 02I24I23 Portland cement was poured from 5 ft bgs to sub-surface.
5a.Well location: Surface capped with asphalt.
Old Dominion Freight Line Site
Facility/Owner Name Facility ID#(if applicable) ification:
150 International Drive, Morrisville, NC 27560 Z/z ez 3
Physical Address,City,and Zip Signature ofCertifie W Contractor or Well Owner Date
Wake 0755196073 By signing this forrn, I 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:
N 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 form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 3.23 (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 formto the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandomnent to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 9 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott Werley 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
3344-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
ECS Southeast, LLP 'FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
W M 0501539
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if knorin
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing material usei'(check-all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout ` `h4: z; e•Bi;[unite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout MAD D ❑Dry Clay
Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 1 5 2023) Drill Cuttings
❑Irrigation ❑ Specialty Grolttlf,_rii;—.;1 ti..,,..• ❑ Gravel
Non-Water Supply Well: r •. ; -1 •::;: +;rr. o
❑ Bentonite Slurry u,,�a�,;t�1G �'Othl:r(explain under 7g)
lMonitoring ❑Recovery
Injection Well: ' 7f.For each material selected above,provide amount of materials used:
DAquifer Recharge ❑GroundwaterRemediation Bentonite — 5 lbs Neat Cement— 15 lbs
DAquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothennal(Heating/Cooling Retum) ❑Oth er(explain under 7g) Gravity feed Bentonite chips to 5 ft bgs.
PVC riser was removed from bore hole.
4.Date well(s)abandoned: 02/24/23 Portland cement was poured from 5 ft bgs to sub-surface.
5a.Well location: Surface capped with asphalt.
Old Dominion Freight Line Site
Facility/Owner Name Facility ID#(if applicable) tification:
150 International Drive, Morrisville, NC 27560 21Zy�ze23
Physical Address,City,and Zip Signature of Certified Contractor or Well Owner Date
Wake 0755196073 Bysigning this brm, I herebycerti j that the wells was were abandoned in
s g f Iy (1 (were)
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:
N 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 form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 10 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 9.90 (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&Iniection Wells: In addition to sending the fonn 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): 8 - (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
Scott Werley 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
3344—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.10 (gal.)
ECS Southeast, LLP 'FOR WATER SUPPLY WELLS ONLY:
Company Name 1t A 7c.Type of disinfectant used:
2.Well Construction Permit#: W1V10501 539
List al/applicable well construction permits(i.e.U/C,County,State,Variance,etc.)ii 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 IN Neat Cement Grout f >'L13 ne tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout O Diy Clay
❑Industrial/Cotmmercial ❑Residential Water Supply(shared) ❑ Concrete Grout MAR 1 5 2023] Drill Cuttings
❑Irrigation ❑ Specialty Grout = , ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurryins=i i "' t..
Monitoring ❑Recovery '-' ": Other(explainunder7g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite — 5 lbs Neat Cement— 15 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer
Gravity feed bentonite chips to 5 ft bgs.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
PVC riser was removed from bore hole.
4.Date well(s)abandoned: 02/24/23 Portland cement was poured from 5 ft bgs to sub-surface.
5a.Well location: Surface capped with hydraulic cement.
Old Dominion Freight Line Site
Facility/Owner Name Facility ID#(if applicable) 8. rtification:
•
150 International Drive, Morrisville, NC 27560 Z/28/Z6z 3
Physical Address,City,and Zip Signature of Certifie II Contractor or Well Owner Date
Wake 0755196073
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.0/00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N 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 form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TW-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 11 (ft.)
10b.For Iniection Wells: In addition to sending the fonn 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: 8.1 8 (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 fonn 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 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
- . WELL ABANDONMENT RECORD��.."3._ r humid UscONLY:
This form can be used for single or multiple wells
I.Well Contractor information: WELL ABANDONMENT DETAILS
Scott Mint,. Jr 7a.Numberofwellsbeingabandulei: 17
Hu . •
WclLCotbraclor Naate(or WWellDarerpersatrallyabattdoning1eeilouhisIterpropcny) For multiple, fillecttwr or rips-wufer1 supply dells ONLY wttb the yroiie
cor l fecrwevaboirdwunc'it,pm exuesab,luf one form.
4561-A j
7b.Appanxiniate t•nlntne of Water�uaining in wells): (gaL)
NC Well ConnaGor Can itication Minter • •
FOR WATER SUPPLY WELLS ONLY: '
SAEDACCO Inc
Queasy Name 7c.Type of disinfectant used:
.2.Weli Construction Permit#:, , W10501112
•
.List ell applk'a41e well permit(tie.Cuirrly,State.Variance.hijediow,ric ifrotoesrr 7d'Aru0nnl of disinfectant used:
3.Well use(dteek n di use): •
Water Supply Well: • 70,Sealing matctialsuscd(clime all that apply): •
•
°Agricultural °Mtmicipal/Pubttc 17 Neat Cement Grout' —. _ MI Hcmonitc Chips or Pellets
.DGeottienn:rt(Hcatingg/C.ocslin,�Supply) ❑Rcsidentr;il Water Supply(single) ❑Sand Cement Gmue '-`'s ..t; ., y ❑'Di Corp
❑hutnstrialiComnrcrcial ❑Residential Water Supply(Shared)" 0 Conctt:te Grout EL Dri._.Culdngs .
❑frncation 13 Specialty.Grout MAR 1 5 202y Gravel '
Nun-WaterSuppla Welt CI BentoluteSlitly,_;;.,, Oilier(e-pksinunder 7g)
;:,1 __,,
❑Monitoring I:Recoven
Injection Welt: • . 71.For each material selected abriviMlrovide':ittiount of materials used:
❑Aquifer Recitar),re . ❑Gititmdriater Rentediation
❑Aquifer Storage and Recovery .DSalinity Barrier
Bentonite.:50 per locationlb ,Wtr:gal.
❑Aquifer Test OStornncnter Drainage T ., . --______❑Experinrerrtal Technology °Subsidence Control 7g.Provide a hruf description of tlec abandonment priicwvlurn:
t7Ge+oilrenual(Closed Loop} I1Tracer
injection points with direct push tooling after point were
• °Geothermal 0-kiting/Cooling Return} . IOther.(c plain under 7g)
done file the location up with bentonite and packed hole
4.Date maw abandoned: 2/14/23 - 2/17/23 with rig until I would not pack anymore forcing the
53.Well location: bentoriite all the way to the bottom
Former Grocery Boy Jr #5
Faeil[1)•/OnnerNamc facility 11Jb(irapplicable) S.Ccrtifirttlott:
602 W. Chatham St. Cary," NC 27511 c C9 Gl�lt 3/1/2023
Physical-Addres,City.and Zip Si iinrcor Cal ilkii Well Con ;rnrorV/c7lOwn.:r . Daic
Wake _ , Hy-signing-this fo m, I hereby certify that the n'el101 was(were)abandoned in
County Pared ld:ntif iluif No.(PIN) acxvrdattre with ISM I CAC 02C.01110 or 2C.0200 fuel/Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrccs/tntnutes/scsonds or decimal degrees:
(ifwell field,one lar/loagIs.siltiexil) 9.Site diagram or additional well details:
You may use the had:of this page to provide additional weil site details or well
. N W abandonment details. You tuay also attach additional pages if necessary.
CONSTRiICFION DETAILS OF WELL(SI BEING ABANDONED UBJI1TAr.INSTRUCTIONS
Math nett cnnilrucihin recur,}/J-!ovtelahla_.•For rrnitiple injection or trJn-nester.Copy}°
welts ONLY with the a nie rstreertoldaffanda r1nrrlt.J Jn CYtn Sabine owe Ann. Loa..Far All Wells: Submit Ibis Cann within 30 days of cdtripletion of well'
IDS:
B1-B34 (odd numbers) • abandotifitcntto the following:
6a,well
Division of WinerResnurets,Information:Processinit Unit; .
•
Gb.Total well depth: 2 0.25 (ft.) •1617 Mail Serviec Carter,Raleigh,NC 27699-1617
1.13h.For infection Wells: In addition to sending the form to the address'iv EOn
tic.liorchole diameter:z.z 5^ (in.) - above,also submit one Copy of this.form within 30 days of coinpletiou of welt
• -abandonment to the following:
Gd.Water level below ground surface:12 (ft.) Division of WaterResourccs,Underground Injection Control Program.
_____. --. 163611tail Service Center,Raleigh,NC 27699-1636
1 •
Outer easing Ica (if known): (ft.) Inc.For W it@r.!Toy,Cc injy fore}V�lia: In addition to sending the fount to
Ge.
F - the addsess(es) above. also submit,one copy of this form within 30 days of
completion of Well abandonment toithe county health department of the county
61.Inner.castn tniting length(if k nntn): (ft.) witcre abandoned,
6g.Screen length(If known): •(ft.) 1
l
•
Fernn GW-30 North Carolina Depaninera of Environment and-Natural Resources-Division of Water Rc5ou¢cs Revised Aiigua 2013

WELL AB • ONMENT RECORD Far Internal Use ONLY:
This form can be used for single or nutllipte wells
it
I.Well CUntr'aetor information: WELL ABANDONMENT DETAILS
Scott Hunt,••Jr 7a:Number of wells being abandoned: 17
elreontradorNamc(or551'.ItownerpetsauallyabandorningWelllanitisiIierprepcnv) Pa' undopte Injection or rvn-%triter svP111y "treks ONLY with Mte sane
car rrrrcnat%mbandlntrntent,you.car.mhrn)tovrsform,
4561-A
•
r 7h.Approximate volume of water a emaining in�vell(s) (gal)
. NC(iellConlwdarC'enifit-alienNumber
SAEDACCO Inc FOR WATER SUPPLY WELLS ONLY:
ConmanyName 7e.Type or disinfectant used: •
2.Welt Construction Perutit!#:. WI 13501112 . .
