Bertie_Well Abandonment_20240119

I.
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 7a.For Geoprobe/DPT or Closed-L,'otip 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
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water re I wining in well(s): 1'06 (gal.)
0
.Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name ,
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if;mown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) M Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring 0 Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
0 Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return)- 0 Other(explain under 7g)
4.Date well(s)abandoned: 01/04/2024 i�' r� �.
5a.Well location: AM 1 9 1014
Myers Groceryand White's Cross Grocery00-0-0000032961&00.0-0000025022
y . IrI``orr42:;i n Pf::t:an:p:.2 usw
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 06 4p. -A MCA OG
1901 & 1906 Wakelon Road, Colerain, NC �e � Q �,. 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6837-05-3544 By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.136889 N 76.86625 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)ifarailable. 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#: M W-1 • . abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9'24 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above,also submit one copy of thisI:form within 30 days of completion of well
abandonment to the following:
2.74 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) , i
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer'casing length(if known): n/a (ft.) IOc.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copyjof this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 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: 11
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Justin Radford 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
3270-A wells abandoned: I I
• NC Well Contractor Certification Number 7b.Approximate volume of waterremaining in well(s): 1'06 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
•/�
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: I'
3.Well use(check well use): P
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 1; P Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) CI Residential Water Supply(single) ❑Sand Cement Grout i; 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) •Concrete Grout 0 Drill Cuttings
❑Irrigation ❑Specialty Grout I' ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 20 lbs of Bentonite!, •
❑Aquifer Storage and Recovery ❑Salinity Barrier
15 lbs Concrete
❑Aquifer Test ❑Stormwater Drainage
,
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour II
0 Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) .
.` .;E Y ,�_s`
4.Date well(s)abandoned: 01/04/2024 !i e, a
5a.Well location: li JAN 1 9. 20?4
Myers Grocery and White's Cross Grocery 00-0-0000032961&00-0-0000025022 I
II Facility/Owner Name Facility ID#(if applicable) 8.Certification: jflfoFmEc+iF.il;7r;
a7,474.,,;.r� (•jlyN
1901 & 1906 Wakelon Road, Colerain, NC 11 owQi oc
b 1/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6837-05-3544 1
By signing this form, I hereby cert(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: Ii
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.136889 N 76.86625 `,1, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED I
Attach well construction record(s)ifarailable. For multiple injection or non-water supply sells SUBMITTAL INSTRUCTIONS
Ii
ONLY with the same construction construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
M 6a.Well ID#• W-3 abandonment to the following:
• Division of Water Resources;Information Processing Unit,
6b.Total well depth:
9.34 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I,
r.
6d.Water level below ground surface: 2.81 (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): 2 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources L Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILSi
Justin Radford i
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
3270-A wells abandoned:'
NC Well Contractor Certification Number 7b.Approximate volume of water Ie I aining in well(s):4.56I I
11 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
• 7c.Type of disinfectant used:
A'
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: lj
3.Well use(check well use):
• Water Supply Well: 7e.Sealing materials used(check all that apply):
0 Agricultural 0 Municipal/Public 0 Neat Cement Grout I, I!Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout I, 0 Thy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) IR Concrete Grout !' 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 1 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry i 0 Other(explain under 7g)
(Monitoring ❑Recovery
•
Injection Well: 7f.For each material selected above,provide amount of materials used: .
❑Aquifer Recharge ❑Groundwater Remediation 40 lbs of Bentonite i,
❑Aquifer Storage and Recovery ❑Salinity Barrier
li
❑Aquifer Test ❑Stormwater Drainage 15 lbs Concrete
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of th`abandonmenti procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour "T
r ;T=,,..
q":
01/04/2024 l ; J�;� I w
y
4.Date well(s)abandoned: 9 2024
5a.Well location: Etta+,.' ni`,O p
i' .,u It_
Myers Grocery and White's Cross Grocery 00-0-0000032951&00-0-0000025022 ,_ _1 ts,e-v 0G .4 .-pi.
Facility/Owner Name Facility ID#(if applicable) 8.Certifrcation: y
1901 & 1906 Wakelon Road, Colerain, NC 9,6z:z.,"1,
'4"' 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6837-05-3544 II
By signing this form, I hereby certif}'that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
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:
36.136889 N 76.86625 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.
I.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED !
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifarailable.For multiple injection ornon-watersupply wells
i'
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-4 abandonment to the following:
I.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35.06 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
!!
7.06 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 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): 30 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
!

