Wake_Well Abandonment_20230428

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NA'r:t....t.AtIANt)l)NNtENT EMCOR I) IF,1 verr..rn 4T-4,'IMI.F
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W r fir.A.00.10010Nirr,NT IlsE1410,5;
f ; vk.,t,q'o.r..,rn-an,t lInt.,rtratv,rzl
RISC V 17.'1'0r:wood 7m..rear OrterpreertailICPF er(Armed-11s,rois Geothermal]Werltrming,ate sarm..
.s1:0 construes iongers.ordv 1 GW-19 ii5 ustadal.. tedrcee'MINI.r DIMBER of .
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. . .%.,,t-k-,,,,.!•,:;74,4,ciro,:.::‘,.,S,N Nu-',..I' a Oh,Am:Tomei:este 1,40mtne.or itenter crermairting En n:TIN: fr,t Lt.
t .W.. Poore Wen&Pump-Co. Ir UR WATER SUPPLY WELLS ONLY:.
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7m:4v:ar t.tWaridant ased: LATH
il...2±Reala
:;_avec Consatrietrienea rarmit W:apr'L'iljeW,
• 112[tx
. A.Veal 0V.T Wald,:wet:cmzp:
i Weer Sent,-Wen: I 7e.Sealime,material:9 used(actictis all true putty): •
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;0:-.t.Apisz-ttlarra.0 EntaskitattEuUtie ED Neat Cement Orme "afentarnte Caps or Met,. .
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OVizza,:=.1.1 4fricesingroaug Sonsfy) ?tisiikittiiiII Water SUrrpty(singte)1 I 0Sr auZ . 0 My City .
,ta.u.,-.2-a-snianiseanteinnall Mt:std./ant Wator Suppty(shoo.* I 0Coacceteffie= -•0 DgfEE Cutaia,
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II Et.fra:Fanoo 1 riSucciaily Grunt XGravell •
1 Non-Wotcr tzappLy We=
I ED Bminuite Starry - 0 Other(=gin:canter 7g) ' '
OnsesiLning EiRecessay I ,
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(litt*.takEtt Welt: I7E Ebr pelt matcriall selected ainne,„maitre must=of thaterints used: . • - -
.11 Oft.z.nfor B....,th..—ge 01Btouttavaler Remediatien i. At •t
arinit tier e.
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1,: Atri, /441Agc CALT,tuft.ur S to.m,.ie mia a.mnety osy Bat
1 0 Ase,4.,-iittr Test OartamtWatrz Drainage I ; ' ;'/' •
I rtfEvcrxt,mailtaE TailltdOgy EISulasidence osulauf i
I tt.-Kizatlenniall(Owed'Loop) Entmax 7g,.Preside a brief desetttion ef the attvuleanatne Emecetfare: •
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I tr.:.Cnseaoll 0,antiunCeating.Bettina ElOthce captain wider.70- •• Par. 3.aP,4v...4.:AL im-9 itzi.
•,9,..,,7 .44e2.2_3 sr-Fe/14_46ml gf 1-4574,--D,
. -E.Elate:TM/KS))ahatUiatted: . ...n.
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'Or.,,r,s=141d,,,s,r,A741....tzip: p.95-0,9r. Sit'=nee . L Vallamtlictcr a- "4 Om= Clam
ILIA f.'- '• — By riguilig(lit i!petit E P.A.-re,r4 y.eptifp datt ere brats)war itlinv)¢F.aszemsof its ..CC,X.I.'y Ibitet Gdentirmatiint No(PEif aceixtimix met ESA MCC(12C.611/0 ei2C.(120 Weil CarzstrzertenSar-..Larie •
canir diroa cuppil di&tvo?rci hos&sail;4111.110m ere well mown
Stn.Ultimate and reukitude its degetcslinittutesisiconds istr decried degrees:
sif.a1011 5401=Wang is;sufticienty
. 9'.Site diagram ur ROW-mat nett&tads:
5c...6sIzs- N. ''''1g.. Caliq<U „, You may no the funk of Ws page 4 provide tr&Etionat0 nOtt sin!cf-ss+ts or,a.eff
" • ithatafultmcut details..Ilan tua.y atm)mach additionat Rs..ssf=ue, tmE /Fp
roe f :vs I k t
r_crvsnarc-rioN rarnttr..s ow%IT:FIN'',BEING ABANDONED h.—'4.....1 * ....
SIMODITA 1..i uNstitornoN...5
.,..c..th.dur.,,,,z..gun.do.,60.-aditte.ecrozatetlefilderemarater-warersitrOmere
0...xtr weal,cle=se corrsimatmei W
thautfutrzimm.k.aanstibuutfra,wpm
h. Alf elts: Sib
. Ut Far iu*.tills rostrmithfra 301 da•ls 014121foliefZU 3 .
C a We aMitufumman te titc folfactUrga. ILV::
II CI. r.11 wep -
Disis1i6ntr etWairm Itquotax.„.tafortitat.idDr.i - Jtk/Fc3. 3 U N
Tosell dh: 5pUP E7 a I
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& EU&For farectime Welts:-lin addition to.sendit dr:farm to drz address in EC a Cc.
abuse,arse abide cue capy of Mis Enua ea Min 33 d135 of'isam[sktion of watt -Beeetratis diametcr: (fmt
attadatunea to tIL:folioniaw • •tt
Incision of Water Resuuresi Efutteegr o and Infect ion Centro tor/Viteloa .
W...Water feud Wow ground surface: CPIL)• (ft)
"COG NIA&race Cettrar„Itateigty„NC 2765,,1-116,16
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Ida Ear%Shaer:Jannis...S..,Fafeetion Wei N:fn aafitioit TA)SVNtr2g tl=form Lo dt.,.r.Outer mitt Cetus=(if Melva: jr." Or.)
adluzges))armsr,also sorstaftt cm:awy of skis foam e,.ithisi 3fS dol.s of domiTt:tiais
air well atnusto ecuMet to sta:-minty =aids drymmataur of thf coun.1, si.t.nre .
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II. EC Bauer casingfuMiuso,;length ur Alum ay: f.114
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,to,INcovockzeilt Mt MILS
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, Sas);y NertY00(f 7r.For GeopruhrilitV11 nr Cifri5C(94.196p Grothereval WerDc hitter&Oar mar
-meg ..ttsourkederh,only 1 6411-31 it;Gtartd..Wirer WOAD,NU,74BE Et of
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ttegil;absod‘in.-M: -
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-:,,-- 7,4r6.5 CerTici.vim,r'Z'rerrtFert 76,..A riVrtWaTaCir V rifts Li.l.a-Or maim remailtrag go oo.--,rfisrP:
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NEW PooPe Weil&Pump.Co. ;Galt whyot SIIPGPLY WELLS 0.1NO,Yr E .
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17r.Type o r eibatrears est Oath. ' ,
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. „.,..,..„„CanntionarEgra Vairrairt P.'6t7t1-67 (-5, _ -11/2.1b i 1 . ••,,,..,..,.,-..,,..,„,,r„wahreourprn?..,,,,a-poraii(i a.;gar.CourtYX.U.,144.D7orhaites.,ea. ifbrieriere 174.A=Imo fir asturacriag actt: •
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?.'wen iLseqebeette wen irtry.:
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i MaCer ScintLyWaft• 1 7r.Srutinz anatertates used(check all titre!appryi: . •
';. c.3.,•tle-nt..-elteirrl fintunalred/Ribtie -a Ntcaccenxna Gtvall
, a,Eremordre Chfcs or rdter .
ce,.-,:zeyer.,=-2n ofriti,E,CrotingStog0.1 X't.esiiktitinE WeettM.Study(singe) CD grutt Can=Grout CD Eby Cllay
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., 0-tri&e..,eerieD,re matentia..1 CIR'crideaUfall UrabmSupplY(steaturb .0 purr=Groan .0 IlltiDD Cattims '1
! 0:rat=iti a• IR Slincialty Coma a frrareD . .
'Neu-Water Sanity Writ: i
.0 Ermitonm Slaw - • CD tgatzr fergairs en-2=724 ... !0Nhuilming,- I:Mammy
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,, Ihtertinen Welt: . .7g.For each MaterfrO suketutt lilme,•,proaide ale.teteut or murders useir 1 • •
ca.c,--to Rortarge C.Gioundultur Rani:dation. i EnvirdriMeiritag FiI . Five Yards
E-1.1,7zifa.sterat,:c and Etreavay 0Satibitsi•Buttior . • ,:
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Laterieihr Test 0Stunitirotrr Drailmae I
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0Et.....7,--iheratall inchnotonv CIStabsidtmee Cbutioll 1 - ' '
1 7r,..Unable a brieldtsgerptiats arthe abandoutneat precede:ern : -
naeith,-iie-ill t,corea Lori* i - attqcgo - 1:Put eaviroctutentzd tin cxiotooto in well frump Illottocra to tap .- • . '
, asalltomat atcacing/Cocifilo Rrnint) Entber trobl`dini wax TO .e.
-E.Elate tGt1authtotIotindtg""'7-4412.3! . • .
Se.WrIE tocatibtar
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F.-,,,,ilizeo„,,,„,iftr,e:- Sankey,LOW Cilrapplteabl4 a'Certifecatio. e* tt -.1 i .. .
//ICA FkuP oeb ARARE4A1A G.. L ;-
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tit'Isrzall POttress..,City.amaip gicryegg- Sigralutcogrest. \V, Coutcaziw or Wel Otuira-
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C4)111K Liya4purs:it:us/Brat-if kirreby ern*LIM:et--ireErs)trar(were)au/atm-x.1kt . . . .