. Litt rd1 upplli.ublr i eIi periults r Co c tr,Stab,#uriurxe.Ihjecitioo,Lick Ifkamwrt 7d Aitiount of disinfectant used:
3.Well use(cheek well use): •
Water Supply Well: 7e.Sealing materials nixed(check all that apply):
IJAgreeultunt IJMumcipallPublic CI Neat Cement Grout ,EXI_Hcntonite•C(tips or Pellets
❑Cletttlurm el(11Cafinef Cooling Supply; ❑Resident%it Water Suppi) (single) ❑Sand Content Gmut v" OrUry Lay
• ❑hld.nstrial/Cotninercial • • ❑AcsideutialWutcr Supply(shared) ❑.Coucaete Grout MAR 20 2 t prat palings
❑lrn Lion ❑Specialty Grop>, 5 V • Gravel. .
N0a-Water Supply Wctl C6entoaite •Slurtr
tl -, Other(explain.tinder 7g)
❑Moffitoeing ❑Recnvery. L�
injection Well: 77f.For each material selected above,provide antotrnt of:rnatetials used: .
❑Aquifer Recharge ❑Gniundwaler Rentediution
❑Aquifer Storage and Recovery °Salinity Barrier
Bentonite.:50 per•locationlb ,Wtr:gal.
❑/qutferTest ❑Storim}iterDiaittage e__ _ _�_______ _ .._ ___.
❑Etpsrinaetnlal Technology ❑Subsidence Control 7g.Frnside a brief description of the abandonment pnrcedure:
P°Geothennal(Closed Loop) °Tracer
injection points with direct push tooling after point were
❑Geothermal(l1cauna/Cooling Return) . DOdicrtexplain under 7rt}
done file.the location up with bentonite and packed hole
4.Date wetl(s)abandoned: 2/14/23 2/37/23 with rig until .I would not pack anymore forcing the
Sa.Well location: bentonite all the way to the bottom
Former Grocery Boy Jr #5
FacilityiOwr r Name Fa:ilily 1Dll(if applicable) S.Certification:
602 W. Chatham St. Cary, NC 27511 c5!o"`- / 7zat '; 3/1/2023
Physical Address.City,and Zip SigtOweofCeatlandWellCni .unrorWealOnur Date
Wake 13)'signing this farm, I/ieirby certify that the ttell.(.st was(were)abandoned in
County Parcel Identification No:(PIN) arxrjrdatace with/SA 2tC.1C 02C.01(10 or 2C.0200 rifill Construction Standards
and that a copy of(his record has been provided to the well miner.
5b.1ntittrde and longitude in deg rces(nttautcs/scconds or decimal degrees:
(%larcn rkaa oily.tatllnng is sualcier1) 9.Site diagram or additional well details:
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 rlecessaty.
CONSTRUCTION DETAILS OF WELLS}BEING ABANDONED SI1RMITTAL.INSTRUCTIONS
Meat we l cvralruellan racurdl(s)-if urioilwie. Par multiple Mjeeeiarr or run-moor supply
. u>:ltx ONLY WO t i wane croarsrrratimt•4z3artbnateat.y Jrl COO sudmzmii rare fino. Ina. Far All Wells: Submit Ibis ratan within 30 day of completion of null
6a.Well ID#:B1-B34 (even numbers) abandonment to the lullOwing;
Diyisiun of Water Resources,Information Processing Dolt,
(6h.Total well depth: ft.
21 ) 1617 Mail Seivice Center,Raleigh,NC 27699-1617
10 b.For Inleetlrsn Wells: In addition to sending the fotnt to•the address in IOa
fie.Porch*diameter:2.2s" - (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
feel.Water level below ground surface: 12 _at.) Division of Water Resoug+ces,t ndergrnund Injection Control Praigram.
1636 Mail Service Center.Raleigh,NC 27699-1636
6e Outer casing length(if Imown): (ft.) 10c. t •trot .sr my&lalcetion Vrll�v: 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
6f.Inner easing/tubing length(it taaow•n): (D) where abandoned,
it
6g.Screen length(If known): (ft.)
Fornt GW-30 • Noah Carolina Department of Environment andNaturat Resources-Division of Water Resonn-es Revised August LOl3

•
WELL ABANDONMENT RECORD For Internal UscONLY: }
This foam can be used for single or multiple wells
• i
1.Well Contractor information: WELL ABANDONMENT DETAILS
Brian Ewing 7a.Numberof.�rills being abandoned: 20
WellCat;iractor Name(ormitunierpets:Utilityalnas!Jmdn;uellinthistiterpropetty) For :Maple ayecliar or mar-::tires svpixfy- Wells ONLY rstrb the swine
(Oxrsfsvcrtauivrurdrtrvrrcirr,pi?COI'.rr rtnlwrejnrnt•
4240-B
71i.Approximate volume of)ratty remaining in Well(ta): (gal.)
NC Well ConlraclorCcniftcalion Number
SAEDACCo Inc FOR WATER SUPPLY WELLS ONLY:
Company Name . 7e.Type ofdisinfectant.used: • •
2.Well Construction Permit r# wI0501112 - '
Lt t di applicable.well perm*:ry .e.Cootur.Stcte,)ririance.Lrfettidri,.Clct lfkrmrsrl 7d.AuiOtnit of disinfectant used:
3.Well use(ehedt well uie):
Water Supply Well: le.Scaling materialsused(cheer*all that appl}•);
ClA,grictdtur:d pMtuiicipal/Ptiblic - la Neat CenictIt.G((roa►t --- r IN UentonitcChipsorPellets.
❑Gieolhernral(Ileatint/Coohu Supply) ❑Residentiatl Water Supply(single) ❑.Sand Cement Gamut',-t s !,�0;Dr'Clay
• • ❑hidnstrial/Coruntcrcial ❑Residential Water Supply(shaded) ❑ConcrcICGruut M ❑ Brill.Cutdnt .
Mitigation 0 Specialty Grout m IA i 5 2023❑.Gravel . .
Netts=!#ratci'Supply Well; • 0 Bentouite SlHrtf', .i:,i2n Pr;,., ?.,,q✓a Cher(espiainunder 7g)
GIMnaltomine DRe.o%•en'- . . EiV'a % .'.,)?i,7
tinjeetion Well: - 7f.For each material selected above,provide amount of.Materials used:
' ❑Ageifer Recharge . ❑Giriund Ater Remediation
❑Aquifer Storage and—Rim—try ❑Saliuitty barrier
❑AgniferTest ❑StonmuutcrDrainage . g_ __
Bentonite.:501b_Wtr al.
❑ExperinteuIal Technology ❑Subsidet;ce Control 7g.Prrnide a hriifdescription of the abandonment prricedurc:
.C)Geothenntl(Closed Loop) ,l]Tracer
BENTONITE IS PUSHED TO THE'BOTTOM BY_MEANS OF HYDRAULIC
OGeothsnna((ffeatine/Coohing Return) . E(Other(explain under 7e) .
PRESSURE FROM PROBE RODS '
.I.Date wcll(s)abandoned: 272472 3
Sat,Well/oration:
Former Grocery Boy Jr #5 '
Facilii)lm%ti—Na a Facility MN(if appliwble) R•Ce�l(Icaeion:
602 W. Chatham Si. Cary, NC 27511 - , - • Brian_ Ewing. 3/2/2023
Physical Address.City.and Zip _Si (its,;<1rccititied Woii COnuacior,r:.ill Chyme Dale•
.
Wake . . By sigrtitig ibis fore:, 1 hereby certify that the well{s)was(Were)rrhnrtdaned in .
County Parecl Idcnllfieallou No.(PIN) acwnlrnice with/5.4 VCAC 02C.01.00.or 2C.0200 iitall Construction Standards.
•
and alma a copyofdris iecord lras been provided to Me well owner.
5h.I.atitadc and longitude in de grceshniitutcslsvconds dr decimal degrees:
(itwell Cstd,otw.luritong is.initieocitl) -9.Site diagram or additional well details:
• 'You'ilia tide the back of this page to pros�ide additional well site details or well. .
- N • - W abaindonnteru details. You may also attach additional pages if necessary.
CONSTRIiC"I'ION DETAILS OF WELL(SI BEING ABANDONED 5,UBMiTTAi.INSTRUCTIONS • -
•:titath(rein waits-action rewrdrs/Jf usOltmrite.-Pei.r midriple litt)ecQrm or limonite,-supply
wits ONLY mink the moirernnsinteaw6ah,itrrhlltnJc7Jt.PAO trot snhmit are form. Ina. For All Wells: Submit this form Within 30.days of cotttpletion of well
6a Well BM: abttndonmeetto the following:
DMVisign of WaterRestuircts,Infonnation.Processing Unit,.
Gb.Total well depth: 2 6.2 5 (fi) 1617 Mail Sciviee Center,Raleigh,NC 27699-1617
I9it.For Infection Wells: in addition to sending the form to the address in 10a
6c.Borehole dlanletew 2.25 (in.) above,alstr submit one copy of this form within 30-days of completion of well
• abandonment to the fallowing: ,
Division of Water Resources,Underground Injection Conariol Friagram,
6d.Water level below ground surface: 12 (ft.)
= 1636 Mail Service Center,Raleigh,NC 27699 1636
Ge.Autcrcasint;1 h(if rfl w 10.For i iy At i tfectigpl WAIN: In addition to sending the foam to
(ft) the address(es) above. also submit one copy of this form within 30 days of
• completion of well abandonment col the-county health department-ofthe county
•
GE.Inner.casidg/tahing Length(if taturvn): . (ft.) where almndoncd,
;
6g.Screen length(if!mown): (ft.)
1
Farm GW-lo North Cantltn Depanm nt of E,wirocmrcat and Natural Resources-Oh ision of Water itcsorui'es Revised August 2013
F

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
•
1.Well Contractor Informal' For multiple injection or non-wafer supply wells ONLY with the same WELL ABANDONMENT DETAILS' I
Gal
5c1?e 7a.Number of wells being abandoned:
Well Contractor3 'ame(or well owner personally abandoning well on his/her property) construufon/abandonment,you can submit one form. ,7
9 lb.Approximate volume of water remaining in well(s): N 010E-(gal.)
NC Wel Conti_ Aj1asihi
or talinNumber
P' L IV tG 4Vi5S o e, FOR WATER SUPPLY WELLS ONLY:Company Name 7c.Type of disinfectant used: t"I-
2.Well Construction Permit#: f v` IF
List all applicable well permits(i.e.County,State,variance,Injection,etc.)if!mown 7d.Amount of disinfectant used:
3.Well use(check well use): pp y.