f '
i
WELL ABANDONMENT RECORD For Internal Use ONLY: •
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
Justin Radford 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
3270-A wells abandoned: I'
NC Well Contractor Certification Number 7b.Approximate volume of waterremaining in well(s): 1.42 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A li ;
List all applicable well construction permits i.e.UIC,County,State,Variance,etc.)if known II
7d.Amount of disinfectant used:
3.Well use(check well use):
11
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 'Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout i 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout 11 ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
. Non-Water Supply Well: 0 Bentonite Slurry I 0 Other(explain under 7g)
'Monitoring ❑Recovery '
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier I,
❑Aquifer Test ❑Stormwater Drainage 15 lbs Concreteli
❑Experimental Technology ❑Subsidence Control i' '
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
01/04/2024 fr,y.'I i'` . i'T.
4.Date well(s)abandoned: 'i '' " a �-. j
5a.Well location: `,A1`I 19 2024
Myers Grocery and White's Cross Grocery 00-0-0000032961&00-0-0000025022 - x
Facility/Owner Name Facility ID#(if applicable) 8.Certification: /)y/-�1 i. ' D�,YO/•3L o
1901 & 1906 Wakelon Road, Colerain, NC �""�/-�� 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6837-05-3544 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:
36.136889 N 76.86625 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 i
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-6 abandonment to the following: i
Division of Water Resources,Information Processing Unit,
6b.Total well depth 12.71 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i.
10b.For Infection Wells: In addition to sending the form to the address in 10a
2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
• abandonment to the following: i I
f '
6d.Water level below ground surface:4.02 (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 countyi health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i'
•
WELL ABANDONMENT RECORD For Internal Use ONLY:
- I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
•
Justin Radford 7a.For Geoprobe/DPT or Closed-Loop p 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
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'81 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 4 •
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known I. •
7d.Amount of disinfectant used: I:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
II
. DAgricultural ❑Municipal/Public ❑ Neat Cement Grout IA Bentonite Chips or Pellets
I.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) I Concrete Grout 10 Drill Cuttings '
• ❑Irrigation 0 Specialty Grout I 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
EMonitoring 0 Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier 15 lbs Concrete
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 1'
7g.Provide a brief description of the�abandonment procedure:
❑Geothermal(Closed Loop) OTracer I.F - >_.. -,! r
Pour I: , ..__. ���x.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) h •- �'�'
01/04/2024 1. JA��� ZG2�
4.Date well(s)abandoned: b
irl',lr :c¢- 7._„
5a.Well location: i; CY h.'1 L;14
C+`►'v '
Myers Grocery and White's Cross Grocery 00-0-0000032961&00-0-0000025022
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 94(7 I!
1901 & 1906 Wakelon Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6837-05-3544
By signing this form, I hereby certh'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 bee),provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.136889 N 76.86625 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 wet!construction record(s)if available. For multiple injection or non-water supply wells
I
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 3 abandonment to the following:
ii
Division'of Water Resources,Information Processing Unit,
6b.Total well depth: 13.76 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 2.64 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
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 form within 30 days of completion
of well abandonment to the county Health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned. II
6g.Screen length(if known): 13 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1. ' Revised 2-22-2016
1
I ,

:. I
•
WELL ABANDONMENT RECORD For Internal Use ONLY:
I I
• I I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford
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 1301,is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate'volume of water remaining in well(s): 1.50 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if known . i
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 a Bentonite Chips or Pellets
ID Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ii ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) NI Concrete Grout 1 ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout i, ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ', ' ❑ Other(explain under 7g)
(Monitoring ❑Recovery 1
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite;,
❑Aquifer Storage and Recovery ❑Salinity Barrier 15 lbs Concrete II
❑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) Daher(explain under 7g) Pour '; �'"^ ;^ y�v
,,iV7Mf
d._,.
4.Date well(s)abandoned: 01/04/2024 �4�1 2 9 ZGZ4
5a.Well location: I; lfiiJl ,=�`Pc^^,� ter^,C �,u:0�(/� •
Myers Grocery and White's Cross Grocery 00-0-0000032961 8 00-0-0000025022 l' per;y am.J 0(3
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1,
1901 & 1906 Wakelon Road, Colerain, NC ; 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 6837-05-3544 By signing this form, I hereby certt&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 Iat/ong is sufficient)
9.Site diagram or additional well details:
36.136889 N 76,86625 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-watersupply 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 MThM W-14 abandonment to the following:
Division of Water Resources,Information Processing Unit,
•
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 11.95 (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: 2 (in.)
abandonment to the following:
6I
•
6d.Water level below ground surface 2.73 (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 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): (ft.)
2 abandoned. i
•
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
Ili

