Wilson_Well Abandonment_20230706

I
WELL ABANDONMENT RECORD .For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. We rley 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: 1
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): 1'75 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY: r
Company Name W M 0501465 (��, 3'•� j F ti
7c.Type of disinfectant used: L.a yl^'-•
2.Well Construction Permit#: JUL © G
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknortn J 2023
7d.Amount of disinfectant used:
3.Well use(check well use): In. Ci^^�%,,l?:-:
Ism:t-..` ''' :':t7(:r f
Water Supply Well: 7e.Sealing materials used(check all that apply): '-'.A-6.8 r
❑Agricultural ❑MunicipaUPublic • Neat Cement Grout II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery ..
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite "' 20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Neat cement -35 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
UGeothennal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/25/2023
5a.Well location:
Proposed Wawa Wilson C-004625 N/A jAs
Facility/Owner Name Facility ID#(if applicable) 8.Certification: c-.2650 Ward Boulevard �•J0�'J ti 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or'hell Owner Date
Wilson 3713-70-4108.000
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC O2C.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:
35.751296 N 77.930054 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 cells
ONLY with the same construction/abandonment,you can submit one form.
MW01 10a. For All Wells: Subunit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (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 subunit one copy of this fonn within 30 days of completion of well
,1 abandonment to the following:
6d.Water level below ground surface:4.34 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
N/A (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: • WELL ABANDONMENT DETAILS
Scott M. 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:°ne
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'75 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: uv:,
-�,,•v ti
2.Well Construction Permit#: WM0501465 - f'f
List all applicable well constructionpermits(i.e.UIC,County,State,Variance,etc.)i known "
PP Yf
7d.Amount of disinfectant used:
3.Well use(check well use): 1 �7 C l�[•j
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout I Bentonite Chips oNRellbp ('r1
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustrial/Cornmercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Sluny ❑Other(explain under 7g)
lMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite ^' 25 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquiferTest ❑StonnwaterDrainage Neat cement ~35 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Gravity feed bentonite chips to 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/25/2023
5a.Well location:
Proposed Wawa Wilson C-004625 N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: C ,
2650 Ward Boulevard � ';0,1,1 Vital 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contractor 01/ell Owner Date
Wilson 3713-70-4108.000
By signing this form, /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:
35.751296 N 77.930054 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 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#: MW02 abandonment to the following:
Division of Water Resources,Information Processing Unit,
20 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
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: 4.34 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (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 M. 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:°ne
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 64:':'. .,;.ti
7c.Type of disinfectant used: Y'*r
WM0501465 .w,• ..z: : f
2.Well Construction Permit#: /�f 4 a' ,�;���„"'+.�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknonn /+ ire 7d.Amount of disinfectant used:
3.Well use(check well use): t�' i,., :; . ,`r�3
Water Supply Well: 7e.Sealing materials used(check all that apply): ^i ;'��.,�,,,,,,vP^593k, +
❑Agricultural ❑Municipal/Public IP Neat Cement Grout I I Bentonite Chips or PelIe't 1,a �'t%i
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
PMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite "' 20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage Neat cement —35 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
`❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/25/2023
5a.Well location:
Proposed Wawa Wilson C-004625 N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: --
2650 Ward Boulevard (\ � ,� li'41 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or` ll Owner Date
Wilson 3713-70-4108.000
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:
35.751296 N 77.930054 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)ifavarlable. For multiple injection ornon-wotersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this tbnn within 30 days of completion of well
6a.Well ID#: M W03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 15 (ft)
10b.For Iniection Wells: In addition to sending the form to the address in lOa
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: 7.31 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the fonn 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): 5 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werle 1
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:One I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.00 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name d �.