;le(SSealing materials used(check all that a 1 ):Water Supply Well: ❑Municipal/Public Ne3t Cement Grout 1 ^- Bentonite Chips or Pellets
❑Agricultural i .
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout •�.•� , :yO;IM tonic
0 Concrete Grout 0 Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) MAR 1 5 2 •:ravel
0 Specialty Grout J'
❑Irr-Waon 0 Bentonite Slurry fir;•: ; -,,.- 0 Other(explain under 7g)
N -Water Supply Well: -. Iji r:i
❑Recovery " :,
Monitoring 7f.For each material selected above;provide amount of materials used:
In action Well: �� L�� � �
. ❑Aquifer Recharge ❑Groundwater Remediation if I Is,I eg d�'iz Pig-chid 3 Iv�(� `�04.1/t '��A1
❑Aquifer Storage and Recovery ❑Salinity Barrier � Sm wr ' 13, 4 /�d79 c+y/�L'y �++
❑Aquifer Test ❑Storm Water Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:OGeothermal(Closed Loop) OTracer C1441kG� wee/ _p !/ AO, Ivan X ive// A 6v3 e t�l.,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) `
IW 1 o 1 ia.id 5 ar�t '( t-e)otz e/,ecG e.e,n a cica,r_-f'
4.Date well(s)abandoned:
15-1 2 3 G✓c'(t r 6 w d�iYrlal'�� �) �him,. �c (veil •�p �Ut fi /sk.1 •
trk/� ,r� /
te, gid e/Jet / rig J4rusItmo gel Ld v�- r:.v, Gealcrebe_
Sa.Well location: tt��
l�C- 5 S 0- O 5a I q V B.Corti ation:
Facility/Owner Name Facility ID#(if applicable) �/�!//-y
L-
bo LL • store o Certified Well Contractor or Well Owner Date
Physical Addr ss,City,and ZiP W �•By e, 0'1'� eg5 sr'n L 0 v f�,,
By signing this form, I hereby certj that the well(s)was(were)abandoned in
1111�� Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient) You may use the back of this page to provide additional well site details or well
3 J �� N r m -3 3 3 S.-I- W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS ,
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one fonu. 102. For All Wells: Submit this form within 30 days of completion of well
y^, d i abandonment to the following:
6a.Well ID#: /®I Vv I
Division of Water Resources,Information Processing Unit,
/ l P 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: Q� (ft.)
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: 3 (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: I�s° 1 0 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 •
t 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 ode 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.)
0(
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells I
1.We ontractor InformaY
rWELL ABANDONMENT DETAILS
7a.Number of wells being abandoned: '
(� ' For multiple Injection or non-water' supply wells ONLY with the same
Well Contra well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form. y�
1 7b.Approximate volume of water remaining in well(s): I"a Dl r((gal.)
NC Well Co/ntractor Certification Number
bl(f _ „lj, j� Assoc., FOR WATER SUPPLY WELLS ONLY:
Company Name /+�''�/J 7c.Type of disinfectant used: A) A-
•
2.Well Construction Permit#: N
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(cheek all that apply y
Water Supply Well: 7e.
Cement Grout entonite Chips or Pellets
❑Agricultural °MunicipaVPublic �__, ❑ ry Clay
(Heating/Cooling Supply) ❑Residential Water Supply(single) ° Sand Cem (Grout- -- ,-
OResidential Water Supply(shared) 0 Concrete Grout..ice..,t—o?s: 1. :!,¢:,p Drill Cuttings
❑Industrial/Commercial 0 Specialty Grout y 5 0 Gravel
°Ir
NosicWate ❑Bentonite SlurryMAR 1 2023 ❑ Other(explain under 7g)
o Water Supply Well:
onttoring ❑Recovery I-.
7E For each'matenai se)`elect above;'Provide amount of materials used:
" Ina lion Well: r, -TA 1 • L / l '
. ❑Aquifer Recharge °Groundwater Remediation 7 1, s, .�' nits•,() t I!' �Dwe e'f /`iii
(]Aquifer Storage and Recovery ❑Salinity Barrier p 0 `S S cr Poll ic� t'e,14/ a v yo13> (4,4e e
°Aquifer Test °Stormwater Drainage
` j
°Experimental Technology °Subsidence Control 7g.Provide an brief description of the abandonment procedure: ,
°Geothermal(Closed Loop) °Tracer r ,-,,r 1�,��,,dq y py�1,, Dot o d„...--� d7_L
OGeothermal(Heating/Cooling Return) °Other(explain under 7g) well t wl-t40 S'l t lia S ra I I� E.
L&/,./ eA_
3l
4.Date well(s)abandoned: -G / X) Cl4os I!l)1 /^v 11 y 1/ C2,) I :.bi Ut- c ea y .Sf �
& .
5a.Well location: /DL �WWLI eel/�✓ t dolt' HIje 11 Altai 49 It /
Lit)ciPS) I 8,Ce tifr on:
U ese�C.l
Facility/Owner Name Facility IDN(if applicable) J
5GD1r• y,a i to ofCertiSedWellCotractororWellOwner Date
Physical Address,City,and
Zip
�F��a�P/]1j��f�,� t71—] d4(�j 010 By signing this form, /hereby cer[t&that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient) 'j You may use the back of this al page a provideils: additional well site details or wellsl (�Jb S. N 8i �'� 3S 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 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#:
W -Z abandonment to the following:
Division of Water Resources,Information Processing Unit,
r 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
I lob.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: O (in.) abandonment to the following:
I` Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: i N,CI (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
•
lOc.For Water Simply&Injection Wells: In addition to sending the form to
fie.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.)
3
6g.Screen length(if known): 1,0 (ft.)
•
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS,
God,y 4, —4 5�eZ" 7a.Number of wells being abandonedI
v For multiple injection or non-water l supply wells ONLY with the same
3 Well Contra 3actor N�a]me(or well owner personally abandoning well on his/her property) cons rruction'abandonntent,you can submit one form.
J� 1 7b.Approximate volume of water remaining in well(s): ®NE (gal.)
NC Well Contractor Ati C Certification Numbe4-
A'\„ yet/�l'p'[L 5-S al-
FOR WATER SUPPLY WELLS ONLY:
Pk-
Company Name 7c.Type of disinfectant used:
•
2.Well Construction Permit#:
List all applicable well permits(i.e.Cmrn%State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that ply):
Water Supply Well: Neat Cement Grout I Bentonite Chips or Pellets
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ` 7 " ,O"Dry Clay
?,.... ' ' '^0`Drill Cuttings
pResidential Water Supply(shared) 0 Concrete Grout
❑Industrial/Commercial 0 Specialty Grout MAR 1 5 2023 ❑Gravel
❑Irrigation 0 Bentonite Slurry 0 Other(explain under 7g)
N n-Water Supply Well:
❑Recovery Irlf.-- s?:<.':� .'';,,. :nj lino
If.For each materi Iselectdabovesprovide amount of materials used:
XMonitoring
Aquion Well: r I i s j &i ci i z'0 i 1S,
❑Aquifer Recharge ❑Groundwater Remediation tj fa Y�'
❑Aquifer Storage and Recovery ❑Salinity Barrier I I44,Tr- Mid Cta:k e '-l 1,�yly�B j p���t•.t�
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ��/� �,/
❑Geothermal(Closed Loop) OTracer giaf4V'pCord t?Jtiti:titt e- LL a J 1JL/1` - -e ( ctit+'ii,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) &10 I p e, _Seri -,1 ,) D/_, •i
4.Date well(s)abandoned:
31 Li 1 a-3 �dr* hay, .. gem z s,f _p 61-a- 4 At—
5a.Well location: IV` Well '/P lad SW, ' V' i"°' ` o ce xei"
Victo0 d.-0311 g a ad usi,,, ux1 dove -
S.Cut'r a ron� ���
Facility/Owru:rName Facility IDN(if applicable)
1
56 u 1 1y oi" p' 31 ci/23
cure of ertified We I Contractor or Well Owner Date
Physicaalddress,City,and Zip
�e- 0-1-7 a�5 a n By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: y Site diagram or additional well details:
(if well field,one lat/long is sufficient) x L� You may use the back of this page to provide additional well site details or well
D6S N — I%3-✓3' 3 r W 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-water supply
wells ONLY with the same construction/abandonment,you can.c,,brnit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Al to J ✓3 abandonment to the following:
6a.Well ID#: VV
Division of Water Resources,Information Processing Unit,
2-3 I. 1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: (ft.)
lOb,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: (in.) abandonment to the following:
/ 1 p/ Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: ! i Q (ft.) 1636 Mail Service Center,,Raleigb,NC 27699.1636
•
6e.Outer casing length(if known): IJIOc.For Water Supply&Infection Wells: In addition to sending the form to
(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): tI 0 (ft.)
•
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Co ractor Information WELL ABANDONMENT DETAILS
7_!
je�ley 7a.Number of wells being abandoned:
(Oar I y For multiple injection or non-water supply wells ONLY with the sane
Well Contractor Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form. �'
333q7b.Approximate volume of water rensaining in well(s):,t 7ii (gal.)
NC Well CoI� clot rtifi anon NumbAss"-
MI
/l/J tr io p,1�2 FOR WATER SUPPLY WELLS ONLY:
Company Name /( 7c.Type of disinfectant used:
•
2.Well Construction Permit#: N
List all applicable well permits(i.e.Cotmry,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use): •
Sealing materials used(check all that app y):
Water Supply Well: f ' � , -� Bentonite Chips or Pellets
❑Municipal/Public Neat Cement Grout 7:,
❑Agricultural `� ,.-'LL_s , !:.O D Clay
(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout Cl-Dry
MAR Grout1 5 2023❑ Drill Cuttings
❑Industrial/Commercial p)tesidential Water Supply(shared) 0 Concrete ❑Gravel
0 Specialty Grout
❑Irrigation ^-�,-"' _'l `" -:-•':�'^❑rpther(explain under 7g)
0 Bentonite Slurry-'':,.:-.V' .., . .::
o Water Supply Well: „`_.;;•-:,;
onitoring ❑Recovery provide amount of materials used:
7L For eac material )acted above,
Inje tioa Well: ]_ II
. ❑Aquifer Recharge ❑Groundwater Remediation .4 i. s, ,, Vlll JO I /! /ow4 e 4 fan
❑Aquifer Storage and Recovery OSalinity Barrier 016 —.C' Pala G►,� l�L'l�n r/ 7•b� �) �v/6y
❑Aquifer Test ❑Stormwater Drainage !!