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: II I
NC Well Contractor Certification Number 7b.Approximate volume of water retaining in well(s): 1 .15 (gal.)
r
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1
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 MI Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑ Drill Cuttings
,0 Irrigation • 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry I ❑ Other(explain under 7g)
UMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier C
❑Aquifer Test ❑StormwaterDrainage 15 Ibs Concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Pour I
OGeothermal(Heating/Cooling Return) 0 Other(explain under 7g) I lam.. — _
01/04/2024 ,e 7�' �'�
" �� ,,
4.Date well(s)abandoned: . ti ,,, �'"
JA N 1 9 2024
5a.Well location: ;,,
Perrytown Service Center 00-0-0000022792irif i. .,_a:. .;,; ,•�,
LI
Facility/Owner Name Facility ID#(if applicable) 8.Certification: - i' '`'L�Cz
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 By signing this form, I hereby certi 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
II
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:
36.138194 N 76.803389 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 we/I construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
I�A,n, 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: l V l V V-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1572 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 l0a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this fort within 30 days of completion of well
abandonment to the following: i
l
8.68 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
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 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): 6 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
.
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford I
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 130 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water i remaining in well(s): 1•00 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A i'
P
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc)if known l i 1
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 a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I, , ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Ie Concrete Grout 1 0 Drill Cuttings
❑Irrigation 0 Specialty Grout II 0 Gravel .
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
r
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite I: •
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 15 lbs Concrete 'I
❑Experimental Technology 0 Subsidence Control •
7g.Provide a brief description of tde abandonment procedure:
0 Geothermal(Closed Loop) 0 Tracer
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour �i , -•,-.--,
k-. iY 1
L
4.Date well(s)abandoned: 01/04/2024 i JAN j 9 2024
5a.Well location: ipicpr,:,g.(`.D tp... .
Perrytown Service Center 00-0-0000022792 I ' . ,...n�'°'h
Facility/Owner Name Facility ID#(if applicable) 8.Certification:526 Sand Hill Road, Colerain, NC �' 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555
By signing this form, I hereby cert(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 beet 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:
36.138194 N 76.803389 `,1, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. l'
10a. For All Wells: Submit this form within 30 days of completion of well
W
6a.Well ID#:
M -1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
66.Total well depth: 16.07 (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: 2 (in.)
abandonment to the following:
I
9.96 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
i
n/a 10c.For Water Supply&Infection 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 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): 6 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY: •
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
.3270-A wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 •17 (gal.)
ii
Geological Resources, Inc. FOR WATER SUPPLY WELLS OI1LY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout .! ' • Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout I . 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) • 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:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite;,
❑Aquifer Storage and Recovery ❑Salinity Barrier II
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete I,
❑Experimental Technology ❑Subsidence Control ' ;'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 'Pour I' 1 ''� �, "c
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) ' i- ( ^ ` '1 .�';ti 4
V' 0-
4.Date well(s)abandoned:
01/04/2024 l ��A! 1 9 e024
5a.Well location: !n '~+^� v ,�`�}u;;?2 V
v
Perrytown Service Center 00-0-0000022792 i,
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
526 Sand Hill Road, Colerain, NC ;' 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well'Owner Date
Bertie 3801-1432-6555
By signing this form, I hereby certifjl 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: I. '
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 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-watersupply ire/Is
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-3 abandonment to the following: L
Division of Water Resources,'Information Processing Unit,
• 6b.Total well depth 1.6.04 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
I
10b.For Injection Wells: In addition to sending the form to the address in 10a
2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) r
abandonment to the following: 1,
•
8 Division of Water Resources,Underground Injection Control Program,
.87
6d.Water level below ground surface: (ft.)
• 1636 Mail Service Cenier;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): 6 (ft.)
abandoned. 1:
6g.Screen length(if known): 1 0 (ft.)
J
•
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 DETAILSI
Justin Radford 7a.For Geoprobe/DPT or Closed-Ioolp 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
3270-A wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water Ie I aining in well(s): 2.91 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
•
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A 1 I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known I 1
7d.Amount of disinfectant used: i. I
3.Well use(check well use): 1
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout i ! U Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ,I i ❑ Dry Clay
t.
0 Industrial/Commercial ❑Residential Water Supply(shared) I9 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry ! 0 Other(explain under 7g)
lMonitoring ❑Recovery r
Injection Well: 7f.For each material selected above;provide amount of materials used: '
❑Aquifer Recharge ❑Groundwater Remediation 40 Ibs•of Benton ite i
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer t
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) Pour
01/04/2024 /; : JAN 1 9 -
4.Date well(s)abandoned: I e074
��ri'r S.
Sa.Well location: ii ltlw�rr,�,/�.B i,�,.�Y,�`�1-^ o_,_
Perrytown Service Center 00-0-0000022792 D Q, `-'"a
Facility/Owner Name Facility ID#(if applicable) S.Certification: j,
526 Sand Hill Road, Colerain, NC !; 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well'Owner Date
Bertie 3801-1432-6555 Bysigning thisform, 1 herebycerti I that the wells was were abandoned in
S S fY �� (were)
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beak provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1.
(if well field,one Iatflong is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 N, 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-watersupply 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#: IVI W-4 abandonment to the following:
•
Division of Water Resource s,'Information Processing Unit,
28.22 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 l0a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: ii •
11 '
10.34 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center;Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county;health department of the county where
6f.Inner casing/tubing length(if known): 24 (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
.
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