CeortF Vartd.P4ntilicatiim No OEN)) acomfanw Iva LIR mac MC ALM or X'.02:110 Well CartranzactitzaSareakral- ::
and Ito a catiyaf(Iii&tward f=ktarprat-'.1.gai to die well aruinr.
Sh.Latitude awl rougtitture tadcgrecs/Ankuttestrecuatfs or ductund thgtura:
titiv‘elLI ail.e.ze radapg is.mfrititut)!
%Site diltgrant or eideadiazrall itriE&trill: _ cr:i r-r%r-,,!,• Jr-/...3s7 , • .&I 4'721a You limy use like bark°Ears page DI)prarle adtruffearll t.t, g;k MI,Log M i V l''''C) •- "
W. .'atratilbonumie&Mits.Yam may rhe=orb attic:V.6'mA pees if irres... rt...
camstrrturcrow n FES MS nvwor.t.(s),Rum::itit.k.NlIONED, ' .
SittlINLITFAL visnurrrms APR 2 8 ltiprquiwmturrxrv-wutersicppljd 2023 ' .
,r.v...thu.sclirccrammseatvzrearotti)elarmil4ae:FurtveerirEr
E2IVEL-weibOtrIcalreconstrnaturviditutifinutt4KSWrcamsubmalcolianst. ,
MT.Or All welvg. Submit lb&tam width 30 dass likiiiirl.4%etra fu....,513416.1.2 una .: .
ea.Wult Etlet: itbiuulatunent 63 ilk rarthwrivr.
DWC1i0OG
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GIN.ri.g,ut wuct&pact Utl,
1717f) MEd=of Water Iketnerres,..Information VroCCSsinr.Uni -
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EGET Mtil&nice Center.Etateigh.NC 27609-C617-
labk.-Vor Tirrectin"clEi: la ration to,sending the face to,the addrer.6-in D Oa
Gs.Dunbar,:chanier ter: ati.:.1.... EtIT.4 AMA,dia submit meg coo'of this foam ttietieu 30 days of cm/avg.-lion of te.et} _ .
abtutomutatt ba the:lb Illatthisr.
W.wake trtiet tadow wawa NUIrraCe: -. 3g. uti) Divisimt of Water Ltusourims,tindermfuttred halartioit Contra Prnraor. .
t1536 MID Service Cram.r-42f'nth;NC 276.39-11.636
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Kg.°ear caring Dength car ram-rsrag. l''.- . OLP Ear-Fur Waren Netinitv...g.'f afar:6ml Wel Ft-e•Ea addition co s--neEta.,Me feint to.dit:
ailtramst(e-sp abkner.asti,suhada artf:copy eir4tiis foun ty ithee 3.0,days,of cimiretaton
'cif wcf.E abutnitargoLnUt CO etv Cuanty bath ekpall=CM.of thz optima ttlicre •
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atklakforia
r,,D..haul(eg.ingiterrim;turegth cill&mom):
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rpg...Strom betigtb Of Luau a): (fp) E'. •
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e 4:111.111 0-;,•,,T4','.:II . Not-th Cac.finw frucmurirows of Eamiitenzuvadi(Alai,-111`is6thi of Muir g&s .7,7,1,s - ELIviNrdt:r.-22:-2.0 V6 ,
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r r calif aith-111091iMLINT ItEIGURII 1 iRis .-firll tell?:
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1 I Kgye ilj 0 giljelei
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77v.,NomPlcr 7E itra is arig dim&neeth 1
Trz wiceb krpreem a, wilt-mew girp,,,e, miry mar ,r4 Or rvIr
",11-rlf•13‘0.1e,:.rc;-.e•-• cl,,-mta p mowalT,p.PitTezeit i!irill-ol&Sam-MTh
,,,,,,,,,..--Jr.1,14e,r+4,,,reg,rs cam 12rEirrn site I:4=i
itr.Arjrcanmistle volzime.tsPrisstr irecageragrm rtilfg:_ida_s."H e/74: .
iii-aif,•-,,,-„,,„-wic,;10,. .,
N.W.Pock Wo S1/4 Pump.Co. , I FuLMEELt agirrbi rxr ung"-------- - -1 TtE '
cr,":7tr,7 r,7,••,. . Tr.Thit area/Astra :star ' -
7-SI,'eti:Carroremearen Pelmet et .6.kp , :4I0 >1
iloc le. 1
Zr,i,e;,,,,,t,,,e;rwer rrel7Farrnat rt.1r,-Cam%altrfe..PaKr:Ner.Nein%trey tatarla im iiii.wd uratremrsu mret,
1 . — ..--7- '- -•----r' 7--
3.WOO are ebeare tre en may:
,w„c„st,i,03.wag: Te..ffeancrettufer unE(eh;crc tit thst g.17-r.121;
r'OAP kekrZ4 Ettitinkkgratoz 13 Meat/rat Ermral:, XEmst=rti eir,ms m•Pcarts
Oar-Isca7V(NrvEsseCcrem.g Strobl >tatknoimir-zavor ctivei: !Er End Cesamerlara ED My 62c2.
Crs. -tnir.tr.ammamekll
CIRmatcattif IT4-m•Esipplt Cilimr4 ca Ct1.711':2 tlfrat " 11:13 Milt Cr4611"gig
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rict-wetrstwtor uttr:
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OMmaLtakrg
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,Pc,Bettkz‘Vertr.
i Warm tick ciztuftE'timid tbirrt gramf le aFts2Frtgtr eatertytezerii.
I¢Nictfirer recettage
MauntwaltrEeivalligibit • :#ae2g;iw:L___ 15:29
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1E244-mac:lap rad Ittzuvrar Callittliv Mat=1 MOM:a-Ten
ElatfartmatcrIkakg zaerzariftaii 4..._., :i „
i1 D'aphi'ltztteIrcthiturugy CI611klittncoCimtmll i - -!T.FIT,(WIT i:EitftEttetertiitirr cE tac thms1;ammurd prrcraFcer
rlertbM7acli tatztst Lucl1)) CErracur .
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i.--4 ratialLtit aaddlitaltda EIrdqttetitillatUlittratitgeattallthrtUlen 64111411"MrlilifrrVar:CrialrEt=1;''Iner.2621reiffC=M71 ApR 2 8 2023
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7.51:thdlitteitsriAL.ATAguzizzlitteolln,
• riUltaii'lLiniilic•C'dila Part It c•mi:sio Wilicre tir.2 ifts drElia cr/se' •
• 35.______SSLSEF: L.5.,:.....jc '771:g_....2-41.11±AL____&:t w armadbmi •ligats:--- • — — ' ciatprr4i.to h Prz•-1-800a-',2 Urb.
ettl In mar est ankh Earth-IL-7d pEez ffa . ' •-
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Itiarglitii?,,40, , , , ,CZ pi ,.:pitkiiiitia-tr.utr 1%4' • .
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Thliccitak irliii than' "thittrioti.a atUilnitiiiiitztrailiclitptriz.
Lk latedark 17,-avaatit ltcii ATata NNitras le esj1 a.ctImiledcs1 er mrii
isr.Welt ED,11 -
• arnemilItcut Di Iikatriatra:
DhillifigIVECurltetatureery larccraV1=PreastEMg Ffriti,
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ND,Tuba well atoll; Mc'
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. LUlit ICI,hiiii&mkt Cettery Itthltb,,irieNSMOBT
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- ,it.. .li 1 4,'1,',It ,LIT trlatirat It Ewa' 73 EA:faz-/ro tr/x Lamm Fri Ea
ilintgareirit tcp7tif tli&Tara strarra 39 6113 cf r=1•47M,Fc/r.crEntll
,.alirPhatignt tal6rrilim4st -;•5.3,4'esEtr lei;ct Utraiiriim:1011tiirrirtec 6:41c UT4 1Thrtrat illififfelicamcari,11,radmseccia irlecam Ccurral Prczcarl,
- kid afffilgriviat Ceater,11.4cPA.NC 116.10-11EM
c-Uorer cramg.Er40111 tor kinirizi: . trt4 _ ..._ • - ct ra en:cli Co Seerz3 13;l:f":711I to ,
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1.111 er4•El*..a4 alit ratagt ut6 ct-a of Vs Es=r.i.,•2•03 33 elyr.or
narglitim a%ill/km.141:z=to te camtir hrtlill 67,tztar=t1 11.d'''' "•`-'-'t'l
zii=c iietar,AE.,
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v+,..'Eli.ARANDONM EN-If RECORD .Fse Vz.f.rmAll RI v4,.•e fra V'
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NITA'.Norwood
7..F..-Grop.rotrrilIGINI or Cforrelf-fl.nop Grorateraml Wairc rmi..-og rir4c.Mlif , ..
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00 5mfirli0104- 0(TOW saFtutivrc
465A ft ? TOTAL MINZER:of . .
' .• •7D,,,icgrr.osirostevotrrore of vulter amnia=iiro 0d0r.cp:, 3g.
1 ,.;14):f.,ti:MI:rd,e7eN.Cc,TtLernzei.,re NCV1,3v1
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NM. Pc Well&-Pup Co. fl Mit WATER 5111:17112 tvrtirs ONLY:
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17r.Typo of disistfeettuf int&
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CMIreg,arr,norior,,or,are)rptirnam ;; • - Ib. . .. . .
1 . In.Autdauf of dislareclantt osorl:I •. .
. . ._5_NV'cill me Who&welt mc): .
' II wzicr'Supply Wel:, 1 7c.Seatitr4=tidal's ase(clink;of11 MU apptyk:
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luzall Ettrunicipattbfie CR Ncatectianatcroul . El Beaccake Clips cir.Pdras ! •
. ;at:to-odic:ma fllosist4IgiCoolfts Sotply) .Xestittaniall WO:easily Csirgle) 0 Sea&CeurerrtGrou: 0 Dry Cray . . . . - •
Etetterorialtorturtcreia/ GIRedikoriall Water Supply(s4areify• I 0 Concrete Grout:. ' , 01 thrall Collirtp . . ,!