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer ,9 / ° C7 Ai:, IA--2. -4 Lt�akh,
S�lr�lL.'',we, h�1r1/�' ,/J��/O,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 6 f of- fed fav4e, '/ /� et 5 hilt C
4.Date well(s)abandoned: V id 23 ®t.//Pt do r 5-wi Pt✓� D uYepA,j c 1-41(.4_/'
Sa.Well location: (� well 1,0, 6 L-/ r > 2 *o t GOL /6- eyrie/tie-Ai
.,
�j P s5 (� -0 3 a2� -I D tli,, 51' ;vow cod es"—
8.C rh o
Facility/Owner Name Facility IDb(if applicable) �� ���/g
*bvl _1 Nog /. �✓.� U
3
Signal ertifiell Con ctor or Well Owner Date
Physical Address,City,and Zip WGG ak,L VI, AO 6c1 D e/b By signing this form, I hereby certj5'that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
p j� You may use the back of this page to provide additional well site details or well
Ss) J N -4 r`�3� �7 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)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
�n i 1_ abandonment to the following:
6a.Well IBM �11 W �Y
/ Division of Water Resources,Information Processing Unit,
2,3 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
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
I
Division of Water Resources,Underground Injectson Control Program,
6d.Water level below ground surface: ' � 33 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
[ 37
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. 1
6E Inner casing/tubing length(if known): (ft.)
?
6g.Screen length(if known): I ( (ft.)
•
Fonts GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources • Revised August 20 t3

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
I.Well Contractor nfornia 'on: WELL ABANDONMENT DETAILS
�n < 7a.Number of wells being abandoned: I
�nt aV r 1 ' 5 e4-- For multiple injection or non-water supply wells ONLY with the some
Well Contractorr Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form. 0 /
7b.Approximate volume of water remaining in well(s): ,- �° (gal•)
NC Well Contractor rtifica on N mbar
1l1 — j &S 45 15S 02, FOR WATER SUPPLY WELLS ONLY:
Company Name /L 7c.Type of disinfectant used:_ N 4-
2.Well Construction Permit#: —
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
le,. cling materials used(check all that appl ):
Water Supply Well: '^ Bentonite Chips or Pellets
❑Municipal/Public eat Cement Grout.;_ , '' p
❑Agricultural 0 and Cement Grout - "'�•_"�' .r, •p_� �ry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Drill Cuttings
OResidential Water Supply(shared) 0 Concrete Grout MAR 1 5 2O2
❑Industrial/Commercial 0 Specialty Grout Gravel
❑Irrigation 0 Bentonite Slurr "'' ''= "' ' 3.-••,:':0,Other(explain under 7g)
No -Water Supply Well: r..•.:
onitoring ❑Recovery 7E For each material selected above,provide amount of materials used:
In etion Well: a Q Z.J �
❑Aquifer Recharge ❑Ground waterRemediation ' I 6‘5, lJ f�l '� i07 _ jo S, i',v
'�/
❑Aquifer Storage and Recovery ❑Salinity Barrier to lM S Typ a�S C-Jf:f 1 y i0&, /Q�ei 1QT•7'�/t1 Alt_
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer c1,4Le-PViaret,4 esZ f1/k do tiov, 't1. Zi.e(/'4 (;t/I ii,1i__ S4
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) at
6 I0I S ,� Ad p / !dill , n0,�,•'/Aelli �,� ctijj�,y
4.Date well(s)abandoned: 3/ W/ �p'.ttgn 1/ CAI I C s e,Stke o cei 'ey `t pc/J� t% �;(i dv+✓^-'/ "'
6G /Ad 7i' /co,Sw'#Ze, -Pad it-, rt9 Aes-L5 0r�t CO Ur~- Lvr`ilA
Sa.Well location:
���CdSS 0-0 5 x i el n 8.Certi (et)ne 4414
ficati
Facility/Owner Name Facility ID#(if applicable) /G/J
yv�L
3_46, 7
Signature of Certified Well Contractor or Well Owner Late
Physics. 1 Address-e and Zip p p �jj}
I�"IJ/Irh,U��.'e D1� �0 5 p�6 " By signing this form, 1 hereby cer[ifr that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient) -y p 2 �g You may use e back of this al page a provideils: additional well site details or well�" (� 3 N -' 'f-b j J 3S+ W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. IOa. For All Wells: Submit this form within 30 days of completion of well
'-7 abandonment to the following:
6a.Well ID#: W m
Division of Water Resources,Information Processing Unit,
•
/ 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: �� (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
`t above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) ,0 abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 1=4 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
7 10c.For Water Supply&Infection Wells: In addition to sending the form to
fie.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): I Of (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD Far Internal Use ONLY: I
This form can be used for single or multiple wells I
I.Wel ontractor nforma • n: WELL ABANDONMENT DETAILS
i
00 7a.Number of wells being abandoned: wells ONLY with the same
rac �'�
For multiple infection or non-water'Well Contractor Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form.
33� 76.Approximate volume of water remaining in well(s):p,, A) (gal.)
NC Well Contractor m ettcn Number4cs'o
Alf
d—
� r/ ` FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N
•
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
N A-
3.Well use(check well use):
7 Sealing materials,used_(check all that app ):
Water Supply Well: - 'Bentonite Chips or Pellets
❑Municipal/Public Neat Cemeni Grout_ <'„_., t..;'
❑Agricultural � � '
0 Sand Cement GrQuAt '• Dry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) IVIA 5 t1 0 Drilly Cuttings
[]Residential Water Supply(shared) 0 Concrete Grout R 1 2023
❑Industrial/Commercial 0 Specialty Grout__ ,. 0 Gravel
Mitigation i t " ;: '-1 ' " •'-.''"� t l�Other(explain under 7g)
No -Water Supply Well: 0 Bentonite Slurry , :"1,,..
onitoring ❑Recovery
7f•For each material selected above,provide amount of materials used:
Injection Well: g I JS L edt9'06111(;C171/1) 5 L4.t V✓
. ❑Aquifer Recharge ❑Groundwater Remediation �/'d] �]
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 8.1V
'1 V .1e-�j ,i 4 �Q (/i, A,t. ere, 4 eoih lti
❑Aquifer Test ❑Stormwater Drainage 0
❑Experimental Technology ❑Subsidence Control 7 ovide a brief description of the abandonment procedure: R
OGeothermal(Closed Loop) OTracer sir f D la/es kerr/ A C �) louts 1-e L,,eI/ A06,5
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) P Y 9 t`'j,.J`► ii. // 1 S,er,4 a', /f �/ 146 ,/h",
14! ,?-33 " 1i4 ) C4oi j sb✓ �'/owe/4.Datewells)abandoned:
5a.Well location' Qf PWit '" M 14')II1/l It- 4" �r W- 4 H�//4 kw/
CPc5 0--03 J a o su kt et- : +4h kb cl.' -Pal 5 X i" ,et
Facility/Owner Name Facility 1Db(if applicable)
et Ire'r'
s. rhfie
G
(,n1 vt t �3 )-3
Signet Certifild Well Contractor or Well Owner ate
Physical AddreT ?_
,City,�d Zip � G�
L)o 0.11 t-5 b gD By signing this form, 1 hereby cert that the wells) was(were)abandoned in
Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient) You may use the back of this page a provideils: additional well site details or well
3 S',-� 23 1— N—VI", 3 3l 21 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);f 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
n v 6abandonment to the following:
6a.Well ID#: �r,
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: q (ft.)
lOb.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: (in.) abandonment to the following:
/0 l Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
•
1 IOc. 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 fonts 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.)
1
6g.Screen length(if known): /� (ft.)
•
Form GW-30
North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Wel ontractor Inf rmati WELL ABANDONMENT DETAILS O
y� t 1
Corr 1t 5c.I ev ;
7a.Number of wells being abandoned:
For multiple injection or non-water, supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form.
3 33 9 7b.Approximate volume of water remaining in well(s): p d v (gal.)
NC Well% Car—/ 'on Number /J
Al— /'f/j�J--• /f��,��.,s��� FOR WATER SUPPLY WELLS ONLY:
Companyp [Name 7c.Type of disinfectant used:
•
2.Well Construction PermitH:
List all applicable well permits(i.e.Cormry,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
Ni+-
3.Well use(check well use):
Water Supply Well: t'-
e. ling materials used(check all that a_ppl )•
Neat Cement Grout-. _r; ;' Bentonite Chips or Pellets
❑Agricultural ❑MunicipaVPublic ..•::��• :
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 and Cement Grout pry Clay
0 Concrete Grout MAR 7 /1 0 Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) 2Q23 0 Gravel
0 Specialty Grout
❑on-Wate 0 Bentonite Sfti ,.t .'"' ^, ;0. ther(explain under 7g)
Non-Water Supply Will: ,,:-:.,.,.':. _-,_ ' ,...1e.1
omtoring ❑Recovery
7f.For each material sel
clad`above,provide amount of materials_ �u_se-d:
In ion Well: 25 s, .11G�-w/ Ih cLvi 2 clet3• we l
❑Aquifer Recharge ❑Groundwater Remediation ��
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 gq.0 fir i 141410, C,"0 ys-eel r lb,Po ,bee 6 eje -
❑Aquifer Test ❑Stormwater Drainage 1
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: (�
❑Geothermal(Closed Loop) ❑Tracer /t,,r ��e�$e�ei(6e t1 cloy C j �aicw/6 fA. il/ �V 6"1 Y`
❑Geothermal(Heating/Cooling Return) ❑Other•(explain under 7g) I�( et 1V Strt p e. 164p 9.e J js.Mk.. dip
_
4 141 �> (ygft%pd L dove, welt ci'rtsIC�Scrtar� f1ecLGQnt v
4.Date well(s)abandoned: 1 I�e� L(� j- ^--�, ��{� - r / �,/
5a.Well` I�catio : dot.tst- -fit (AA T V lct�S 1N' e � ,4 i_
Nees) 0--03� 140 . (otiw� cows w,i coaGY4-
8.Certific on:
Facility/Owner Name Facility MN(if applicable) p r.,
6o vY► �1 l/. Ate, *el
and Ziptt'ire of Certi ed Well Con ctor or Well Owner Date
Physical Ad ress,City,
(A)U 011 oZ `J 0 cl 0 b By signing this form, I hereby certq that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient) 11 You may use the back of this al page a provideils: additional well site details or well
SlW J S N g; 33�ST W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTIONN 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 con submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: //�/] abandonment to the following:
' '
Division of Water Resources,Information Processing Unit,
�/� 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 1 (ft•)
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: o (in.) abandonment to the following:
i
•-7 �f Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: ✓ ' `7(ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
•
�,/�.`� �t`^ 10c.For Water Supply&Injection Wells: In addition to sending the form to
of this form
6e.Outer casing length(if known): V r►t (ft.) completionthe s(es)of well toto the co ve, also submit one copy ny health departmenttn 30 days of
of the county
r ed where abandoned.
