Chatham_Well Abandonment_20231215 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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 GWi30'is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY: '
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoron
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-.j- Z­C,',�.;��f q� Berta ite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) El Sand Cement Grout " ► !"'E) Jc}gay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout DEC I 4 rill Cuttings
❑Irrigation ❑ Specialty Grout 2�"tavel
Non-Water Supply Well: ❑ Bentonite Slurry afw.6a'Qp3ctl�n(explain under 7g)
toe . .
eMonitoring ❑Recovery Dti`v W,�;`.�ttd
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —30 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Bentonite chips were poured into the well and tamped
until chips rose to top of well casing. Casing was
4.Date well(s)abandoned: October 10, 2023
then capped with original locking cap.
5a.Well location:
CPF, LLC Not Applicable
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Moncure Pittsboro Road & NC Highway 87, NC 27559 K-�S��2-11-2023
Physical Address,City,and Zip Signature of Certified tCoractor or Well Owner Date
Chatham 95729 - By signing this form, I hereby certify that the ivell(s) ivas (were) abandoned in
Comity 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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional wellldetails:
35.692759 N -79.169751 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
Auach ive/l construction record(s)ifavailable. For multiple it jection or non-tvatersupply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W 7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.) 1617 Mail Service C i enter,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: —7.8 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1 .
6e.Outer casing length(if known): NA (ft) 10c.For Water Suonly&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.
i
6g.Screen length(if known): 20 (ft.) i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NCWC 3510-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
I ,
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.)ifknou'n
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing material;used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Gout; 'a ;4 19.Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout -_jD,13'Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout DEC I V 023O Drill Cuttings
❑Irri ation ❑ SpecialtyGfoet CV ❑ Gravel
Non-Water Supply Well: +DrryT"" ref,
PP Y El Slurry �;,�,�e(�)her(explain under 7g)
RMonitoring ❑Recovery DVVQj20G
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —35 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test -OStormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite chips were poured into the well and tamped
until chips rose to top of well casing. Casing was
4.Date well(s)abandoned: October 10, 2023
then capped with original locking cap.
5a.Well location:
CPF, LLC Not Applicable
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Moncure Pittsboro Road & NC Highway 87, NC 27559 �'12-11-2023
Physical Address,City,and Zip Signature of Certifi W Contractor or Well Owner Date
Chatham 95729
By signing this form, 1 hereby certify that the ivell(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 tire ivell owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.692759 N -79.169751 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-ivahersupply wells
ONLY witb the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 27 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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: —21.6 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) loc.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one'copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 7 abandoned.
I
6g.Screen length(if known): 20
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
{,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water rf maining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement G o e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement root+ ,.Z '�'b�i Lfl iDry Clay
❑Industrial/Commercial ❑ XResidential Water Supply(shared) ❑ Concrete Grout s a^E]'�D011 Cuttings
❑Irci ation ❑ Specialty Grout 0 -1023❑ Gravel
Non-Water Supply Well: ❑ Bentonite$lU ❑ Other(explain under 7g)
-ra"��
eMonitoring ❑Recovery ,
Injection Well: 711 For each material s ti-1116vey provide mount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —30 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Bentonite chips were poured into the well and tamped
until chips rose to top of well casing: Casing was
4.Date well(s)abandoned: October 1 O, 2023
then capped with original locking cap.
5a.Well location:
CPF, LLC Not Applicable
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
Moncure Pittsboro Road & NC Highway 87, NC 27559 —12-11-2023
Physical Address,City,and Zip Signature of Certi ed We Contractor or Well Owner Date
Chatham 95729 By signing this form, I hereby certify that the ivell(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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.692759 N -79.169751 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
Attacl,well construction records)ifarailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
(Oa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-B abandonment to the following: ,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.) 1617 Mail Service C+nter,Raleigh,NC 27699-1617
10h.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: —2.8 (ft.) Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): NA (ft) 10c.For Water Suonly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

i
WELL ABANDONMENT RECORD For internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis
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
NCWC 3510-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifhnown
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 { (•_ 'S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout t`'"-. i",i? r D lag
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout DEC 7 ❑ ?111kuttings
❑Irri ation ❑ Specialty Grout l V ?��ilavel
Non-Water Supply Well: ❑ Bentonite Slurry)r"L-f' ^gib n t�r4 V c^ ❑ Other(explain under 7g)
RMonitoring ❑Recovery ..�,� ten,„•. U5�7
Injection Well: 7f.For each material selected abovte,p b*ide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips —55 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Bentonite chips were poured into the well and tamped
until chips rose to top of well casing. Casing was
4.Datewell(s)abandoned: October 10, 2023 then capped with original locking cap.
5a.Well location:
CPF, LLC Not Applicable
Facility/Owner Name Facility IDk(if applicable) 8.Certification:
Moncure Pittsboro Road & NC Highway 87, NC 27559 12-11-2023
Physical Address,City,and Zip Signature of Cert red W Contractor or Well Owner Date
Chatham 95729
By signing this form, 1 hereby certify that the tvell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the ivell owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.692759 N -79.169751 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 ityection ornon-water supply wells
ONLY with the saute construction/abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-D abandonment to the following: 1,
Division of Water Resources,Information Processing Unit,
6b.Total well depth 49 (ft.) 1617 Mail Service Ceriter,Raleigh,NC 27699-1617
106.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: —41.9 (ft) Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) I Oc.For Water Sunoly&Iniecti In Wells: In addition to sending the form to the
address(es)above,also submit one copy of this farm within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 29 (ft.) abandoned..
I
6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor information: WELL ABANDONMENT DETAILS
I
Brian James Bellis 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
NCWC 3510-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Not Applicable
List all applicable ivell construction permits(i.e.UIC,County,Stare,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materi Is used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Gr�uP,,' Bentonite Chips or Pellets
�K sti
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout �"'>! "E1'Ijry Clay
"• y
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout DEC ❑ Drill Cuttings
❑Irri ation ❑ Specialty G(pu�.rr .54 ZQ?lo Gravel
Non-Water Supply Well: ❑ Bentonite Slurry " ^
, a-w•�eC.. Q,Other(explain under 7g)
x
eMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips —40 pounds
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite chips were poured into the well and tamped
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
until chips rose to top of well casing. Casing was
4.Date well(s)abandoned: October 1 O, 2023
then capped with original locking cap.
5a.Well location:
CPF, LLC Not Applicable
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Moncure Pittsboro Road & NC Highway 87, NC 27559 42-11-2023
Physical Address,City,and Zip Signature of Certifie Well ntmctor or Well Owner Date
Chatham 95729
By signing this form, 1 hereby certify that the ivell(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.692759 N -79.169751 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 wellconstructionrecord(s)ifavailable. For multiple uyection or non-water supply wells
ONLY ivith the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW E abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 32 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in.) above, also submit one copy of thin form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —13.3 (ft.) Division of water Resources,Underground Injection Control Program,
1636 Mail.Service Ce 4nter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Sum&Iniection;Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.inner casing/tubing length(if known): 12 (ft.) abandoned.
i
6g.Screen length(if known): 20
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016