,MEI-Eau%- I E SPIcelargroutt 0 Gravel . . 1 I . . : :• '
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Naa-Water- ATell: 1 : .!
!El D'autocitc art* DI alter aspW:a=der 7gte
011etaitt 0Rooevcry
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!Tir-For•eacit nrattlazE&erected:hose,Made zaranct of reatzetals used: ,alquifer Rerlarac -ECrosind\cater Remediation
l Ertyfrongtentatfitt. . - . . - "
TrilaYarc4- .
'0:Aquifer&lease and Recovery- EtSalitziV Batrier
•. •0AquifecTWt EIStinurmater Datinage !
I .0F.Ay!...ieleatalIteclutotogy CtSubsidence Control -:
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:Crized=iell(Closed Loop) Meares I 7g.Proside a briertfeseritidert(XV=abandainacat proceder=-
4I Fut ectificaturentaL Ot canters 11/wea frdite tzw.0;371 to tap
aCtoD annul alcadit#Madingt Return) -Malec Oteenlailt under 7g1 tI
4',Date Neell(st abandoned:ca-'411111:7•2423' ' .5,1L.Wel II Location:
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ra-aiii,..-1,40.4ora-Nane .Ezaity IMP garptieattte) ! :.artMeatiint:. , ! .1 •
iiiit gAidrOliale4144,1N6 I :V . . 1 !
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P114:,...sizz.7 etediess,.COi.owl Zip
ayiraturo era. amll - zatvrwciloom.T.
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BS,'string dirisfarrat r-4a4aiy cert&ara rli "wears)liras ifutergl atudoxied LI
corr."! rattet rdtattiattratikr,ViNI 'ocrordance witA Mil Mr GC.0160 ar-.7C.01F0 Fria t cat-re - ^.---; '-
and tfrato ally cif this mauz I au be e r a prevrAi eo r.rvsee;,,o,:ke‘ Ir ... ', k iir.:,7---,,
57.e.Latitude and lottaitude fad ads or decimal&Trues: ; 1.r1...*....1 i V C.Li
frElf.rta field.ore lartoug suflidestry . ,! . 7.Ste diagion oi-adtiftionalsrell detail's.:
5ST 65121:7 NI —-IT.:-(4 02— ,‘,.. Tow may use m back af Us' paw re prosiek r4Mional well AtpiRt.r2 1 0 23
‘-' - **Unita=clettolS,.You may&mallado additienel iEr.,ecosiery..
C17:NeaftkliCITU7N DRTARS.C1IFIITZ.LIST ISPEKT:ARANTKINETI
St iTtNIETGAL rs's II tar:rums intorioraism Pm-cwoira Ur -
-
4.4.;r4orla.slavtormommorcur0)favediar.tin-andtii4Orvrootocruoloireursuirt.prtrits
QAEr Nee Ole sa.,it omortemorrithotottlaucart you am sobmirowfitor DWQMOG
EQ ritill.lat's-&bask this loan widriza 30 clays of cornpletiont of-well ,
abandonment rat the tbilearinat-• ,
Ga..'We LI DM':
Dieisiont of Water Resources,Ihrortnarlam Process:lir,:Ude,- .
611.Teta otth depth' 1 .5 Ert-1 . 1617 3fail Service Center„Ratette,NC 2:76?91-116117- . ,
Cot:Go ediralc Tat/toter: I ,C 1114 9k- t
. LUtt.Mir Wed.=e Welts:: fi' t addition to scaling tft:faun t reams ete: le
g . Uri
abase;als0 submit otte coo of this Agri Isithiza 30 deli'of c:emplction of won
abottifonnuatt6.3{Toniug.: -. , • . . '
i • -
;
WI.Water tort bekor ground suirfacc: •/3. m.p illsisitut of Warear Retenerrelts.illett'ociptracd ltrfectiks Corasoll IrELVAIL.
ECUS SlailiSettelet.Center,Ralelgt,NC 7.7694-11636 ' r •
. . .
We.For Wirer Su only.i.".•faked='weak;ra mat.i!an,t,,,wag ;.s.1424:Earma ra az.
64.Clan-coolug rtugth fa'iiarlicoIl - OP!
trdtkassfay fatn•C,s also setual:or:copy otirbiS 6...wil.bi.3F AO ofcianduion
of.twill.114=4=4111.to the county&rant &pence=of dt:malty rte.=
.••=5..dito alettudona
cdf.,Lutes cadtig4tobitagt lengtfa of Kann* crr4
• .
--,......„
! c;;;:.litatorui lemurs(if Laos itt; (ift4
•
: .
i - -
. ar.60.12.-2,f-ze to
i IVALZI 6"..V-1,4o Noah Cootine Erktp11=CIVI of Eini,CiEira.d 6.1‘atgor-%sill=otWo2a Hoomccs,
; 1
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•

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t r,tib.:Iiiiii ni) iliAlli. NI itliGUER • -irglio.1 PAU: . ..
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t1 .• . .. •. .
--,,,...--,4.--, 1,•,•71,-.T.' r.11-re.er.7 7•••••Ftillptmt,eto ..
',.....D1 0:r::tr•7 r t•T r 1 L.:fr.,,,,,,C^re mr .... . .3YILLABINAlfrinfaff_DETAJIL.1
,. --......c,
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i„..t,7..5.,„cIf irOro faIlcg Ebt,rthach '
,-.=,i q.".”.,,-r:.t-riv Ptvt.(t•.!.....Ed.-:-.c...n,g Prscceirrt21-trEvt!.:7e tiljtzr.eStrgsrpctf) • „
., -......,--.1 ,,,,-----* - P -6Pez r
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i,tr-Arrecd=vte-trahirze career 1111111,Pidag F1P?ten* , • .G."'• : .
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7ra7 V4.,•?i 4.1"c't÷,tv....,C.F,T.IgtaTtre TVet-sSts- 1 .
NAV;Pon19-WeN1 Ilii Pump Cm MR WM=sumz WELLS Crill..X: ' ,
......_
,.
c.7rn,,,,,,IT Nrint
riergyv al[Shrike:Era roan if/77/ . _ ,
•
- •
7.Well CcuOrtancra rectsgE Ffitt4ift"0615.003-72;23 • . 10, 40
" 0,,,..--,PerVr watr2,../ccro,A.. . ol, art;raeoc.fr,Ereceireq.r egy Orme. la AEITCLITI1E a rtirsraittfrA etetr: ,
. .
3.wen VIT.ODatirk wan tar): ... •
to,Wo fir;Striply*Oh 1 It Sultag ett ferret rut5(ettek erf thst x0,71,1:
t.
EM&-ufaictrzoll. EINfatkfpriaarkg I
f CD Mat CemeaU Cfr,mt. - CD Efmr=ritr-args ar;saes
1 . .cr,G6z,•:rzunad IllintingfirevErcx Stwgr) Alf mr,rntTall yilitcsargy Carril4 a Eradaic=111:4 : . ED 177 COV,1 .
et...7.1zezi!rilre'esueeacterl Eritiegfaltill!Witteasug5r Cirerct4"•1 Cl C.c=idt'(1=12- EV IhiLif Ccitalas ,.
farzatigebn - )(14'in,ifalt7 Mad- •
'4.17,n-VfLen•Stmaly WeErr I,(CE IfeifeeffeErenp . • CV OtIketecifffe7 araer 7:0 . . . . .
•
. Clitemay .
114;ctEcra Went "'Mk-crank arferfd atria exrref Frei ray tir.zrzaganziprlfda tue'Sr. . .
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I 12Agulfar accitzsm CICIttrundmrwItekalrtirn -
' HaqViRejlifi .°Eirr 4 , .
-c 9 L' -*yo •
;CIAzigardCetzga aid Retavar CfSafttirramicr . '-Pi LA- - -
.. I• .
1 atqdift"IrdE OStatIMItarDtabraz
110E:cc:lira' umlat Tceinefugy CfSpislifamo.Cingtyli I:7'' fie ao firienfrzerig=at tlie•tEratftwV pecrecdsze; ,
act.a=i1101:fes.tt.11 Ulla= • •
11:6filmthurallpsitfutiCtIollitg IteDfriS .CLIItherfinfaliviinfete.-- I " " --
..• . • 1- ' . " ' "i.Dalt intIN Fetiaabuttlt/ ,-.4.1 . -
.
.
irg. Yet tderattlat il 4
- ./ :'' I
,-....
• • -
FtilityiV,Itnet1W=0 , , EitliftraltItappllielliy - 6° --i—irel 1 airy' .-.4( _0,--: •
2.712fa
- c,---./V . • .......--- '
Elittisfitaillittt;Can EmiZ:11 4 75- .- firtaitkeittentill range.eziVilll Neu- .Ekrt
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fAJA x
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Kigo' . . . .
- .
,Ilk trgrOg gt4fran I rlirraW=V aal Cie wag)W.;glarti eardvred rz ' .
ataz. ' Fazillfrietiffhtlfetilte.(4114 accin-ItLeciffieliate TIC.(110&,7.2C.00 Will Carshin.!fn ,, 1----9-, D
•
datfirie arcupyietBlirrpvcril=Ecaspmf al f ra the.trell awrtr.r\CLi,I:.LI v r
. .
a:,LaLftetrt itistkleitastite ful iltrialinfartfeilittatit(If tfectaurf&grew
67,11,-11 afklairAiiiiig ft iiifSifirzo, - .. • - 1,Site qiir:it.s,,F,„.5igitatist IttlIftfttillt: I. •A"nn 0
.35.(4,34.092—N --72.&V30. 3, wLitI'-iddacdbr4y,,- - 8 .
a
trey arse tilTurz edifieell pegs Efe=r-sm.