6f.Inner casing/tubing length(if known):J!/ (ft.)
6g.Screen length(if known): 511 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well tractor Info matio WELL ABANDONMENT DETAILS
i
L it 'C tQ 7a.Number of wells being abandoned: . �"
10
�� , For multiple injection or non-water supply wells ONLY with the same
Well ontraUor Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form.
3.J 76.Approximate volume of water remaining in well(s): id o f V 17 <gaL)
NC Well ciontrastor CertiB.tali n Number
•
/I ,( —
e _JLf�L 55o FOR WATER SUPPLY WELLS ONLY:
Company Name �� 7c.Type of disinfectant used:
•
2.Well Construction Permit#: / V
i If-
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.S sling materials died(check all-that,apply):,
Water Supply Well: Neat Cement Grout <.; ❑:Bentonite Chips or Pellets
❑Municipal/Public , ..,._ ,,
❑Agricultural ❑D Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 and Cement Grout MAR 15 , .�^ ry y
❑industrial/Commercial []Residential Water Supply(shared)
0 Concrete Grout .Drill Cuttings
0 Specialty Grout Irt;_;;;_.,,• :1 t:,•. . ❑Gravel
❑Irrigation r_ r r.-`
0 Bentonite Slurry C•',',';;);';..,-2,:,,;O Otlie'r(explain under 7g)
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
7f.For each material sel cted above,provide amount of 4tijere/
erials used: Div:
f 1
❑Aquifer Recharge groundwater Remediation ,(�CIaI s; �G3� /2- Lt/(/,
❑Aquifer Storage and Recovery OSalinity Barrier -yy I ✓�Z ��1•T(a'i C S?�G
❑Aquifer Test ❑Stormwater Drainage I J- f 65,
❑Experimental Technology ❑Subsidence Control 7f)j,..
Provide a rief description o the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer i/ W 1 ,4'❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /111l/ !!Air n ` / L eipt^ t d`E*t le- tf,e//�L a
4.Date well(s)abandoned:
3/"1 !� 4,�''is// t./w4r 41/4 by gels t Y- /1-6,
p h0
Sa.Well 1 cation: h' ✓/ci t/d 4/9/y ra r lelur t`s - Ce 1�✓1 4
S.Certifi a on: Ce U��1 RrL�i 9 G�►
Facility/Owner Name Facility[DP(if applicable) /" //�
s6o1 �i bh ?t (a/&Y ,iv C C+ 3
and Zip ' ature of Ce ed Well Contractor or Well Owner ate
Physical?d�dr�s,City,
(,( 0tre cDi 1 Ag5 �Scl D By signing this form, /hereby certy that the well(s) was(were)abandoned in
VV vv r ' Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one let/long is sufficient) 2 You may use the back of this page to provide additional well site details or well
�s /.� S r N — glJ 5W 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 10a. For All Wells Submit this form within 30 days of completion of well
wells ONLY with the same construction/abandonment,you can submit one form.
/ abandonment to the following:
6a.Well ID#:4S_1-1tint r1-("10
Division of Water Resources,Information Processing Unit,
I 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 l0a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: in.) abandonment to the following:
/
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: /52 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
/
lflc.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. I
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 Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Coitatractor Informati WELL ABANDONMENT DETAILS
5� 7a.Number of wells being abandoned:' I a
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.
7b.Approximate volume of water remaining in well(s): /2® (gal.)
NC Well Contractor rtification Number�f
0411'1)
/C11, �{ b(" FOR WATER SUPPLY WELLS ONLY:
Company Name �jC 7711 7c.Type of disinfectant used: A1/E_____
2.Well Construction Permit#: A*
List all applicable well permits(i.e.Conroy,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that apply):
Water Supply Well: _ 0 Bentonite Chipsor Pellets
❑Munici aVPublic Neat Cement Grout', :-� ,--- —
❑A icultural P
❑Residential Water Supply(single) Sand Cement Grout '•=}°%..:'{, ', ❑:DryClay
❑Geothermal(Heating/Cooling Supply) 0 Drill Cuttings
I7Residential Water Supply(shared) 0 Concrete Grout 1g
❑Industrial/Commercial MAR � ��2�Gravel
0 Specialty Grout
['Irrigation 0 Other(explain under 7g)
Non-Water Supply Well: 0 Bentonite Slurry;',=.;; ;�;;-,• .�-
❑Recovery '...�� �:� iJ;-"(
❑Monitoring 7f.For each material selected`above;provide amount of materials used:
Injection Well: 0
❑Aquifer Recharge ,r Groundwater Remediation `r t0 loll, w h-" ,�i a, 0 taere,.44, -7,
❑Aquifer Storage and Recovery ❑Salinity Barrier -/ f loll
t-�®� n� C
❑Aquifer Test ❑Stormwater Drainage �T'( (� /
❑Experimental Technology ❑Subsidence Control /7 .Prov e a brief description of the abandonment procedure:j
❑Geothermal(Closed Loop) ❑Tracer Or 1 gy pet, MIN,41. tZk, Cj ail/v ht;r ' td,,,i,4-
0Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 0"`"7 ��s � 1�L , /),�6,e OBY 1,let J 1l A
abandoned: 1Cig- t& ' N•- I v h U Y` � IAA ..--
op 6I`U it tier
4.Date well(s) 1
5a.Well location: /led al&li i 4.$-t 2, ,t rJ f'ttbitt/,e F 4s1-44`0 A Gd)6g/7 wit.
Wq 8.Cerhfiea j
Facility/Owner Name Facility ID#(if applicable)5(20/ II/VA gi Pelyii W i li vdi 164
Sig'nat re of CpCptUufied Wel Contractor or Well Owner Date
Physical Addres,City,and Zip i e oil m 5 'ci 0 p
o By signing this form, I hereby cen fy that the well(s)was(were)abandoned in
V ! Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient) t- You may use e back of thisapage a provideils: additional well site details or well
ia� I I Sfs'� N �, 3��J W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
4$ '1 2 fir/' 4-5 2.3 abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
3 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: J (fl.)
106.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: (in.) abandonment to the following:
I
�1 Z. Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
•
3 3/
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.)
9
6g.Screen length(if known): (ft.)
•
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor nfor on:o WELL ABANDONMENT DETAILS
ii
6611 S e,'' 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.
3���' 7b.Approximate volume of water remaining in well(s): P° r---(gal.)
NC Well ontrac r fits on Num
/44 W_��a'�'L 5'0�, FOR WATER SUPPLY WELLS ONLY: i ilk.
Company Name T' J 7c.Type of disinfectant used: D�'
2.Well Construction Permit#: Ar
List all applicable well permits(i.e.Couto',State,Variance,Injection,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well:
7e. sling materialsiused(check all,that.appl ):
❑MunicipalRublic eat Cement Grout Bntonite Chips
or Pellets
❑Agricultural ❑ThyClay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 and Cement Grout 0 Concrete Grout MAR 1 5 2O
2p Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) ❑Gravel
0 Specialty Grout iri;,_ n ,.:' ;-''-- ,r, •;
❑ -Water
'0'Other(explain g
No -Water Supply Well: 0 Bentonite Slurry L. , ( P n under 7 )
No
❑Recovery
7f.For each material sel cted above,provide amount of materials used:
IAquiooWell: GS 1($ /e J_ l y) j
. ❑Aquifer Recharge ❑Groundwater Remediation 1 V tj {�j yQ-o 71 111��� (Ay), 3'S �dls• tt-a/may
� 1 �
❑Aquifer Storage and Recovery ❑Salinity Barrier 15 1 bS,-rife 1/°i /t'r/ Cent�iiL IS Il S, /'a Lvdie `j. ?h
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
i 4
❑Geothermal(Closed Loop) OTracer LajA6L p ire/ 4, 94/`�(�.si13 1i i,*- %.- / # L:�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ikiit led. 1/ a. sus / j ay>j' ,,/jsi -� j 1-5
4.Date well(s)abandoned: 3/ `/ 3 16 dtp.i'rl01+°A- 1 lt4i/ t- s✓/ IA ,usc44'J /t ect C 4*-94
5a.Welllocation: 6t117L"it- . "It: I"t'b/I9 lr L L'44' 6`4 ft �Git Swket,
V'C1P55 0-•03 1 q 0 4 pi, It,. 2' ' sl-cei ut�tiah }� a,t;//1 1,0 )11,
Facility/Owner Na o- Facility ICU(if applicable)
8.Cent shoo:
5 (�v �4� G, A -1 3 Z3
) /• U Signature of(Certified Well ontractor or Well Owner ate
Physical Address,Ci and Zip LA)
(,
A )tlf4 oii a6J g b p b By signing this form, I hereby cert that the well(s)was(were)abandoned in
t/ F Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one'at/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
3�i l v J �� N �, 3 J W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can.submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
1-.C 0 C- ( abandonment to the following:
6a.Well ID#:_ J
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699.1617
66.Total well depth: 3 S-1) (ft.)
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: (in.) abandonment to the following:
j [�l Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: / �) 7 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
{ 51 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.)
i
6g.Screen length(if known): ® (ft.)
•
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well C tractor/Inform - n: WELL ABANDONMENT DETAILS
�/y (!�� SC4e��
7a.Number of wells being abandoned:
r For multiple injection or non-water I supply wells ONLY with the same
Well Contractor Nameg(or well owner personally abandoning well on his/her property) consmrction/abandonntent,you can submit one form.
CoJ l 7b.Approximate volume of water remaining in well(s): NU/L't - (gal.)