1
WELL ABANDONMENT RECORD
For Internal Use ONLY: 1
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 11
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 130 is needed. Indicate TOTAL NUMBER of
• wells abandoned: '
3270-A .
NC Well Contractor Certification Number 7b.Approximate volume of water remaining aining in well(s): 0'78 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check a that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout 6 ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
lMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite;,
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of tli'e abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
0 Geothermal(Heating/Cooling Return) •❑Other(explain under 7g) }�'y " --
4.Date well(s)abandoned: 01/04/2024 l r4 1 9 2024
5a.Well location: I, inftwiri;e i.^.n p,
Perrytown Service Center 00-0-0000022792 b 2LIG r`�
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
i
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 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:
36.138194 N 76.803389 `,1, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)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
W
6a.Well ID#:
M -5 abandonment to the following:
I'
Division of Water Resources,Information Processing Unit,
6b.Total well depth 14.40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
961 Division of Water Resources,Underground Injection Control Program,
.
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Injection\Veils: 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 Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY: - ' i' .
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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 lis needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: I I
I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.00 (gal.)
Geological Resources, Inc. •
FOR WATER SUPPLY WELLS ONLY:
Company Name i•
7c.Type of disinfectant used: i
2.Well Construction Permit#: N/A 1
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
1
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I • Bentonite Chips or Pellets ,
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) • Concrete Grout I 0 Drill Cuttings
❑Irrigation 1 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: ' 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite i.
DAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
0 Geothermal(Closed Loop) 0 Tracer Pour 11
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
It
4.Date well(s)abandoned: 01/04/2024 JAN
..:,
1 9 2G24
5a.Well location: c
jf}wa::frig `).—r:�-:-n �_ '
Perrytown Service Center 00-0-0000022792 a;YQ'J0 W ,
Facility/Owner Name Facility ID/I(if applicable) 8.Certification:
526 Sand Hill Road, Colerain, NC -= 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 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 IaUlong is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 W You may use the back of this page tb 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 1
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 14.97 (ft.)
lOb.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
(ft.) abandonment to the following:
6d.Water level below ground surface:
8,82 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cenier1
6e.Outer casing length(if known): (ft.) Raleigh,NC 27699-1636 ,
n/a 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 Resources Revised 2-22-2016