„ . ..'_, . . In3Orin:7421c.'m Prr.-mleig Unl,
C.0,:i5plif:q11 : _ IP• OUNI INIITAEFkrilICTION5 ' D‘,110/3!DG
s.aztiA'vsigIgg. . . . .7.,. 6. 4.... . corrivrAntirnmi- ' .
.tatiVt1.4iridid i dna 'atl 4`silgtibmitTaiiii fon 'rategglitm • :LU'r,TveAlliViat llatit lids I.=witlin RD drys cii ctwiTed2 er wed
i,iartuatat ' - - eandbantt ti pi remETF
. , . , nhlifa,Trd:Witferiterearcer,Zprikartftem Freer/deg Era%,
46,'Text nr4'kV&.. (9... fa-) 1:611D fill Etrifee CeatirrifsfdgEr ric2TUNGS7
v .... .
',:..3zrelitEe dreaterzer, ,2: Irt9
ION Fe rafftfkr2WrifFt-fa Ward fa EZZIER;t5:ropa ro L'Ir::Arica LT DEt. _
..,5110;ilialttraleetlaii eV*farat Narro SU esys el'cuzpEiffeis 017%611
.aillemuutt tiilliereltedele
;6-111.4stschicii kitilientillitiatitfiltr,-.'7 A.,•.el
- -. ' CCU 1 BIWitaa aLlilfitlicputeere Ehadttgrceet,9 k/eadee Ceara Pregarp, ,
,
'' - fdatilllAiTreeceakr,EbtretkNerT02-.16151 -
.5,.-guilty'.attlqgliemititTritintivirlr, 144 . .. lisk.rgr'71tc;',76illir.stiVeigtm Wells En'grim. ET 1..-ettrEcg Me kg.39 ET
lb:pleat 41.7etriiiT,"dia.:r...buit cree ally er es Ea=rifEra la treys cr
cnarge.ifaii cif tviiralutatmluca Iv ezr.eatnIty heda deputcr....e,cE Ca:ect.7.4
Nene tramitibrell. 1.4
::-.ISTer tETEEETZEndrEUX 1:5R,Iilil glininejii (MI ,,
- - ... . c,t14 - ..
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•
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• ,IfFlifittAilififtitattatrattim.tkag.........-—- •-_

rruLki1111)'0IMI ' 'r uurry
'
this fo nn•eanbaused mtb
for ebtgle or• 1U 1b.sy []x �� I UBC�I1U!'
i.1Vell tilrnclerInrur •, --
11'ell oaIrSclur!June(or well osvoer personally ibendon1nB b®erptoperty) For71.NmulUpGer vf Inf�� onelnp abandoned:or O
f r ropey trill, ONLY HA the some
5 133nilcon,trueann/obandonmtm,you eon submit(inc./brut. •
rdC Well Coutrectar Cettrncadoa Nrtmbcr 7b.Approximate tolnme of triter remaining In rrell(a): (gal.)
N.W. Poole Well & Pump Co. FOR WATER svrrl,xI,IsbNzxf '
•
Company Nellie .
2.Well ConrtrucUon,Perwlt If:V1V'p�96 L(/-- 7�Type of ilbinfeebenf nredt___:_kla• '
.,u:all appllcoble will prrrnflr(Le.Count.;Sla1t,Variance,IetlreNon,rtc)(Omni .
7d.Amount of dlalnfecLint used: I, (6 p'L
3,Well use(check well use):
.Water Supply WV ell t
oAgtioullurnl le.Burling mmter-(tdt used(check*U`thnt apply); .
- ❑Munloipal/Publlo 0 Neat Cement Grout. •
❑Dcnlonha Chips or PdclsIGeoUclmal(Henilng/Coolbtg Supply) Xit caldmUal Water Supply(single) 0 Sand Clement Grout • 0 Dry Clay❑R:aldenUal Water Supply(shared) ❑Concrete afoul
.0Ir11 anon 0 Drill Cuttings
•
Nov-WYalcr Supply Well: • peclally Grout 0 Oenvcl
❑hfnnhorLtg • ❑F3atladla Slurry 0 Other(explain tutdcr 7g)
• Injection Well! •
1711qulfer Recharge 7L For ea h material selected abort'provide amount of wa(eerlaals used:
❑araundwalerIlemcdlnllo]] •
s- 5i Vi /rh '1'7714"
❑Allulfcr Marna and Recovery' t7
ecover5alml(y Bards
IOAquifcr'1'eal ❑SlormwalcrDrainage '
❑Experbncnta]Tcolutology
C]Subsldeneo Control
i'
Oaeothennal(Closod Loop) ❑Tracer • 7g Prorlde t bile[desertplfon of the ebando�nmeyen�f procedure:
U(7calhetmal(I•Iodltng/Cooiln' Pcltint) ❑011ter(mrp kin tojdcr7Q1 '',. pitralii �'f,� AL ® L
•
t.11nle uell(s)abnudoned: t424A3 L` �eJ - �A re) /4E,i�.f 4i
3n.WW'elllocation;
•
y �� "r/�� �/�r�
adbly/Dtrner HMO.' Facility IDll(lfapplicable) •
V' ,
Phyrlcnl Addrare,.Clly,and Zip A— 7;3
f L � t. -• & 8ldadur of Cm i tillC film! - ell Owner DAN
cowry •By rlgning lhl.r./orny I I4 cerfry(hal II.le well(s)]vat(Pere)abandoned In
Part:dl IdoaU4taUon Na,(Pm) aebvrdiutdt IfilN•ik1iCAC 01C.0100 or 1C.0100 Well Cowin:than Standards
cb,I,aUludb and;louglttiUC In']Iegrcei/rtdirnlei/tecondt of decimal degrees, and tha{d copyofrhlerecordhas been provided to the well owner,
(!fn•ell'tieid,db a Inion li tli i'ltt o
�� t • 9.Site rllagnttn•or adr(ltlUdttl well dellrllt: �'d� t"�° ',
. ••• N �j�j ( Teti mlij'A ,ltfoFick of flits page to proyiilo od'rli(lonal we sitc dctifsluritvcll
•
WY abandonmentatidla; You may also attach add111 ,,l ages if e¢. l •
werla .141t0 !Tier' m c ;V .f,':}k
bur erltirrtillabal)ddiiiriitil,.ilk ir'n,6Frilllb niorn, iralrr'ngpfy Infoeor:;aisri Pr•�^9r
• IOa, r a ��Uni
;et.Well DM • I or• Ii 1J:r;rt •Subutit this form width] 30W}s vt oo�iplcUoo of well
abandodtitorit Io llto'follnwing:
r bt'fnlnl Well depth: �� Dlvtrlop'otWAfer l�eroureeslAifuttnaflvrtIerueersing Dull,
(fl.) •
I617 ilftiil6enice Can fer,ILrle1ghl NCY7.G99-1GI7
e.Borehole dlnmeferr. • alb IrnrL, nl r ,In,additlon Iv sending the form to Om adrhoss In Ina
(In,) , above,.alatiilliffr(lt,ofib t}opy..of htis fornt wlhrbt 30 days of completion of wall
tbandoru!ienl ld'.11id following:
•Fri•WW`aterlei.elbeldir•grnttriit'iitrfaie:. .: �� '
(ff,) Division•oJf;W'ri](tilEr$eisqurees rnu
Underground Injection Control Frog nun,
ll�errice Canter,Raleigh,NC 17699-I G3G
zc.Oulcr cnilug lahglhi(If 1tilUtris);
(f1) _ lOt; •
tile'ad Uun 1Y : In addition to sanding the Conn to
Ell`:iiiclyfi,.nlip ',built ono copy of this form witlilo 30 days of
c inner cosing/ldblug•lenglh(Iflwirrvn)1- omp]tkiti Goan of tv6ll;abaitdonlnenl to the county health department of die county
• (fG hoto) cdonecl,
;I•Screefttli!iJ{il''If:;''(If,Iii�oivh)I'; ��
„• • . . • (l)
•
i nrip OW-30
• ' North•(-'tiullatbepidtbentbfLtarlreameerindthi. -ta-:-:.:..• •_,

•
•
•
rrDifi ,n,ciyDVIYVII',R1CORD ' F‘:Ifi iUmONLY:lltfa furnrcan by used For single or•mtilUplb-vtU,
!.1yell Cu elr.,clur an rum,n(lune
fi
5, �// • &ELL ABANjIpI`IMENT I)ET1�II.q. '
,` 74 Number of hells being abandoned:
Well Contractor Natne(or well q er personal(•abendotilngir'iUtro Wdher property). Far mulllpb frtrrellvn 'or Wort-tratcr :apply wilt ONLY with the dame
F 4
� daa,rrvenon'abondonmrnf,you con rubmlr one form,
NC 1V 1t Conti-weire Uon Numbs ••
7b.Approximate TOlnme of-rrater remaining In Tr'11(a)1__ (gal.)
N.W; Poole Well & Pump Co. . FOR WATER 0UrrLr1YELL9ONLY: '
Company Nemo
�° 7e.Tare of dirinfeetan(need: hfrTitf, • '
2.1yeU Cnne Iry ellou.l'erwlt N: sf " �d �:• Lrrr all applicable torspr.rmlrr(i,e,County,Star,Variance,In/ed ian,era)((brown .
7d.Amount of dlalnfcctint rued: yi
3.Well use(Check well no):
.1Yalcr•Supply Well:
C7A8rluullurnl 7e.6ealing materials used(cheek all that apply);
• C3MunlolpeUPubllo Neal Cement Grout.