NC Well Contractor rti5cation Number,�
m/ iC ' 72-4SS(0C FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
•
2.Well Construction Permit il: IV
I)---
List all applicable well permits(i.e.County,State,Variance,Injection,etc.);jknown 7d.Amount of disinfectant used:
3.Well use(check well use):
e ealing materials used(check all that a p1 )•
Water Supply Well: _. Neat Cement Grout__ __ Bentonite Chips or Pellets
❑Agricultural ❑Municipal/Public �� _• 1 ❑ ry Clay
0 Sand Cement Groutt..;,__.'-..,•:
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0Drill Cuttings
OResidential Water Supply(shared) 0 Concrete Grout 1 5g
❑Industrial/Commercial 0 Specialty Grout MAR ZQZ3 Gravel
❑Irrigation 0 Bentonite Slurry: ❑Other(explain under 7g)
o Water Supply Well: __;,.:.,•.:,: t :'t,:,_:, ...:.1
nitoring ❑Recovery pr'
sssss''"'��� 7f.For each material selected'ebove,provide amount of materials used:
Injection Aquife Well: a J /)S L CIO A eerie-/e1 11
. ❑Aquifer Recharge ❑Groundwater Remediation J f! nJ/'c �' IA
❑Aquifer Storage and Recovery ❑Salinity Barrier g'i /5, '1 pez k /t tt 2.0 9a . (,t.o
❑Aquifer Test ❑Stormwater Drainage 0 /9
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief desert tion��of tl e a Won € t procedure: �j� �/,�
OGeothermal(Closed Loop) ❑Tracer r S D W e, D jy 61411. 14 u P., h- ga4 't'
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 7g) ✓ `� p4 D e� y/ ^ n!_
,j et g /* s vr� 1 l�> #/' _/-i-- 4-101 ,--
3/ JZ3 n�
Pu��� d0.� U�owl, j-ls. 4�// SLs-vr� ,PG�`re,/ y1.e
4.Date well(s)abandoned: / / f �3 �J ��
5a.Well location: ClI' ��� �n4 t�L I1 / t r�
VICPC3 q ak ��t� � Ce/tit:/ete PI d it 1 -�(� yr z. ,�G __tr,ay,
d 3� � I B.'Certi cat o � bf �,,yh.pa
244
Facility/Owner Name Facility IDl1(ifapplicable) e
5GD1 1 l214'ghl AU- e1, ,/ . lY 316123
Physical d ress,Cs ,and Zip Sigma of Certifier!Well Co tractor or Well Owner Date
/V,l
O Q b 1"1 .a 5 �'I n b By signing this form, !hereby certi that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance cwith of this record has been provided toC.0100 or 2C o0 Well t well owner.
Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient) �} You may use the back of this page to provide additional well site details or well
` (� 7 ��� N "��, : j��'J�f' 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 10a. For All Wells: Submit this form within 30 days of completion of well
wells ONLY with the sate construction/abandonment,you con submit one form.
5'o —e� - J abandonment to the following:
6a.Well IDN:_ I
Division of Water Resources,Information Processing Unit,
�6b.Total well depth: 3 51 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Iniection Wells: In addition to sending the form to the address in 10a
N above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
e� 1 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: I`�r/ Z (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
I 1Oc. 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.)
go 7
6g.Screen length(if known): (ft.)
•
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Wel ontractor I forma ' WELL ABANDONMENT DETAILS
G�Of j s 0✓ 7a.Number of wells being abandoned:
For multiple injection or non-water 'supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can s-ubmit one form.
-333 ` 76.Approximate volume of water remaining in well(s): P D'v —(gal.)
NC Well Contractor Celli cation Nu bet
/)A IV - � � 4- coi, FOR WATER SUPPLY WELLS ONLY:
Company Name tt��" 7c.Type of disinfectant used: 10 4---
•
2.Well Construction Permit#:
List oil applicable well permits(i.e.Carmry,State,Variance,Injection,etc)if known 411 ill''.--
7d.Amount of disinfectant used:
3.Well use(check well use):
7e. sling materials used(cheek all that'a ply t
Water Supply Well: entonite Chipsor Pellets
❑Agricultural
❑Municipal/Public Neat Cement GFouf _ - : . •
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout=-`•• •'�r_. 0 Dry Clay
0 Concrete Grout p n 0 Drill Cuttings
❑Industrial/Commercial O)tesidential Water Supply(shared) MAR 1 5 2023 0 Gravel
0 Specialty Grout
❑on-Waon 0 Bentonite Slurry;;.•;:. ;, ❑Other(explain under 7g)
No -Water Supply Well: _�;.. � •.� •-%
onitoring ❑Recovery -.
7f.For each material selected above,provide amount of materials used:
In coon Well: t /
. ❑Aquifer Recharge ❑Groundwater Remediation 'V ,'/4� , j p, �/t CIO ) 2.5~�fC�1 e
❑Aquifer Storage and Recovery ❑Salinity Barrier Io j, ,' Aphid orif ///, .��•Zs 1n �,r
❑Aquifer Test ❑Stormwater Drainage 1 b l
❑Subsidence Control 7g.Provide a brief description of the andonment procedure:
❑Experimental Technology
gY //r �
❑Geothermal(Closed Loop) OTracer /:CUf All t�v b" l {gJ Z A le%t/L. K it-di
_❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) i-, „ ,h-S 1 U/" led 1("de. 1/5ele a
a 3il I)-3 Q,ly/S i •/�' C//�7j t:4. top-eu i's $t✓
4.Date well(s)abandoned: "Y 7 nn/
5a.Wil 1"ppcatio : D1)We/ fl t/ fien 'e4 th14�1 /; 1�I/ IA y,Z-
1 N G'��� V tie
©—Q 3 o` I I U / U✓ 6;1 ® J ✓4k- ` ec, /" Co/7i:WV',
yV__ 8.Certifie i : �{i�s'/yu3 �n
Facility/Owner Name Facility ION(if applicable) CO-yiy
Signature of Certified Well Contractor or Well Owner 1)a e
Physic Addres ,City,and Zip Unn �i
0k 011 p�'5 Q -1 b O By signing this form, 1 hereby cert that the well(s)was(were)abandoned in
���///VVV Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one Iadlong is sufficient) _ You may use the back of this al page a provideils: additional well site details or well
e�SS�� N fig, 333 S 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 sam construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
5.0 B- 01•L� abandonment to the following:
6a.Well ID#: / (� W
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 3
r� 1617 Mail Service Center,Raleigh,NC 27699-1617
(ft•)
10b,For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: ( (in.) abandonment to the following:
�/ Division of Water Resources,Underground Injection Control Program,
{
6d.Water level below ground surface: I J• 7 CA (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
•
/ IOc. For Water Supply&Iniection 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. 1
6f.Inner casing/tubing length(if known): (ft.) 1
6g.Screen length(if known): 04 (ft.)
•
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I,
1.Well ntractor4-.
for Ion WELL ABANDONMENT DETAILS ;
A��� •, 7e.Number of wells being abandoned:' I
111 e For multiple injection or non-water supply wells ONLY with the same
Well Contra�ctor?l}Tame(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit oneform. p ,a l r�
•, ) J J� 76.Approximate volume of water remaining in well(s): 1�/0'°r(� (gal.)
NC Well Contractor Certiticati n Numb
in J1 4 t� , ) f- Jot FOR WATER SUPPLY WELLS ONLY: /1-
Company Name �'� 777��'�" 7c.Type of disinfectant used: /V 'Y
2.Well Construction Permit#:
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.)iflawwn 7d.Amount of disinfectant used:
NA--
3.Well use(check well use):
7e.Sealing materials used(check all that apply):
Water Supply Well: eat Cement Groutentonite Chips or Pellets
❑Agricultural ❑Municipal/Public ;r d-❑Dry Clay
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 and Cement Grout j
0 Concrete Grout , � ,�"��- ❑ Drill Cuttings
❑Industrial/Commercial oResidential Water Supply(shared) t1 0 Drill
0 Specialty Grout;MAR 1 5 2023
avel
❑on-Waon 0 Bentonite Slurry 0 Other(explain under 7g)
No -Water Supply Well:
❑Recovery :�i,�•,,,:..,:.::! :
Monitoring
7f.For each materiarse acted above,provide amount of materials used:�
I quife Well: /(S, <_ � 2.V Is, 1 —
. ❑Aquifer Recharge ❑Groundwater Remediation �(5) €'J v /1/ ��
❑Aquifer Storage and Recovery OSalinity Barrier "Nate �� ly ! c tt, ,��+,� ize
X--
❑Aquifer Test ❑Stormwater Drainage
Fi �,ri cr
❑Experimental Technology
❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
,
OGeothermal(Closed Loop) ❑Tracer Z.1-- S"Nr e p ref eft / C4'11 e/ixeJ-fee 144(Av GO
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) 51
U if ft 1aill (q/�� mar? /y4r/d if, A�_ir) �•��1�6,`
) I}3 f°urgi A.ed— c ent44- do 1L1—?' tve-0 G�.ile.-�✓v'LT/
4.Date well(s)abandoned: LL�" / [ pp�� !� /- /' /
5a.Well location: VI 7� C' S al T R' tab, /w koil frA� /- t'd efi
o-• o3a 190 -flush 4 '
8. erti stet
Facility/Owner Name Facility IDtI(if applicable) ^, ,/� y �� 7
Signat560 1 Vocal Meihdtv,t, u rtified`Well Contractor or Well Owner Date
Physical Addr s,City,and Zip V)a e- 01-1 gq "I �0 By signing this form, /hereby certify that the well(s) was(were)abandoned in
�S
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details
(if well field,one lat/long is sufficient) You may use the back of this page to provide additional well site details or well
��j����� N'� l "' 33 3S 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 sam nstruction'abandomnent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
r o c- 6/_1,3 abandonment to the following:
6a.Well ID#: c�{�cj t1J
Division of Water Resources,Information Processing Unit,
`` 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: �J� (ft.)
lob.For Injection Wells: In addition to sending the form to the address in 10a
Vi above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: I �1 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
I 1 IOc. For Water Supply&Injection Wells: In addition to sending the form to
his form
n 30 days of
6e.Outer casing length(if known): (ft') completions of weloabandonment to the county health the adres(es) abve, also subit one copy of t department tof the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): POI
(ft.)