i. i I
WELL ABANDONMENT RECORD For Internal Use ONLY: ' '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: I 1
NC Well Contractor Certification Number 7b.Approximate volume of water r1 Iaining in well(s): 0'62 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY: ,
Company Name
7c.Type of disinfectant used: 1 i
2.Well Construction Permit#: N/A I'
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: l'
3.Well use(check well use): 1.
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout !, • Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) U Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout d 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:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier I
❑Aquifer Test ❑StormwaterDrainage
15 lbs Concrete
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
0 Geothermal(Closed Loop) ❑Tracer Pour 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �=
1
4.Date well(s)abandoned: 01/04/2024 "JAM 1 9 2024
5a.Well location: inforr, r;i ,.1,•,.,
� , �:•h�h11�'4'rl�tf,i
Perrytown Service Center 00-0-0000022792 , ;gar". OG
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 By signing this form, I hereby certifi,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:
36.138194 N 76.803389 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
' 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 14.34 (ft)
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
II
6d.Water level below ground surface: 10.52 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1
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): (ft.)
5 abandoned. 1
6g.Screen length(if known): 1 0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources „ Revised 2-22-2016

i
.
II WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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 130 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: f
NC Well Contractor Certification Number 7b.Approximate volume of water'I e G aining in well(s): O'70 (gal.)
•Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A 1, 1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknoirn
7d.Amount of disinfectant used:
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout i I Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) • Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry i.
0 Other(explain under 7g)
•Monitoring ❑Recovery !
t i
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
DAquifer Storage and Recovery ❑Salinity Barrier 15 lbs Concrete 1
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control i
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Pour 1
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) t'^:
V =�
4.Date well(s) 01/04/2024
abandoned: 1 'JA�N 1 9 CO2 f
5a.Well location: ins _
yir�a s%32l 7�.:,...
Perrytown Service Center 00-0-0000022792 - - .
t�: �C,,Jo-6 .��% Si Facility/Owner Name Facility ID#(if applicable) 8.Certification:
526 Sand Hill Road, Colerain, NC i, 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 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:
36.138194 N 76.803389 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)ifarailable. 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#: M W-8 abandonment to the following: i;
•
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 14.42 (ft.)
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: i
•
10.12 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
1
I
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 Resources ;, Revised 2-22-2016
!

WELL ABANDONMENT.RECORD For Internal Use ONLY: I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
• Justin Radford 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
3270-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water i remaining in well(s): 0.68 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
• 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A i'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known :1
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 N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) P Concrete Grout ❑ 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:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite I'
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test ❑Stormwater Drainage 15 lbs Concrete
I.
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
0 Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
01/04/2024
4.Date well(s)abandoned: ��'a Ai Li
!p1V CLIZ�t 5a.Well location:
Perrytown Service Center 00-0-0000022792 ,r'r,�;,;.�r;l�� 1= err.
Facility/Owner Name FacilityID# a applicable) 8.Certification: i !�''e >''�* `'Y
tY (ifPP ) 30G
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bettie 3801-1432-6555 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: i
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 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. l
1�A`fl' 10a. For All Wells: Submit this form within 30 days of completion of well
V'6a.Well ID#: ' V V-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 14.45 (ft.)
• 10b.For Injection Wells: In addition to sending the form to the address in I0a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
1028 Division of Water Resources,Underground Injection Control Program,
.
6d.Water level below ground surface: (ft.)
1636 Mail Service Center',Raleigh,NC 27699-1636
' 1
n/a 10c.For Water Supply&Iniection 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 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. j •
it
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