DGcuUrcnnal(1-lcaling/Coolie Supply) 1 Clay Chips orPcllcts
B PP Y) csldetrUal Water supply(tingle) 0 Sand Cement Grout O Dry Clay
Olndustrinl/Conuucrelnl '❑`ResldrnUel Walex supply(altered) •.Cllni dilate p Corir�te Grout O brlU Cuttings
No 1 elicit Supply Well: ❑'Speolally Grout •(Grnvcl
OMonlloriug CIFlatttxdlo9ltrrry O Oilier(explain wtdcr7g)
. Infection Well: rII,000Y
17r1gtllfcrliceltorge If.For each material seleete teary provide arneuu(bf materials used:
JAQulCcrfilotuge and Recove' ❑GroundwatcrRemodlnllrnt
ry ❑S ii (•Barrio ���� ..cPA•ef:?.g4S40-914
OAquifcrTeat ' , ' ' ,� �11' r /f.�.5'�; ' �''�, : ❑SlormwalcrDralltego d��`f ....•
"
Jlixpbrintcall Technology.. C)Subsldeneo Control
C1Gooihcnnal(Closed Loop) "":'ClTracer • 7: Proride a brie[dtsuipllon of the abandoumenl procedure;
•
l7dcolhcunal(Ilcdlln /CovlingItohitii) ?'[70Uter(rncplablWldaga) rr��*�9
."� / ,`I 1 Ulm "",
i.
•
4,Dale well(s)abnudoui d: .,.: % �G' /
tell lneallunt ' l " •i�
. z-2-116:77,7 E.5-r--. d-
raeilityiNtterName pacitltyID�(Ifappllcablr) •• ` g,CertlscU...5.• . .. „ ,
.......„
, .nt_.�,
y �T .ate-=` i(T 6
Phyelenl Addreaa,Cily,toed ill) r,n, , *� �'
at, gigrtf'uro of Cnthlitd •onlnolor orWell bn- er bete
—__Olitea:
county •By rlgning this.j°nn,Ih4 certify Graf the well(i)war(tpeie.alJnnel°IIEd Ill
Paled'ldonlifeadedfo,(psi) ace°nGiridsIfilh'IJA''Atfd 0.7C,0100or.2C.0100;Veil Construction Standards
and:lougttud In degreeihulnului/seeoad,or decimal degrees: rind Maid y°frl,U record has been provided to the well an'nrr,
:CI,Lahlludb
tirn•ell'neld,'ont+k1/16 ig ti WISel674
__ e "1 33�(�/ N �,C O 9.6f1e iltagrrlrn•vrat)i<tUcfixl lfell'delxU _
1 l0 ) k ��E :i ram�f!
2�3 You mliy,10:1 o.1iac of tills pago to pr• . IQ•ui1(�il�ipptt n�l�yel�s elgil or well •
T` abandonment'drtalla: l'ou miry also allach a un«I"pages gf nece"s 71).
re!!a ," UCTI ONG A P K 2 b 2023
vfi' i� )i'��'i ire•t brit)ri eel 'e6a .f,;:1fi t7}1 'r(lfF bn"6r.rron tretir'nyply'
llddiViirill jilk cbh rbbririr i.r jotrrr,
,n,1Ye111bt/: • ' 1tic r •yubtnit thus folic i Put l"�i'S F t ( S
! • abandodfnefil Ili WS foll&wirtg; d s3p rontptctl'on of Well
t bt'.fntnl bell depth: •
17lvWoti of yaferIiesourcerllgfurwa(tonProcessing Unit,
• (ft•) 16.i7Mali Service Center,IialeIgh,NC21.693.1617
� / • 1064 Flii'LtJrfTy�� ti.
;r,IJorchole dlnmctcr:. E r In,addIllon to sending the funn to We address In Rh
is In.) •,above,•relat7'sllttlillfpfib do'' of this form will& 30 days of complc(Ion of well
•
, abegdo:ufient iif:lile following:
•
•Fli.Water iei'cl bcldn•grotlnil'iitrf ace:...;' (rt.) DI•lalbn.oil}Yeller.lie:nurser/Underground lnJecUun Control Prom
f 6 6'KF1all der,•Iee Center,Ralclgh,NC 17699-1636 g
er;.Outer enitng•leltglh's(If 1tnOrn)j `
(IL) — doe, ;
In addition to sending the Cunt luIho ad `:elt}i6;'albo aubrdt ono ropy of this form within 3U days of
:Inner coding/lubing•length(II'+lfndtyn)t.-••' •
w er abut of 1voh:abendotti»ettt to the county health department of Ott county
(CL) titiittxcebeirdrntcd,
•
• , In:t ocreettllen (l(;',(ll':1 d'nii;uji'I
I'nrpl a�V•3f1 '
' ' • NbttllCltUliaiberlrllheUtbfEnviretumntimmi....,v_._..... -, ,. I

WELL ABANDONMENT RECORD For Intemal Use ONLY: ' 1
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood 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 G)-30 is needed. Indicate TOTAL NUMBER of
4165A wells abandoned: ,,//��'
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '°'`7 (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY: 1
Company Name HTH
�y ] ¢ 7e.Type of disinfectant used:
2.Well Construction Permit#: gt�" v`/`aft :r
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if/mown 1/2 lb.
• 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ' Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Xesidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation DSpecialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Shiny 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection'Well: 7f.FFoor�ea'h.nat..rtat�aio..t...t ahnve,provide amount of materials used:�
❑Aquifer Recharge !' OGroundwater Remediation �% / m1�ll-C_ GayJ / Ld 6^ .�
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test .❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.P ovide a brief description of the abandonment nrocedure:
DGeothermal(Closed Loop) . . ... .❑Tracer - ..
❑Geothermal(Heating/Coolis g Return)I °'.Obther a(explain under 7g) / 1 dfwtrg ,% P 6
•
4.Date well(s)abandoned:/Q ' b' c P "'
• V E
5a.Well location:
APR282020
Facility/Owner Name Facility IDII(if applicable). 8. rtification: lffOC'9P.ayienr�r,-}r , uri
d � �` e..--dui
Physical Ad esAya ,7({r 1 i afore o ertified ell Contractor or Well Owner Date
4:21
By signing this form, I hereby cerlifi,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
P'I,;'' r''• 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:
55. )' _557/h N —1? ` (30 1°13 W You may use the back of this page to provide additional well site details or well
:J 1 abandonment details. You may also attach additional pages if necessary.
I'ij ,r,
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,yo}'can sribmit one form.
_i,i ;! I 10a. For All Wells: Submit this, form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
. P""' I:I III;i Division of Water Resources,Information Processing Unit,
Gb.Total well depth: � (1't;),l: 1617 Mail Service Center,Raleigh,NC 27699-1617
I;I'° I'; 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
Gd.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Ge.Outer casing length(if Icnoivii)r'• "'''''. (ft.) .10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
_ of well abandonment to the county heals epartment of the county where
6f.Inner casing/tubing length(if known):• -,f , (ft.) abandoned.
r
6g.Screen length(if known): • • (ft.) •
Form GW-30 I'I Sloitlr Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016

•
'C0 • �� IUtcO�ItY: _.
This form-can be used fir simile or•mtiWplt-pret •
i.wen alrnclor 1nrorwntion:
tXtnitiglatnaptieLtEri
Well ouusctor Nuns( well owner peneoal(y abtmdonlug frill hlt/herp:Qpa 7a,Number of hell:being abandoned: •
tty)' For multiple Injection or non-voter r 1 lull,eonrrraetfon/obondonmrn{ WrPY ONO' with the tame
you can rvbmn On form.
NC Well Conirttclor Card pcanoe Number �• f"
Tb.Approximate plume of-outer remaining in xeU(a): teat)
•
)N.W: Poole Well & Pump Co,
Company Name FOR WATER SUPPLY WELLS ONLY:
• i ' 7e.T37n of dtzlnfeetant used, r
1,'Well Construction N: '�`
•
LL,r an applleoble will permits(i,r,C1 r�
ry;Sra'ri,r'arforrcr,IM1Ieallon,rrc)(flr,oxn . A
3,Well use(check well use); 7d.Amount of blare-client used:
•
Water Supply ii'ellt
7e.Sealing materjalr used(check all that apply):
• CDMunlolpal/Publio Nest Cement Grout. .
f7Agr1°ulltual
>03
f7 e
❑Oenthennd(liealing/Cooibrg Supply) ,I?I+E.esfdential Water Supply(single) ❑Sand Cement Grout Dry Cl lie Chips or Pellets
❑IndusLrtal/cnntrnerol� ❑Resldenaal walerliv I (shared) ❑Coco Concrete Grout CI Dry Clay
.I7lrti allolt Supply( CJ Drill Cuttings
Non1 elle r Supply Well: ❑'Speolalty Grout . pctrnvci
0Mnnilorin6 •
❑Bentardlo Slurry • Cl Other(explain under 7g)
Injection Well: ❑RxnY
❑AquffcrIlccitargo 7f.For each material selected abort'provide amount of materialsa used:
f7A ulfe ❑GmundwalerRcmallnlllnt °j ,_c �C 41,4.5
rI r 5torag'o1 Gird Itccovery i r ❑Salbil(y ldaitia e t tee?"
—
I❑Aquifer'fesl �,I �,�!'�",,1 ❑Slormwahx �
.; ,Ill',1i aF''r' Drainage •
I DExperbnental Technology ,,.,;j I, ����
I r�Geollnernlil(Clonal l sop),: CJSubalderrco Control
p '16
ClTracl1d • 7 Fronde a brief deauiptlodro the Abandonment procedure:
L IDl7eot etntaI(HOa(ing/Cooling.RcGitii) ❑Oilier tmro
lain undtx7
1,Date well(s)nbanilonetl
•
.ter $.