•
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well ontractor Infor ton: WELL ABANDONMENT DETAILS
(jt"t f /5[ �s' 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
333
,)9 construction/abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor rtification Numb
ill 1 _ j 1�1 ,.,1,Lic-Numbs'.
., FOR WATER SUPPLY WELLS ONLY: /�/ y�
Company Name 7 7 ` l ' 7c.Type of disinfectant used: /`r '/
2.Well Construction Permit#: / ' 11
List all applicable well permits(i.e.Cmrnry,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well:
7e.Sealing materials used(check all that appl ):
,�-- --::❑Agricultural P c - __
❑Munici al/PubliNeat Cement Grout_ , :
- ,B_entonite Chips or Pellets
_, ,. �
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ---- ._O` ry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout MAR 1 C 023❑ Drill Cuttings
❑Irrigation 0 Specialty Grout L 0 Gravel
Non-Water Supply Well: 0 Bentonite Slu'rry�- : _ :1 -_ -,CI (explain under 7g)
onitoring ❑Recovery
I ' etion Well: 7f•For each mates I selec ed above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation T-14 t eAl.tt.f idgt%9e/5 I`dI
❑Aquifer Storage and Recovery ❑Salinity Barrier g-+r -rr- �l ,/►L�Irlied awed- ix pb,ifrier-*/ J
❑Aquifer Test ❑Stormwater Drainage r7 (t•� �2(�/ S /��
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the
f abandonment procedure": J
❑Geothermal(Closed Loop) ❑Tracer S�,L(�t 'e-f cured 4 e/t�•JJ/'L d o Aloft Pie ti-df (?Bill /l-
❑Geothermal(Heating/Cooling Return) [Other(explain under 7g) _ 1 1/11f 0- 5-I et L So ft�, r fµ9 1 7 rfir
]G2-, �J�iS(�s'�e. �ilftr'e'.�
4.Date well(s)abandoned: 2)20I 3 t,•2a L C.e y1i24L I :mil Ltc1 j j4 tl r 1 N' Is '4 l9Zl
5a.Well I pcc_aation: ill-lte, a� e�</oil-- iLL tT li -3141t c f,,G ue---Grl�- CC1Lcri
a r% Louty P' Ct�,L(J UX'P j,_ ZN fa l /J,j 4w j r 4 IS,
Facility/Owner Name
Facility IDi/(if applicable)cTh 8•Certific ion:
.jp I i lid, ,e-ie4,A, /V 6. 21
24` �3
Physical Address,City,and Zip pQ, Si of Certified Well Contractor or Well Owner Date
fO-ke L'Z Zay"12��Z 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:
� / :Pi
You may use the back of this page to provide additional well site details or well
3J t t�19 j �� N D s !�'11 1 �� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandomnent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
id-g abandonment to the following: •
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
Q' 1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: tJ r (ft.)
lOb• For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
I Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
3 ( 10c. For Water Supply&Iniection 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): SC C/) (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well ontractor nforma an: WELL ABANDONMENT DETAILS
1
Well
/. 5 cker 7a.Number of wells being abandoned:i
Well CCrtracr Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
✓d el consnuction'abandonment,you can submit one form.
I
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contract%j /4
cation Number0 L 455 f„ FOR WATER SUPPLY WELLS ONLY:
An
Company Name 7c.Type of disinfectant used: v
2.Well Construction Permit#: P
List all applicable well permits(i.e.Cmtnry,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used: 1111
3.Well use(check well use):
• 7e.Sealing materials used;(check all tliat a pl ):b•TM.
❑Agricultural ❑MunicipaUPublic
Water Supply Well: '.'.=�,1.;._.'
p Neat Cement Grout --' Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout MAR 1 5 Z,y)pry Clay
❑Industrial/Commercial OResidential Water Supply(shared)
0 Concrete Grout ` rill Cuttings
0 Specialty Grout 1Ci+, ='l
+_':,;' .7[7.Gravel,.i
❑Irrigation �,;.,. ,..,
Non-Water Supply Well:
❑ Bentonite Slurry " "`-'; -;;_❑Other(explain under 7g)
,onitoring ❑Recovery
7f.For each material selecte/above,provide amount of materials used:
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation r 014 f, e e. oitj!t t(1 40.s 7,c 6 4-1...3 Ins-d-V4'
❑Aquifer Storage and Recovery ❑Salinity Barrier I O i Lj S, e Pt� rltd Gttr9tplJr' i�1�, 4 kafir P, »
❑Aquifer Test ❑Stormwater Drainage t7 y`1 /
❑Experimental Technology ❑Subsidence Control 7 .Provide a brief description of the abandonment procedure:❑Geothermal(Closed Loop) OTracer /Clird Li.4nl/'F t44.) t�Ci.-tt • /.c.•C//it, Id el '. liwksi./ L^
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /
Z 1/grebe' /Le 9 eW Jz. 5W 0-,Pc tit //)[6(/ Ge td� G,r��L'c'.ui
4.Date well(s)abandoned: 24 2-0) ? J j'�/i 47144 Lyn f& Lg-e/ Y /a s"fj't"r ce, A�/ Ly
Sa.Well to ation: 5(I a r i11,0 tti1:L t�'�`�Jr Lit evil rim
i 66�..1 t--1
t! a, e up 1,tiviii _ _
Facility ID/I(if applicable) 8.Certificatio
Facility/Owner Name /�
etei:,4 /lite-, 41 6:-- z/24/2_3
a J and Zip Signs f Certified Well Contractor or Well Owner Date
Physical
WO i/��
e I'7 le to 2y 92 By signing this form, I hereby cert)'that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
r c N 0: 'r 5'g a e' O You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment.you can.submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
h). 3 4- abandonment to the following:
I Division of Water Resources,Information Processing Unit,
fe- 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: > I (ft)
106.For Injection Wells: In addition to sending the form la the address in 10a
Qabove,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
/ `I.0 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
' 1 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): J Q (ft.) i
•
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Wel ontractor Inform n: WELL ABANDONMENT DETAILS
� Ct UU , 5 c 7a.Number of wells being abandonede P
Well C ntractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water I supply wells ONLY with the sane
3 (. construction'abandonment,you can submit one form.
S7b.Approximate volume of water remaining in well(s): -a (gal)
NC Well Contractor/f `tcation Number
/7)O rd- �1— A - , i VC, FOR WATER SUPPLY WELLS ONLY::
Company Name / 7c.Type of disinfectant used: /"
il-
2.Well Construction Permit#: ��
List all applicable well permits(i.e.Cmrnry,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use): •
Water Supply Well: 7e,Sealing materials used(check all that apply):
❑Agricultural ❑Munici al/Public p Neat Cement Grotir . , - ;;, enton�. ite Chips or Pellets
_ ` }`
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) 0 Sand Cement Grout '" '- -''is. 'OrDry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout MAR 1 5 Zan❑ Drill Cuttings
❑Irrigation
0 Specialty Grout Gravel
A .
No,-Water Supply Well: 0 Bentonite Slurry+fc-,:.-:.::::f ?;_- ,❑.Other(explain under 7g)
onitoring ❑Recovery �'% t=
Injection Well: 7f.For each material selected above,provide amount of materials used:
. ❑Aquifer Recharge ❑Groundwater Remediation Lc 11.5. ge Jtt`l•d.. (;�i` 5 Z's-c%�S, LCt ?"—
❑Aquifer Storage and Recovery ❑Salinity Barrier l0' -rip� Gl
4,11- A c eit. I_ 1 L Au.,"p f' A C�;1, (}/7 �
❑Aquifer Test ❑Stormwater Drainage 1 � 1
❑Experimental Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:'J / y�
❑Geothermal(Closed Loop) OTracer e0 1 ed bedntlS c/o dowel- ���I 4D i.l-Ellin. idC('`14-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) r / /
t ) I o11� S ttiA t'. kCid 1� c45. sei��taifel ri ce,teiL.
c 8 ` / 'e,'c!`v►l�e.. c ¢ ct
4.Date well(s)abandoned: �1 i --3
COtW D' G9 rd 1 1 ty lr 1 g & llt
/� `. et vee iv.. coA.cie
sa. ,`1 cation: 51.�'�,ol;e, 4Ild� le�l- owl,.,�-
ek e- (�Wi r 8.Certific ton:
Facility/Owner Name Facility ID#(if applicable)
il'A(•V/id; Pielyi AX 6- ti.41 /f/A-Z -2-4 ntiz 3
Physical Addres,City,and Zip Si na re of Cectified Well Contractor or Well Owner Date
Oka (1 �±q VO4"1 c'`1 IZ By signing this form, I hereby cerlh*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) ¢j 9.Site diagram or additional well details:
3-ct 1 6✓r 'r/Jo N Q'i .g o elf- You may use the back of this page to provide additional well site details or well
W abandonment details. You may
also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment.you can one form. 10a. For All Wells: Submit this form within 30 days of completion of well
1y) —3 abandonment to the following:
6a.Well ID#:
l Division of Water Resources,Information Processing Unit,
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
II
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: I p (ft.) Division of Water Resources,Underground Injection Control Program,
L ' 1636 Mail Service Center,Raleigh,NC 27699.1636 •
I
Ilk. For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): 1.5' (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): —J (ft.)
/
6g.Screen length(if known): 1 a (ft.)
Form GW-30 . North Carolina Department of Environment and Natural Resources—Division of Water Resource Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well ntractor for i nn: I WELL ABANDONMENT DETAILS
>"1/''L,/ 5u Lei— 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
je1 construction/abandonment,you can submit orie form.