. j
WELL ABANDONMENT RECORD Forinternal Use ONLY: •
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: i 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.60 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: I
2.Well Construction Permit#: N/A I'
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.)if known
7d.Amount of disinfectant used: '
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): •
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout • Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Thy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) I Concrete Grout I. 0 Drill Cuttings
II
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:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
DAquifer Storage and Recovery ❑Salinity Barrier ;,
❑Aquifer Test ❑StormwaterDrainage
15 lbs Concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
OGeothermal Pour ',
(Heating/Cooling Return) ❑Other(explain under 7g) t ''f , ,<. ,•'' %.a
4.Date well(s)abandoned: 01/04/2024 i' Jfi hl 1. [U2`t
5a.Well location: jtlivir'i ri^1 7r .`.j,e'f;?�(jly?
Perrytown Service Center 00-0-0000022792 . . 1 `'`'L}"L
Facility/Owner Name Facility ID#(if applicable) 8.Certification: ^ , d .,� % ..
526 Sand Hill Road, Colerain, NC t�lUy . I' : 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well:Owner Date
Bertie 3801-1432-6555 '
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:
36.138194 N 76.803389 N, 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)ifarailable.For multiple injection or non-water supply wells i
. 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-1 0 abandonment to the following:
I.
Division of Water Resourccs,;Information Processing Unit,
6b.Total well depth: 13.74 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
.
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this f'orin within 30 days of completion of well
abandonment to the following:
1
6d.Water level below ground surface 10.04 (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 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 Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
jl
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 44
7a.For Geoprobe/DPT or Closed7Ll op 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
3270-A wells abandoned: 1 i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.43 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known .
7d.Amount of disinfectant used: •
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
•❑Agricultural ❑Municipal/Public ❑Neat Cement Grout Bentonite Chips or Pellets
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout El Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) III Concrete Grout ❑ Drill Cuttings
0 Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry 1 ❑ Other(explain under 7g)
IMonitoring 0 Recovery
Injection Well: • 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite'' , • -
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) 1
4.Date well(s)abandoned: O 1/O4/2024 -'\ c
i 0,- y j
1 ,5a.Well location: `'��'� �G24
Perrytown Service Center- 00-0-0000022792 jnf,:;rme::I`n ,•,,
Facility/Owner Name Facility ID#(if applicable) S.Certification: 9426 Dud; J304.3 ll.r.
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip • Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 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: .
36.138194 N 76.803389 `,l, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS ;'
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-16 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 12.23 (f,•)
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: i .
6d.Water level below ground surface 9.62 (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): 2 (ft.) abandoned.
6g.Screen length(if known): 1-0 (ft.)
Form GW-30 • North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I ,
WELL ABANDONMENT RECORD For Internal Use ONLY: '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: i 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining maining in well(s): 1'51 (gal.)
Geological Resources, Inc.- FOR WATER SUPPLY WELLS ONLY:
I
Company Name
7c.Type of disinfectant used: I
2.Well Construction Permit#: N/A 1
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc)if known i
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 IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout i ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
ii
❑Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
uMonitoring ❑Recovery ;,
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
1
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
01/04/2024 ^.y i�i i -,y
4.Date well(s)abandoned: , 'jA� p p
5a.Well location: J�il�� A eU24
Perrytown Service Center 00-0-0000022792 _ _ il►n;;,;;,::r;`.;, r
Facility/Owner Name Facility ID#(if applicable) 8.Certification: G [j'y Q,nJ0V U k-,
526 Sand Hill Road, Colerain, NC ' 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie • 3801-1432-6555 By signing this form, 1 hereby certif%that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
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:
36.138194 N 76.803389 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 I' '
Attach well construction record(s)tfavailable. For multiple injection or non-water supply sells
ONLY with the same construction/abandonment,you can subunit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
IVI W-20 abandonment to the following: 1'
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 19.61 (ft.)
lOb.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in,) above,also submit one copy of this forin within 30 days of completion of well
abandonment to the following: !, !
! 1
10.32 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 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): unknown (ft.) abandoned.
6g.Screen length(if known): unknown (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
•Ii
1.Well Contractor Information: WELL ABANDONMENT DETAILS
•
Justin Radford 7a.For Geoprobe/DPT or Closed-Lloop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-g0 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: I 1
• NC Well Contractor Certification Number 7b.Approximate volume of water remaining maining in well(s): 0'67 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: N/A j
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known II
7d.Amount of disinfectant used:
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check all,that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 1. IIBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout j ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) I Concrete Grout ❑ Drill Cuttings
y
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry 1' 0 Other(explain under 7g)
•Monitoring ❑Recovery ' 1
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite ,'
❑Aquifer Storage and Recovery 0 Salinity Barrier 15 lbs Concrete
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control I'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
4.Date well(s)abandoned: 01/04/2024 11 t w
5a.Well location: JP.N 1 2G2
Per town Service Center 00-0-0000022792 �th.t�,<Va ,
rY ...,:,,: Fa
Facility/Owner Name Facility ID#(if applicable) 8.Certification: I Qi o C OG
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip , Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 ir
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
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:
36.138194 N 76.803389 `,l, 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.
I.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED II
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit one form. I'
pA
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well DM: M V V`n,-23 abandonment to the following:
Division of Water Resources,Information Processing Unit,,
6b.Total well depth: 13.31 (ft.) 1617 Mail Service Center;Raleigh,NC 27699-1617
I;
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: I
917 Division of Water Resources,Underground Injection Control Program,
.
6d.Water level below ground surface: (ft.) 1636 Mail Service Center;Raleigh,NC 27699-1636
II
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 form within 30 days of completion
of well abandonment to the county; health department of the county where
6f.Inner casing/tubing length(if known): 2 (ft.) abandoned. I'
6g.Screen length(if known): 13 (ft.)
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
I, I
Ii ,
I-