•
!adhiyin,rneryme �vl. , •
„' I .ipn PedlU ((ftppperble) • 8, er011catlonr
Pbyelcnl Address,•Ily, � p f r•
�r ' � 8lanaltad of Cet d WC Gonlnal°r nr a ptroer `
'sd
r :d' a 3dG�' �r` a e
Couul}� •
•Dy signing fhli.f°rm,I/:c cerfry that the well(s)tear(lucre)abandoned in
I•:;.';,, Peleel ldetttlfcadotiNa(PIN) dcoorrkindt Iflilai ''NC,lC 01C.0100 or 2C.0100 Well Construction Standards
3b.I,aUluderand:Ninglttillih'llegreel/minalei/secandi.or decimal degrees:
°nd►hafa�F3'OflhLrrecartihurbeenpravfdedl dre^trellonyl�r,
orn•ell'ti eid,'uoe leVibng li iiiA{oleb0 ,
,y 2--� 5 1.'', 9.She lllagrttm:or ad iliolixl well delnl)st
5. d<
N =7s.9 0�•"1L.}' YoU inky V.34.1io,$'ark of this pago to provide a yy{{ r w I si ��ei�alls or well
.4ribeh•Ni r ,.. . 1e abandonmwt'd�ialla; 'ou may also attach addlifar'"arragt:s trndCFshfy,
+rellk(7fQ t,: '•• lied- n rron-Irartrr, (' SONS • :r. r
'iri )r'�kr tot,abut cdd;sl'� , , •.:...:f:}fi iE ail 6 ru
a alkiatiiii,f,j•dkeidiruhs'ilydtieAtm Prpy. Inksl�i"=�G I'r•=. Pr. t,fKl
in.1Ye11'IbNI 10a, a11�rQtr' U"
lror•All,:�'e r 'Submit this form within 30 days of completion of well
,c:
• • abandodtnetiiI to UIo tollerwing:
r.
b,'.Colai tvell deplh;'-`I a' blvtrion'oflYaferResourcea,Information Processing Volt,
(fr.) 1611 Mill Service Center,ILaieigh,NC 27699.1017
"c•I7urchole tile rnefcr;. 1Db,
• I' v'�uit t .In.addlifor to sending Oro form to Oro address In loa
(In,) above,tda (tiifilfb$o dopy of this fomr within 30 days of complellon of well
' :i ;,:, I' , abandon:nen!id'.diefollowing:
d,il'ater level bc16M groUrilt iitrface,.1.;
(ft.) DlYfalbn.ofl}Yatirl�eepvrces,Underground Infection Control Program,
f6 f;ilhlle Can
;'se.Outer`eniing•lenglh(If l iUisp)i;;1,u'':. rrfee fern Raleigh,NC 17G99 IG3G
(ft) _ IDe, •
the ad : In addition to sending the Conn to
E!'ab •,,. elan aubmlt ono copy of thla form within 30 days of
=`;Innercasing/IUbing length(It�tiuj j�pa)I• eompletban onevch sbaitdottinrnt l0 Ole county hcalUr department of die cowtty
-'.,i,' r. . ,+ (fG) tirfrtxo abandoned.
. it:Scree'tttliiigtH;,(iticx1oivi)t'i;' •
•
' 4 1 ',,i. Inabd tttIDO
I .,•� INor>b•Gaivl p' IdtllparltbtvnenlYndN.,,...,o.:_:.... .

ONELL A.1IAN1)UNWVIL+N 1' RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood
• 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW/0 is needed. Indicate TOTAL NUMBER of
4165A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): , edi (gal.)
N.W. Poole Well & Pump CO. FOR WATER SUPPLY WELLS;ONLY:
Company Name HTH
f�V9a,.si' 7e.Type of disinfectant used:
2.Well Construction Permit#: IA�f) kVA-
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc)if known 1/2 lb.
• 7d.Amount of disinfectant used:
3.Well use(check well use):
•
Water Supply Well: 7e.Sealing materials used(check all that appl,.
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout / ntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) f1 Concrete Grout 0 Drill Cuttings
❑Irrigation OSpecialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge, ;' pGiound A water Remediation 4 _VII 445
❑Aquifer Storage and Recovery ❑Salinity Barrier G' "-1
❑Aquifer Test ❑Stormwater Drainage p��''`/'
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) . ❑Tracer - ---- - •• • . —----'- •---
❑Geothermal(Heati g/Cooling Return) " ❑Other(explain under 7g)
d � ro /9F.. fj 4L 1J /
4.Date well(s)abandoned: 1/ ' '
5a.Well location: ""-. " r Li
1[1 ;',• I .' AIR 2
f t i
2023
Facility/OwnerName - ' . -Facilt IDfI(if applicable) 8.Certification:
i L.� •
1t71 j� tifRi; toil ( * t g
rieti„.....df
Physical Address,City,and Zip Signat e of Certifie. • ell Contractor or Well Owner Date
..vl;. , . By signing this form, I hereby cent that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 a'2C.0200 Well Construction Standards
i' 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:
Ze
36.1 P3� N 15' 0 ii Q 31 `,4, You may use the back of this.page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can'submit one fort:.
;;i , IOa. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: abandonment to the following:
I ,i.r,:: I Division of Water Resources,Information Processing Unit,
Gb.Total well depth: 5(ft.)nii,,i 1617 Mail Service Center,Raleigh,NC 27699-1617
,. .. , ','a' , IOb.For Injection Wells: In addition to sending the form to the address in 10a
Gc.Borehole diameter: (in.) ' above, also submit one copy of this font within 30 days of completion of well
/, j abandonment to the following: '
•
Gd.Water level below ground surface: fi . (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1/Ge.Outer casing length(if known):-, -•• (7 (ft.) .10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
•l,i i of well abandonment to the county health department of the county where
•
6f.Lrner easing/tubing length(if known): '•,1,...••• it (ft.) abandoned.
-XS:6g.Screen length(if known): (ft.) '
Fonn GW-30 ' ''" ''' 'North CarolinaDe Department
p Quality-Division of Water Resources Revised 2-22-2016

, .
.,..
\NFU:IL ARANI)ONMENT RECORD Far Ogrnrzta 01.6x wax: , ,,
1_IN A'ii C.cants•ntarr Ilnirantntttiinni: %VISA.RINNTLft,V.IIENTIr META 01,....5 : .
1! Barry(1\10TegMd
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r,
.C,,,i:rztutralrOr wel ennurpururnety 3N-we:tunnel itut Nteraruzuwerttyp well cria=mrttrAllvt,t0ady 0 GW-30 ut Brea.r&dcr.,z TOTAL NI-103.-
IntrITS e...hra5n2110: ' ' f
// -4165A
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7,111.krinnnuf.annt Vail=al-latjar actamomarg -
n-4:-.-nnwear C=Taiveira'Amen:
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-FM1
Conv rry Namt.
7¢..'llyge airdliinarectimmt used:
i.' .2..wet Owilannttivai Utrur;.11 gr.Gliar"-'61,3:5167t0'!7,,E52..-9-3
r 1,32.:744,74161.*4,30 ZWZ1212U2600/P.M.(A,gur_tu.gc c....t.?,..axe.tra,fi.p.04 ffintpura
741.1uniunttatlIcienirsintntr azolti 12:Eltn_
, .
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''i 1 N.N.ttor-'... 11.24-%%•Le.. Te..Sci.164,,,,mmtarfna uzni Cdtedcrt..9 Lliza attaik.:
'i q ak=rd....•=1 EltunintinINtitft ED 11=ttC'ararnt(Oa= .;C'Brarzailz 11".:L;p or Perkez5
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1
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,., fillnizezian Wert. 7it.Far otelh umnrriitil sinkcrirdi .1!oznatn;17.mikts mamma el riatami mei;
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0,AO:A. 96044SS .
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MU.For thl•Nreil Sailcadizt Lillis's E'smal Within TB 60.*s•of awngentingn of
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• WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Conty ctor Infor tion: WELL ABANDONMENT DETAILS I
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.
333� c. °� "A°Y`F� e��L,.� 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor rti cation Number
��
'M t J, /"5C4'1+ 9. S zUZ3 FOR WATER SUPPLY WELLS ONLY:
Company Name s tr.:. 7c.Type of disinfectant used:
A1/4—
2.Well Construction Permit#: ,...,,..:.a.n,.1•3 P if-
List all applicable well permits(i.e.County,State,Variance,fnjectr'on,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
ly)
7e.Sealing materials used(check all that app
Water Supply Well:❑Agricultural ❑MunicipaVPublic 0 Neat Cement Grout entonite Chips or Pellets
0 Dry Cl
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grouty
0 Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) 0 Drill
0 Specialty Grout
❑Irrigation 0 Bentonite Slurry ❑Other(explain under 7g)
N en ion Well:Water Supplyx Well:
,,,,
onttoring ❑Recovery 7E For each material selected. Ul'eAv d o)above,provide amount of materials used:
I
❑Aquifer Recharge ❑Groundwater Remediation f q-c
❑Aquifer Storage and Recovery ❑Salinity Barrier 5v ,dS. we/e
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer til,( 5 G /�ei �dl l� 51,11,4Lep[1tr es, /je„kl9/
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) r JA�') ®`t, t p A/ /1'jj/(��tt t c�J�/�1.4,r� i
4.Date well(s)abandoned: 14I 1 7/23 (t d- �r la)) fLLf e, I? 4v1c/�d h( d
5a.Well to tion: 45 `� p4 •�— !
t/"U t le (. ` 8.Certifi >"t .