7b.Approximate volume of water remaining in well(s): (gal)
NC Well nt cc r Certi atio Numbe
ffpibL'" .SSvG FOR WATER SUPPLY WELLS ONLY: 4/4__
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Ai/—
List all applicable well permits(i.e.Canny,Stare,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that appl ):
❑Agricultural P
❑Munici al/Public Neat Cement Grout -� -- -- - --Bentonite Chips or Pellets
i�..• --v•; -_
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout._r'--..' _ ,,..,O.Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout MAR 1 2023 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
No -Water Supply Well: 0 Bentonite Slurry,...__ .•; ❑ Other(explain 7g)
. .,. .� ( p nunder
onitoring ❑Recovery
No
Well: 7f.For each material elected above,provide amount of materials
used:
❑Aquifer Recharge ❑Groundwater Remediation 7-/ . 4 e j, c,chaos i c eeff fie% t--
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 I y:,,f G n ere J/Lem' is /6.. Aq..,14- 91
❑Aquifer Test ❑Stormwater Drainage I[IS tL-/ [
❑Experimental Technology ❑Subsidence Control 7 .Provide a brief descrip ion of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer �t ,/i )e„ $t�� ,G',fig cjoun -1{ (,, ki,i:lick a,i
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) I f (s y r v L�`� I `fit R'-f et(e� /E t+y�
oe-
j l ��p �rc�61 ,v,9, h �- CCU.s iJf1&e, s .;-t=ek
4.Date well(s)abandoned: q
5a. ell loc ion: /) 4 0,41 et RuY lti'kot447��L,' t:'O Vi'//I�� all K cm.ce,41, cat--
,
Facility/Owner Name
&rili iDit(if applicable) B•Certify tion:
-;.4
5"1- (or�wf Ai/ P(elt1 AC, a�z,f 2_3
Si of rtified We Contractor or Well Owner Date
Physical ddres,City,and Zip t�
1�u 4 RU `, Bysigning thisform, !herebycertr 'that the well(s)was(were).abandoned in
�,�� g g h ( )
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 Iat/long is sufficient) 9.Site diagram or additional well details:
� }/ p You may use the back of this page to provide additional well site details or well
V),3531) N Q1 '�% C t=V�° W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment.you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
!/Il /lti " L p� abandonment to the following:
6a.Well ID#: (�i w 7
Division of Water Resources,Information Processing Unit,
/3
ft. 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: ( )
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)ffil abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 1'9 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636 •
S
,
,t 10c. For Water Supply&Iniection 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.)
1
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Wel Contractor nfor tion•. WELL ABANDONMENT DETAILS I
£O(y
-sL t✓v' 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-warer supply wells ONLY with the same
construction/abandonment,you can submit one form.
76.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor�rti�cation Number
44 t ,Il't,l� � ..//STa- FOR WATER SUPPLY WELLS ONLY: .
/1)4—
Company Name lj1 T f 7c.Type of disinfectant used:
2.Well Construction Permit II: N+--
List all applicable well permits(i.e.Counry,Stare,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that op ly):
❑Agricultural ❑Municipal/PublicNeat Cement Grout 'A Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ,❑`Sand CemenfGrout RP - --.1..0 Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout - " 1.0 Drill Cuttings
❑Irrigation 0 SpecialtyGroutMAR 1 5 2023 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
onitoring ❑Recovery
In ction Well: 7L For each m4,,h4?tE..
ake ected, ove;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /0 A5' '-s' r Z.v 9i s, P-C
❑Aquifer Storage and Recovery ❑Salinity Barrier p 45,Thp`i- Portiaeitet ,&" /j, rA l e O `'
❑Aquifer Test ❑Stormwater Drainage 0
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief descry Lion of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Prl� a eiiRe 'f-/ do deco- Tu 4,4[ Tel tek—�
L OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) 9
/9b i /Cat/ Ida,ex g rAte Any-d rt_di- eYan /
4.Date well(s)abandoned: _Z/ �/ 23 AtItt_. I' well. 411 6 ,, l l ty /y `al/5.t'4 e, 14 Lwr[
QL� t I f /'
5a. ell locution: U ftfrS�it,6fuot1L Lf`v'y s 4-& ctAri elc f t"' c✓cc' 1h & _�-
�u' B.Certific ion: ��C / //r ,�n`
4.5
Facility/Owner Napre Facility ID#(if applicable)
c (fir/Rid l l lug Ai( 2zf/z..3
Physical Addr ssand Zip G Si re of rtified W II Contractor or Well Owner Date
Vyl nv.11 't 'i L By signing this form, !hereby certIfi'that the well(s)was(were).abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
/ y You may use the back of this page to provide additional well site details or well
S r rJ q ►Vj p t� ��� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)If available. For multiple injection or non-water supply
wells ONLY with the same constnrction/abandonment,you can.submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
M�A :.5 abandonment to the following:
6e.Well ID#: /�
I Division of Water Resources,Information Processing Unit,
�+ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: l"
11 10b. For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: i i (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636 •
2._la IOc. For Water Supply&Iniection 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.)
I6g.Screen length(if known): 0 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resource i Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells ,
1.We) ntractor Info tion: WELL ABANDONMENT DETAILS
s
�Ly J sae,- WELL
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
331 construction/abandonment,you can submit oneI form.
-fr76.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certi cado Number
f/J i I iC Sip( FOR WATER SUPPLY WELLS ONLY:
Company Name 6 lJ/C'''��("'777�� 7c.Type of disinfectant used: IA
2.Well Construction Permit#: Ain-
List
all applicable well permits(i.e.Counry,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e. eating materials used(check all that a pl ):
❑Munici al/Public .Neat Cement Grout - --,-.-; entonite Chips or Pellets
❑Agricultural P Ir.
0 Sand Cement Grotit __,`':,y i�_, 1,' i,, ;Dry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 5 n
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout MAR 1 2l'23 0 Drill Cuttings
0 Specialty Grout ❑ Gravel
Non-Water- on Supply Well: 0 Bentonite Slurry._ i^1
❑I - _ ._p,Other(explain under 7g)
; _,; ,,. ,_. ... .,+ •.,...
vlonitoring ❑Recovery :
Injection Well: 7f.For each matey al se ec(ed�iia,e,provide amounto of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 145. &4?.,v�e I e aws I l�, ,U Leo -® f5eVenik
❑Aquifer Storage and Recovery ❑Salinity Barrier to I ryte j all ti,d 1 e37i t
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Ca t;(�-yv f.s.,i '
sf'L O �'jer t 1a't'w / &_. Aare) b,,dese a c.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ll[[ r
�5Joc kit Jv5 / is /• s7.t
4.Date well(s)abandoned: �e 2.D( 7-33 "lieL Gcp.-eAJ- vp I"t i-CI4( -,j(I1✓l' 3--IA/ l" i led
5a.�ell
loc lion: /7 �
cfprei-ft-ofretiliA,ow
�� e `^ L4111 8.Certific• .n:
Facility/Owner Name Facility!DI/(if applicable)
5 -7.'2 0 .6479/ &di Foleiqk Ai, C, ,,, ii.441 C--:44---% 2-1 Zi/2.-S
Physical Address,City,and Zip :••Si of Certified Well Contractor or Well Owner Date
T e V ; I92/byAZt,_I fr 2 By signing this form, !hereby certj'that the well(s)was(were).abandoned in
County LL 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:
' q You may use the back of this page to provide additional well site details or well
,ra ((ji,� 6, N )jr � f% V W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple Injection or non-water supply
wells ONLY with the same construction/abandonment,you can.submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
fI) W-6 abandonment to the following:
6a.Well ID#: V``�" t7
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: q'� (ft.)(
10b.For Injection Wells: In addition to sending the form to the address in 10a
/ I�` b�� above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: t (in.) abandonment to the following:
t '1 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636 •
2.54 10c. For Water Suaaly&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 Resources Revised August 2013
I

WELL ABANDONMENT RECORD For Internal Use ONLY:This form can be used for single or multiple wells I
1.Well C�oactor In rmatio WELL ABANDONMENT DETAILS
/ Giiw� // : �'),�f,. ,€i' 7a.Number of wells being abandoned:
Well Contractorttra 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.
�� 713`Approximate volume of wafer remaining in well(s): -a (gal.)
NC Well Contractor Ce fication Number /,
fi/�'l f` (slat! .1L5 fPL FOR WATER SUPPLY WELLS ONLY:
Company Name TTjj�r((( 71 �l 7c.Type of disinfectant used: Aik
•
2.Well Construction Permit tl: A 1
List all applicable well permits(i.e.Connry,State,Variance,Injection,etc.)if mown 7d.Amount of disinfectant used: /v
3.Well use(check well use): '
Water Supply Well: kealing materials used(check all that app ):
❑Agricultural ❑Municipal/Public at Cement Grout Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement G;out ., l. ; ❑ Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 0 Concrete Grout tt11 ID Drill Cuttings
❑Irrigation 0 Specialty Grout MAR 1 5 2023❑ Gravel
;-Water Supply Well: 0 Bentonite Slurry ,❑ Ocher(explain under 7g)
onitoring ❑Recovery I;t;,2.;y,::;.._ .. .. ..,.
Injection Well: 7f.For each material selected above4rovide amount of materials used:
. ❑Aquifer Recharge ❑Groundwater Remediation 4 Its.b oYvt•.tk CLifS 2,1)9 5, ix 4^
❑Aquifer Storage and Recovery ❑Salinity Barrier g As'p v e CF / C•p Qet,i)ei ainnel./ `_l j tp t re Pre./-!e/J�i/
❑Aquifer Test ❑Stormwater Drainage L l
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the bandonment procedure:
❑Geothermal(Closed Loop) OTracer co.f1,�--jeetar ei [e.4,L ,l dety. �LG( 74 if v�--.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) J/� - / //J
i �(1 13 . �C411 Su✓ I2. 3iit te. ol.f4•f et j'c_jm � Gict/d._-/-9 Gc'e/
4.Datewell(s)abandoned: / / 1 .{(,t-tot'-rvi to ,j iv(I
OIL-
./k rilto Ari--(0,v'v
fL 5a. ell to {tion: Church 1(F Ci� ��Ot`t 2x oL/G Oi c /�
WG ` to wviy
ts
8.Certific ion:
Facility/Owner Name Facility 1DN(if applicable) `
5 V G,I P A M! Ada/4 AL G), al 212-//2-3
Physical Address,City,and Zip Si a of Certified Well Contractor or Well Owner Date
ip Q, 112,HAVel� By signing this form, !hereby cert�that the well(s)was(were).abandoned in
County V�� 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:
0� You may use the back of this page to provide additional well site details or well
J�r �n.� 3��� N L W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment.you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
�q� ✓"7i abandonment to the following:
6a.Well IDti: �/I •�
' Division of Water Resources,Information Processing Unit,
Q' .... 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: �l'. (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
11
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
( Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 4. (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 •
e, 10c. For Water Sum*&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): 6 I
(ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013