.
I
WELL ABANDONMENT RECORD For Internal Use ONLY: ' I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
•
Justin Radford
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
3270-A wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water reimaining in well(s): 0'67 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLSIONLY:
Company Name 1,
7c.Type of disinfectant used: •
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
•
7d.Amount of disinfectant used:
3.Well use(check well use): II
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) I Concrete Grout 1 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ; , 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g) •
(Monitoring• ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier •
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
•
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure: •
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) I.
1:71
01/04/2024 -^= ; y n 9
ry�
--;
4.Date well(s)abandoned: 0 L!,Li
5a.Well location: Jfii! �. [G24
Perrytown Service Center 00-0-0000022792 �_._ �.<i. ,�
in,,�r,:�r.. .;l, fig .
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
a c,'3oc
526 Sand Hill Road, Colerain, NC 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 By signing this form, I hereby cent fy 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:
36.138194 N 76.803389 M You may use the back of this page to provide additional well site details or well ,
abandonment details. You may alsolattach additional pages if necessary.
• CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS l•
Attach well construction record(s)ifas'aitable. For multiple injection or non-water supply wells 1 •
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 --23 abandonment to the following: I'
u
Division of Water Resources,Information Processing Unit,
1331 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 l0a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I. I
6d.Water level below ground surface: 9.17 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cent i r,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): 2 (ft.) abandoned.
6g.Screen length(if known): 13 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

h
WELL ABANDONMENT RECORD For Internal Use ONLY: )' 1
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford• 1'
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 I30 is needed. Indicate TOTAL NUMBER of
3270-A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water i remaining in well(s): 0.62 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY: •
Company Name 7c.Type of disinfectant used: '
2.Well Construction Permit#: N/A II
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout •Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 1 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
(Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite'
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) "
4.Date well(s)abandoned: 01/04/2024 ii, ,° ' 4..„,r r'•iv i l G "
Ls
.5a.Well location: I JA N 1 9 2024
Perrytown Service Center 00-0-0000022792
BTlS v,/r%.ld.it a r,.-.n;......: ,
Facility/Owner Name Facility ID#(if applicable) 8.Certification: i • �,^^es,? 1,70?
526 Sand Hill Road, Colerain, NC '1 1, D�'°•Q'3`''
01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 1,
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: I!
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 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 I
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells I
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 --25 abandonment to the following:
Division of Water Resources;Information Processing Unit,
6b.Total well depth: 14.05 (ft) '1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this(form within 30 days of completion of well
abandonment to the following: I
1
6d.Water level below ground surface: 1 0'26 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636 •
6e.Outer casing length(if known): ilia (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 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

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS!
Justin Radford , !
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
l wels abandoned:
3270-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.62 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 1
7c.Type of disinfectant used: I '
N/A1
2.Well Construction Permit#: I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if known I.
,
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 I'1 II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
ir
❑Industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout I! ❑ Drill Cuttings
❑Irrigation i 0 Specialty Grout ' 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry '! ❑ Other(explain under 7g)
SMonitoring 0 Recovery 1;.
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite '
:Aquifer Storage and Recovery ❑Salinity Barrier
:Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
['Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ''.
4.Date well(s)abandoned:
fi JArti 1 9 2024
5a.Well location: i'
Perrytown Service Center 00-0-0000022792 2ri"2.r6,5i,,^
Gi'.S.'„+) �'t'17
Facility/Owner Name Facility ID#(if applicable) 8.Certification: .v k.:-'C�La
526 Sand Hill Road, Colerain, NC +, 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 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
t.
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: j'
• (if field,one laUlong is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 W You may use the back of this page to,provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-watersupply wells
•
ONLY with the same construction/abandonment,you can submit one form.
p 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M V-25 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 14.05 (ft.)
'I
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface 10.26 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1 I
1
• 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 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 Resources Revised 2-22-2016