Facility/Owner Name / Facility ID#(if applicable) , ��
j ( , / (eifi /V C, 7 6 , (4 44/77/2
f� � L ign re of Certified Well Contractor or Well Owner Date
V
Physical dd ss,City,and Zip
wa((e I'1D'? ' Is'i I By signing this form, 1 hereby certify 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:(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
3 v 11I 9149 You may use the back of this page to provide additional well site details or well
7 N 41O 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 cons 'talon/aba donrnent.you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
VU abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
�) above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: " ` g bid (in.) abandonment to the following:
n `/ Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: �/ (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
041uD-N 10c. For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft•) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
p p QUA where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): t/V111(4 o(/1'(A (ft.)
i
•
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: I
This form can be used for single or multiple wells
1.Well ontractor Inf rmaf'ten WELL ABANDONMENT DETAILS
Well
L1 1 76 A.-�✓ 7a.Number of wells being abandoned:
J For multiple injection or non-water l supply wells ONLY with the saute
Well Contractor 6/(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contra for rtificetion Number �► _
111 I Jt�1 0.4r� f6 550� L Z—p 6- FOR WATER SUPPLY WELLS ONLY: A i /J
Company Name APR 2 b 2023 7c.Type of disinfectant used: J�
2.Well Construction Permit#: 1i�itt oNr�T)
Cl1:�a'l�i'
List all applicable well permits(Le.Cmtnry,Sale, (rr5cI� 3t. 7d.Amount of disinfectant used:
`
3.Well use(check well use):
7e..Sealing materials used(check all that apply):
Water Supply Well:
DAgricultural ❑Municipal/Public Neat Cement Grout Bentonite Chips or Pellets
/❑Dry Cla
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 and Cement Grout y
0 Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) 0 Gravel
❑Irrigation 0 Specialty Grout 0 Bentonite Slurry 0 Other(explain under 7g)
s1 n-Water Supply Well:
onitoring ❑Recovery
7f.For each ate ial selectedoebove,provide amount of materials used:
nject
Aquife Well: .3D 4 46 �IJMIG e cA,"p5 2-,0 q of 5, INq�'�
. ❑Aquifer Recharge ❑Groundwater Remediation �S,f Pi✓1 / [) ,�
❑Aquifer Storage and Recovery ❑Salinity Barrier ,5[45, '),t�e r p�f it.j L.e.st ei I—/& o 1/-144 l `ti `e
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology OSubsidence Control 7g.Provide a brief description of the ab nndon/meot procedure: /
OGeothermal(Closed Loop) OTracer <II l�c�pale/ �j 'yr/�C G6r',)Alm_- pe r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) (� / 10t , l6�Sttr GZ.
/Li" tit/t
/23 A.i(ddr-1 i d i 51/���Y-i9 b ui�d l/1-�'a�i C cct it- i l(1 u4 (Z"c:-eC/
4.Date well(s)abandoned: ,�- I ' /r
Pie 1"t/ ft) Shia : lei/T a t,tl� ZPitc/tL t-' 7'/1v S1^wvta1L—Co�'->
Sa.Wellto ationj•�
eMtre, Lew k • C,i/i2-/9UL,Vli- I'8 Ls,
8.Certrfica n:
Facility/Owner Name Facility IDI(if applicable) _ ��1
lm4 /vJL
#417-
5ignre of Certified Well ontractor or Well Owner Date
Physical Address City,and Zip G
[OP'
�Q- `"o2,(o'7 I �Oy I By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
IJ 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 lat/long is sufficient) 9.Site diagram or additional well details:
] / 0, q ' l96(Z003 You may use the back of this page to provide additional well site details or well
W
3 St [Ct�cob N 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 o struclion/a andonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
V liti— I f abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
a � 1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: J (ft.)
106.For Infection Wells: In addition to sending the form to the address in 10a
Qa� above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: f J (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 31 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
•
lOc.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
\1 F� where abandoned.
6f.Inner casing/tubing length(if known): P" © � (ft.) !
fig.Screen length(if known): J A1:C4ow1A (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: I
This form can be used for single or multiple wells I
(
1.Well po
p
tractor Information: WELL ABANDONMENT DETAILS
�1r y 4, �'S chit 7a.Number of wells being abandoned:
•
1 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 pne form.
3 3q i'�: f .,, ''p 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Cotractor fication,Numbe a—..'ir! ; d...r
FOR WATER SUPPLY WELLS ONLY: LJ 1
G � ����` 1�� ^PRniZQ" /iy ii)—
Company Name 7c.Type of disinfectant used:
rat /r ir
2.Well Construction Permit#: it
lniOfsc' :Us1 S�l.� "ru�'r�1..!
List all applicable welt permits(i.e.County,State,Variance,Injeciitiriiewn 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that p y):
Water Supply Well:
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout Bentonite Chips or Pellets
p ry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout y
0 Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) 0 Drill
0 Specialty Grout
❑ 0 Bentonite Slurry 0 Other(explain under 7g)
ion Non-Water Supply Well:
onitoring ❑Recovery amount of materials used:
7f.For each rrr��aterial elect d above,provide
n
Aquife Well: _ • )/ 2� 1til f _v5
. ❑Aquifer Recharge ❑Groundwater Remediation 1JJ�`l(,�' (J (l�/ (�%
❑Aquifer Storage and Recovery ❑Salinity Barrier V T4 (il'01- ,y-
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a(eta-
bfief description of the abandonm nt zedure:
❑Geothermal(Closed Loop) ❑Tracer4 / c/�f u'aai, k�
r
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Z`. v� -et/ n��ri� 'r f "� / ct t -1 t r, / p�
Lig/ I z3 ' ki-'^�' �- ,i e ilgr cs .
4.Date well(s)abandoned: 1G7� s" t'"C ��
5a.Well 1 cation• , (_ l- /
(4)O(e- Li(d , 8.Certif ion:
Facility/Owner Name Facility 1Dt!(if applicable)
2�41 _ 5. 'Powell Si-, /0i -4 N G (---7—Ze- X ��l,�'�23
vV0 !s' tyOWQ ` I / azure of Certified Well Con or Well Owner Date
Physical A dress,City,and Zip �����(�
LA/P e ��03 -1 By signing this form,I hereby ceriffi,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:(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:'/Z You may use the back of this page to provide additional well site details or well
7S'Till
2 I N O 9��L f 2- y 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
�-5— abandonment to the following:
6a.Well IDH: /"�,An`
Division of Water Resources,Information Processing Unit,
6b.Total well depth: : t 1617 Mail Service Center,Raleigh,NC 27699.1617
1 (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
�j l'I above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 0 (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: �U (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c. For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): UlAlitbl r7 CVO- (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
j where abandoned.
6f.Inner casing/tubing length(if known): IV 9 Aig (ft.) '
• 1
6g.Screen length(if known): lAutoINA (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.Wf '
II Contract r Info rjsatio WELL ABANDONMENT DETAILS
a l•� Ft , S;, �'✓ 7a.Number of wells being abandoned:
V For multiple injection or non-water supply wells ONLY wit the sane
Well Conte Same(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form.
``//1717;;
R .
�~r rr9'l..' + i 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor canton Nu, er
I 0s4 C Co lam, 3 FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
IA) 41-
2.Well Construction Permit#: r�°}�jrM `' 7d.Amount of disinfectant used: IA)
List all applicable well permits(i.e.Ca m%State,Variance,InjectionYeYet. ]Fno>,•n
• 3.Well use(check well use): •
7e.Sealing materials used(check all that tip y):
Water Supply Well: 0 Neat Cement Grout 'Bentonite Chips or Pellets
❑Agricultural ❑Municipal/Public 0 ry Clay
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout
0 Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial °Residential Water Supply(shared) CI Gravel
0 Specialty Grout
❑Ir 0 Bentonite Slurry 0 Other(explain under 7g)
ion Non-Water Supply Well:
vlonitoring ❑Recovery 7f.For each material selected ab^o�ve,provide amount of materials used:
Injection Well: � f171
q rL (,Gt`ps
. ❑Aquifer Recharge ❑Groundwater Remediation !'o f 17 J, 6 e,,,k61 t t'
❑Aquifer Storage and Recovery ❑Salinity Barrier -1 u J5 ✓�j
❑Aquifer Test ❑Stormwater Drainage �t di !U
❑Experimental Technology ❑Subsidence Control 7g)rovide a brief description of the abandonment procedu e:
❑Geothermal(Closed Loop) ❑Tracer SLt4tZ�l�,u✓ 0 4 tsa�i7lltl�� (ltUf1) fiu9 u�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) e� t
2A NC- /WC-I 11 ft' w, V 101' {—fir' 10•001 s'fiag, r Aliz '
4.Date well(s)abandoned: WI 17/`—� 1tt- p6Lt tb G`s ji /11, /in T�e_ Sra
5a.W 11 II capon:
8.Certifi /on: ► f
Facility/Owner Name Facility IDt/(if applicable) // 11
j. / /��
jI/ k S �CPt Ali C/ C �ai�r(;- 411/1
11if Jl
Pt�l l ' r� � � Signature ofCcftified Well Contractor or Well Owner Date
Physical Address,City,and Zip
�� /G e ``1O��'7 I i4 I By signing this form,I hereby certh&that the well(s) was(were)abandoned in
v v DDD��� 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 to provide additional well site details or well
3,, � (�3 N �,(6%l Ip y 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 some construction/abandonment.you con submit one form. IOa. For All Wells: Submit this form within 30 days of completion of well
in `, -'3 abandonment to the following:
6a.Well ID#: I/�
Division of Water Resources,Information Processing Unit,
'6b.Total well depth: 3�� (ft.) 1617 Mail Service Center,Raleigh,NC 27699.1617
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:
31.
f Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
I10c. For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): N l,/2 DLv� (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): t`r)U N/' (ft.)