W M 0501465 7c.Type of disinfectant used: '`"-( .,
2.Well Construction Permit#: Jo/ ['�"'d<,�"
List all applicable well construction permits(i.e.U!C,County,State,Variance,etc.)if known © `'` '
7d.Amount of disinfectant used: it1 rC ( 2/1,
3.Well use(check well use): 'f.�''
Water Supply Well: 7e.Sealingmaterials used(check all that apply): `hi'''�'1 s''��
PP Y PP Y): ti,.ti C�.., •�?�:,hw
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
IMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite ^' 25 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Neat cement ~35 lbs
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
UGeothennal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
+❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/25/2023
5a.Well location:
Proposed Wawa Wilson C-004625 N/A
Facility/Owner Name Facility lD#(if applicable) 8.Certification: C-, 1
2650 Ward Boulevard Jed ,�4 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Vvner Date
Wilson 3713-70-4108.000
By signing this form, I hereby certt,'/y 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:
35.751296 N 77.930054 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 tie/i construction record(s)i/available. For multiple injection anon-n•atet•supply wells
ONLY with the some construction/abandonment,you can submit one firm. 10a. For All Wells: Submit this fonn within 30 days of completion of well
6a.Well ID#: M WO4 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 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
abandonment to the following:
6d.Water level below ground surface: 7.71 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A 10c.For Water Supply&Injection Wells: In addition to sending the fonn to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016

WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Scott M. 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:On
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'10 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name �ti
7c.Type of disinfectant used:
WM0501465 J J
o /
2.Well Construction Permit#:
List all applicable well construction permits 6.e.UIC,County,State,Variance,etc.)ifknoun © C'
7d.Amount of disinfectant used: lRrui;;x_. 2023
3.Well use(check well use): '•�•,,
Water Supply Well: 7e.Sealing materials used(check all that apply): .r ''
❑Agricultural ❑Municipal/Public I Neat Cement Grout • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Cornrnercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: • 7f.For each material selected above,provide amount of materials used:
❑AquiferRecharge ❑GroundwaterRemediation Bentonite — 25 lbs
0 Aquifer Storage and Recovery 0 Salinity Barrier
❑Aqui ter Test ❑StormwaterDrainage Neat cement —35 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/25/2023
5a.Well location:
Proposed Wawa Wilson C-004625 N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: -,
2650 Ward Boulevard , 1 6/23/2023
1
Physical Address,City,and Zip Signature of Certified Well Contractor on Will Owner Date
Wilson 3713-70-4108.000
By signing this form, 1 hereby cert f 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:
35.751296 N 77.930054 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;tell construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one firm.
MW05 IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb. For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 7.07 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): N/A (ft.)
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): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (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 M. Werl ey 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:one 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 '75 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ' '4:`'•(' .'-n
,,,$
WM0501465 ..L
2.Well Construction Permit#: -d ,, y-.f,,?
List all applicable well construction permits O.e.UIC,County,State,Variance,etc.)ifknonn JO/ ' s<„
7d.Amount of disinfectant used: p '..
3.Well use(check well use): 1P.;ct._-_:.
Water Supply Well: 7e.Sealing materials used(check all that apply): G1 y,ti. ,;
❑Agricultural ❑Municipal/Public IR Neat Cement Grout a Bentonite Chips ot`Pelfas I3a
❑Geothennal(Heating/Cooling Supply) DResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commnercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
Monitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 'r 20 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Neat cement —35 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
OGeothennal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/25/2023
5a.Well location:
Proposed Wawa Wilson C-004625 N/A
Facility/Owner Name Facility ID#(if applicable) S.Certification: c
2650 Ward Boulevard ' d
� ,b1) > 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or We'l/Owner Date
Wilson 3713-70-4108.000 By signing this form. 1 hereby cert(/j that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.751296 N 77.930054 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.
MW06 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (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: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
,1 abandonment to the following:
6d.Water level below ground surface: 4.1 1 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A 10c.For Water Supply&Injection Wells: In addition to sending the fonn to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit one'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Fonts GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

WELL ABANDONMENT RECORD ForintemalUseONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. 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:One 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 '50 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name c'b,-( r?'-,
W M 0501465 7c.Type of disinfectant used:
2.Well Construction Permit#: JO/ .r Vt; '.,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known Ill,. 6. © ,,�
7d.Amount of disinfectant used: '�t 4,-., 2...1
3.Well use(check well use): r,l)
Water Supply Well: 7e.Sealing materials used(check all that apply): -s( •g vh'
❑Agricultural ❑Municipal/Public • Neat Cement Grout • Bentonite Chips or Pellets t
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑IndustriallComrnercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
•Monitoring ❑Recovery
7Injection Well: 7f.For each material selected above,provide amount of materials used:
❑AquiterRecharge ❑GroundwaterRemediation Bentonite 'r 25 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑StormwaterDrainage Neat cement —35 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
ElGeothennal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
OGeothennal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/25/2023
5a.Well location:
Proposed Wawa Wilson C-004625 N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: cs-,
2650 Ward Boulevard c ',0i) fli& 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contactor orWV/Owner Date
Wilson 3713-70-4108.000 By signing this form, I hereby cerli/v 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:
35.751296 N 77.930054 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)iifavailable. For multiple injection or non-tinter supply wells
ONLY with the same construction/abandonment,you can submit onejorm.
MW07 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the fonn to the address in lOa
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: 6.16 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit one copy of this 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): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werl ey 7a.For Geoprobe/DPT or Closed-L000p 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:One
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2•S0 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY ELLS ONLY: .