6g.Screen length(if known): U LA ke p Wil (ft.) 1 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: I
This form can be used for single or multiple wells
1.Well Contract
or Infor ation: WELL ABANDONMENT DETAILS
� �Cp� 7a.Number of wells being abandoned:
For multiple injection ar non-water supply lls ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form.
�`� ` r i-L, L y g^^;i 76.Approximate volume of water remaining in well(s): l) (gal.)
NC Well Crontracto Certification' Number 6 1,---- ='.e q �/' ,.,,,
V`"t 11_ 1 �i ` c 0rf.SAB G n P c L LJ FOR WATER SUPPLY WELLS ONLY: A
VI ` ��/ V
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well permits(i.e.Couny,Stare,Variance,Inftc'dlu)atca't. knowtr 7d.Amount of disinfectant used: t
3.Well use(check well use):
7 .Sealing materials used(check all that apply):
Water Supply Well: Neat Cement Grout Bentonite Chips or Pellets
❑Agricultural ❑MunicipaUPublic �
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 and Cement Grout ❑ ry Clay
0 Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial °Residential Water Supply(shared) 0 Drill
0 Specialty Grout
avel
❑ i iWaon 0 Bentonite Slurry 0 Other(explain under 7g)
N n"-Water Supply Well:
Monitoring ❑Recovery
7f.For each material/ selected above,+ ) provide amount/ of materials used: f
I ction Well: �� I7 5. /J e_ lv f f h.��1S f 1�1, ` ./es'S/ je`z�itii't
. ❑Aquifer Recharge ❑Groundwater Remediationla
❑Aquifer Storage and Recovery ❑Salinity Barrier r5 AY fy.oe-i it'rlcd (eine/Lk 2.0 gels. (`-`-��''
❑Aquifer Test ❑Stormwater Drainage 1
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer y SI/4,te.',pctiG�Le 1,� dickcAS dui, frc 2` ,e e /
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Gt//,!,;14 l0 r 01-itt /t'7/1 s,,/,4 -/fA yw/&2`�(
47/ 7l�3 —'k C li / G(T� c,CF-8.'i/"AC I i-f Lc S_1,4),-Gz,/o e/ •
4.Date well(s)abandoned: ,/
5a.Well oc lion: P l tc2-G 0.4/ tl DI�:-t i'�d711 I Xy (�D` /p 1141, - f t O� T'r.
i, A tr .e. [/ l col svo C'�
VU Facility ID#(if applicable) 8•Certif ation: J �/ ` /
Facility/Owner Name t oz/ g it:_ l(j/��
201 1N• M6p�t`l�S�• I&13k1 Nc �� ty / CCC Q((
7 Sign lure ofCe ifi Well Contractor or Well Owner Date
Plty cai•Ad less,City,and Zip flO 7�1 I�9
ViGLs(. __ By signing this form, 1 hereby certij,that the well(s)was(were)abandoned in
VVUV����//// 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
3Jr g0� N V �� ZL7�� 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
nn.l, , I abandonment to the following:
6a.Well IDN: (/v t V�
t Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699•1617
6b.Total well depth: `� (fl.)
F.U 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:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
O/l.l'�f1 U h 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
Ai 0o_ ( ) where abandoned.
6f.Inner casing/tubing length(if kno�wn):i� ft.
liA
6g.Screen length(if known): V �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
I.Well Contractor Information: WELL ABANDONMENT DETAILS
(✓toi A. (--igekee
7a.Number of wells being abandoned:
For multiple injection or non-wafer supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) construction/abandonment,you can submllone form.
3 33� 7b.Approximate volume of water remaining in well(s): !) (gal.)
NC Well Contractor Certification N ber .
tt ,1 - sf l I L sco 4 ;"•� r —i '�� FOR WATER SUPPLY WELLS ONLY: �U�
Company Name f APR 2 8 2023 7c.Type of disinfectant used: /�
2.Well Construction Permit#: tf d:ri:i //V �f-}—
List all applicable well permits(i.e.County,State,r��qir�iance: acid n-etc v 7d.Amount of disinfectant used: t I
3.Well use(check well use):
7e.Sealing materials used(check all that apply):
Water Supply Well:0 Agricultural ❑Municipal/Public 0 Neat Cement Grout entonite Chips or Pellets
0 ry Cl
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grouty
0 Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) 0 Drill
0 Specialty Grout
❑I 0 Bentonite Slurry 0 Other(explain under 7g)
Nonn--WWaaon ter Supply Well:
Monitoring ❑Recovery 7f.For each material sale tad abb ve,provide amount of materials used:
t0Aquifn Well: ii-.0 As. 48`� t �//
. ❑Aquifer Recharge ❑Groundwater Remediation '[ dI , t/4/
❑Aquifer Storage and Recovery ❑Salinity Barrier 2,0 4 (s c,�
❑Aquifer Test ❑Stormwater Drainage t
DExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
�Lef L J
OGeothermal(Closed Loop) OTracer t" •� owe/ 6edAh.u'Vt- c '5 /_JOI.w'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) N (i'e aL t /)-f'j A"[1 t l /— �� /j j-i Hill^
t4 •
( 4-(23 i o G -(-1, l c4 yt r4z ae. 7 ILidr /6
4.Date well(s)abandoned: ` '
Sa. t(1o.fr
Well 1 cation Umikt 8.Certifi t' nFacility/Owner Name Facility IDIi(if applicable) ��/J �
OAA
1
lisbur SA-. liA I, �, f-. I
3� 5.Sa �4 g ) Nc
Signature of Certified Well Contractor or Well Owner Date
Physical A�d City,and Zip 3 6�y1
([ ) e- 0 By signing this form, I hereby certh,that the wells)was(were)abandoned in
Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
l
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� z�� Cr N �r Cp�l7Tv 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-watersupply
wells ONLY with the sane construction/abandonment,youform. 10a. For All Wells: Submit this form within 30 days of completion of well
fill .L q44- abandonment to the following:
6a.Well ID#: Y!L l/�
Division of Water Resources,Information Processing Unit,
r/ 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: `r' (ft.)
lOb.For Infection Wells: In addition to sending the form to the address in l0a
�/1 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: b (in.) abandonment to the following:
/ Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: ��'" (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
•
9 � 10c. For Water Supply&Injection Wells: In addition to sending the form to
ays of
6e.Outer casing length(if known):v V Uk i nov" (ft.) the a eties of weles) l abandonment submitove, also one copy of this to the county health formdepartmenthiof 30
dcounty
} {�J complwhere abandoned.
6f.Inner casing/tubing length(if known): i'" 1_ (ft.)
OA k4Oikh . 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 ForinternalUseONLY:
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: 19
Well Contractor Name(or well owner personally abandoning well on his/her 71-0/,),..,.c. For multiple injection or non-water supply wells ONLY with the same
v• 9 construction/abandonment,you can.submit one form.
us }-NC 3322-A tL �'
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
•
Regional Probing Services APR 2 s Z02-3 FOR WATER SUPPLY WELLS ONLY:
Company Name �, ,y•r,;;r?]Ut'^
p y rn Z t• 7c.Type of disinfectant used:
' ae v ",
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Counry,State,Variance,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout l Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
0 Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
CI Aquifer Recharge ❑Groundwater Remediation Bentonite Chips:1.6 Ibs/ft(13-88 lbs/well)
❑Aquifer Storage and Recovery OSalinity 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.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MW-3(19'),MW-5(20'),MW-6(18'),MW-7(18'),MW-8(18')MW-9(28'),RW-4A,
4.Date well(s)abandoned: 3/13/2023 MW-10(22'),MW-11(12'),MW-12(8'),MW-13(50.5')MW-14(34'),MW-15(50.5'),
5a.Well location: MW-16(23'),MW-17.(22'),MW-18,(22),MW-19(55'),MW-20(25'),MW-21 (15')
Farmers Supply Market
Facility/Owner Name Facility lDti(if applicable) 8.Certification:
3532 Old US Hwy 1 Lawrence Opper,%o- -7L °-- 3/22/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake By signing this form, 1 hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.6811744 78.935613 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 form within 30 days of completion of well
6a.Well ID# Monitoring Wells-See 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
8-55 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Infection 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:
5-25 ..Division of Water Quality,Underground Injection Control Program, ,
6d.Water level below ground surface: (ft.) • 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water.Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
• completion of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if known): 5-50 (ft.) where abandoned.
6g.Screen length(if known): 5-15 (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources-.Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned: 4
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
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS ONLY: p • y / ,'D
Company Name 7c.Type of disinfectant used: APR Well Construction Permit#: APR Z 8 tU23
List all applicable well construction permits(i.e.County,State,Variance,etc)if known
7d.Amount of disinfectant used: 777 .. UnK
3.Well use(check well use): L'1"etZi3 1
Water Supply Well: 7e.Sealing materials used(check all that apply):
El Agricultural ❑Municipal/Public ❑Neat Cement Grout l Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: • 0 Bentonite Slurry 0 Other(explain under 7g)
ElMonitoring El Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips:6"well:429lbs/well 8"well:1025 Ibslwell
❑Aquifer Storage and Recovery ❑Sal inity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Filled/hydrated from bottom-up.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
RW-2 (6"x30'), RW-3 (6"x30'), RW-5(6"x30'), IW-1 (8"x41')
4.Date well(s)abandoned: 3/13/2023-3/14/2023
5a.Well location:
Farmers Supply Market
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3532 Old US Hwy1 Lawrence O er' — "�"�°�
PP m.,da ;, °�'° °— 3/22/2023
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 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.6811744 78.935613 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. IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: RW-2,RW-3,RW-5,IW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth 30-41 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
well dia: 6-8 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 Quality,Underground Injection Control Program,
6d.Water level below ground surface: 10 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
5 where abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): 25-36 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013