W h,L� r-.
Company Name a
W M 0501465 7c.Type of disinfectant used: Jr Jr "t
2.Well Construction Permit#: ® 2023
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)ifknoun inter,---.....t:
7d.Amount of disinfectant used: 4.t t :),.
3.Well use(check well use): r
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite Chips or Pellets
1
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRetnediation Bentonite — 25 lbs
['Aquifer Storage and Recovery ['Salinity Barrier --
❑Aqui£erTest ❑StonnwaterDrainage Neat cement —35 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
['Geothermal(Heating/Cooling Return) ['Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/25/2023
5a.Well location:
Proposed Wawa Wilson C-004625 N/A
Facility/Owner Name Facility tD#(if applicable) 8.Certification: C—, r�J5-4
I
2650 Ward Boulevard � L� 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or We II�Owner Date
Wilson 3713-70-4108.000 By signing this form, /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 qf 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:
35.751296 N 77.930054 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 jam. I Oa. For All Wells: Submit this fonn within 30 days of completion of well
6a.Well ID#: M W08 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 fonn to the address in lOa
6c.Borehole diameter: 6 (in.) above, also submit one copy of this Porn within 30 days of completion of well
,1 abandonment to the following:
6d.Water level below ground surface: ^.29 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
1
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 M. Werley 7a.For Geoprobe/DPT or Closed-LI op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only l GW-30I is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:Tw°
7b.Approximate volume of water remainingin well(s): 2.40/2.10 (gal.)
NC Well Contractor Certification Number PP (g
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY:
Company Name ,'''"'
7c.Type of disinfectant used: % !'-w-.
1�' i+ - f-,,,,
2.Well Construction Permit#: 'V/A ''�.-e r Y,b pr'zi
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.)ifknoun ', .
7d.Amount of disinfectant used: JJ/ „1
3.Well use(check well use): uti re-i, ,.y G j
Water Supply Well: 7e.Sealingmaterials used(check all that apply): s''"^
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite h'ips- i;Peliet'r f
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Cotninercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
IMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite "' 30 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Neat cement -35 lbs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
Remove stick-up casings and pads
4.Date wells)abandoned: 5/25/2023 Pour neat cement from 5' bgs to ground surface
5a.Well location:
Proposed Wawa Wilson C-004595 N/A
Facility/Owner Name Facility[Di/(if applicable) 8.Certification: c
5003 Raleigh Road Pkwy, Wilson 27893 � fig,( (Uua/r 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or'Yell Owner Date
Wilson 2793-44-7081.000 By signing this jbrm, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 or 2C.0200 Well Construction Standards
and that a copy o/•this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
35.762862 N 78.006258 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 tcith the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this fonn within 30 days of completion of well
MWO 1 & MWO3
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection 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
abandonment to the following:
6d.Water level below ground surface: 1 0.20/ 1 2.00 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636 '
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Iniectio I 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): 10 (ft.) abandoned.
6g.Screen length(if known): 1 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 M. 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- 0 is needed. Indicate TOTAL NUMBER of
3344-A wells abandoned:one
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.75 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY: '' `r' �-,
Company Name j't��.
7c.Type of disinfectant used: f J/ ' ,�' _
2.Well Construction Permit#: N/A 0 /7
List all applicable x•ell construction permits(i.e.UlC,County,State,Variance,etc.)if known ,R fc'1't:.;�:.,
023
7d.Amount of disinfectant used: *1-1 ;Al._
3.Well use(check well use): :t: '"
Water Supply Well: 7e.Sealing materials used(check all that apply):
[Agricultural ❑Municipal/Public II Neat Cement Grout a Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
0 Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑AquiterRecharge ❑Groundwater Retnediation Bentonite 'r 35 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StonnwaterDrainage Neat cement -35 lbs
DExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer Gravity feed bentonite chips to 5' bgs
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
Remove stick-up casings and pads
4.Date well(s)abandoned: 5/25/2023 Pour neat cement from 5' bgs to ground surface
5a.Well location:
Proposed Wawa Wilson C-004595 N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification: c-m 0 11
5003 Raleigh Road Pkwy, Wilson 27893 1/u4J
,_c�l� 6/23/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or\\ II Owner Date
Wilson 2793-44-7081.000
By signing this form. I hereby certi/jr that the we/l(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:
35.762862 N 78.006258 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)iifarailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one jbrm.
MW02 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 13.19 19 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the fonn to the
address(es)above,also submit one copy of this form within 30 days of completion
.I 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): 20 (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016