I
I,
WELL ABANDONMENT RECORD For Internal Use ONLY:
ii
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS`'
Justin Radford 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
3270-A wells abandoned: i 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'50 (gal.)
VI
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known ;'
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public CI Neat Cement Grout [M Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ! ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 1 II Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ,' El Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 1,
0 Other(explain under 7g)
(Monitoring ❑Recovery I:
Injection Well: 7f.For each material selected above provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite .
❑Aquifer Storage and Recovery ❑Salinity Barrier
- ❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete ;'
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �'
A
01/04/2024 ; Co `� " r; ,
4.Date well(s)abandoned: ! ' Jt4iv
5a.Well location: fn+�fn^F.'i�.1)
Perrytown Service Center 00-0-0000022792 �,9 ._; '-: Uti:;
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
526 Sand Hill Road, Colerain, NC 94f7 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555
By signing this form, I hereby certift that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.138194 N 76.803389 N, 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-watersupply 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-26 abandonment to the following:
I.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19.26 (ft.) • 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form within 30 days of completion of well .
abandonment to the following: I
, 1
6d.Water level below ground surface: 10.08 (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 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.)
' . 1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
y

i
WELL ABANDONMENT RECORD For Internal Use ONLY: I ' .
f
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 7a.For Geoprobe/DPT or Closed-i#oeip 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
3270-A wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water e i aining in well(s): 0'98 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name i
7c.Type of disinfectant used: '
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known I, '
7d.Amount of disinfectant used: II
3.Well use(check well use):
t
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout U Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout I; 0 Dry Clay
0 Industrial/Commercial 0 Residential Water Supply(shared) C Concrete Grout 1.( 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
IMonitoring ❑Recovery I!
Injection Well: 7f.For each material selected above:,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Sal inity Barrier
❑Aquifer Test ❑StormwaterDrainage 15 lbs Concrete
r ❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the.abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Pour l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) r^^•:'-_" �r�-�)( A 7 µ^'P i
v ^am a,,.�'Mnm+1 GP Y,..a�)'
I.
4.Date well(s)abandoned: 01/04/2024
JAN 1 9 26Z4
5a.Well location: ye,lt`" ' 7 Pr'",=L' r9 l}
1111v1 Y��-"•:
ra
Perrytown Service Center 00-0-0000022792 D
Facility/Owner Name Facility ID#(if applicable) 8.Certification: 9407tifii526 Sand Hill Road, Colerain, NC j; 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bertie 3801-1432-6555 Bysigning this form, I herebycerti that the well(s) was were abandoned in
S S .f .�', (were)
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beenpr•ovided 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:
36.138194 N 76.803389 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 ,i
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
I.
ONLY with the same construction/abandonment,you can submit one form.
I►A`/t, 10a. For All Wells: Submit this form within 30 days of completion of well
V'6a.Well ID#: ' V V-27 abandonment to the following: j
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14.26 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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: 2 (in.)
abandonment to the following:
Q I !
6d.Water level below ground surface '26 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
I, •
6e.Outer casing length(if known): n/a (ft,) IOc.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county;health department of the county where
6f.Inner casing/tubing length(if known): 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

,, ;
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS •
Justin Radford
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
3270-A wells abandoned: {
NC Well Contractor Certification Number " 7b.Approximate volume of water remaining in well(s): 12.80 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name •
7c.Type of disinfectant used: {
2.Well Construction Permit#: N/A
List all applicable well construction permits(le.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use): i,,
Water Supply Well: 7e.Sealing materials used(check all that apply): •
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 1, I Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial 0 Residential Water Supply(shared) II Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
(Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 250 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier 50 lbs Concrete
❑Aquifer Test ❑Stormwater Drainage {
❑Experimental Technology ❑Subsidence Control r
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) 0 Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour �I
01/04/2024 . F .
4.Date well(s)abandoned: �� us
5a.Well location: ! ' �' 9 614
Perrytown Service Center 00-0-0000022792 -'�ter;-==�a4a r,•- ; ,;;
Facility/Owner Name Facility IDlt(if applicable) 8.Certification: 0;-VC.;�-"',3(y �f'
526 Sand Hill Road, Colerain, NC /1" , 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Bettie 3801-1432-6555 By signing this form, I hereby cert(15 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 p%ovided 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:
36.138194 N 76.803389 W You may use the back of this page toll;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 II
Attach well construction record(s)ifavailable. For multiple injection or non-water supplywells
{
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#:
RW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25.47 (ft.) 1617 Mail Service Center;Raleigh,NC 27699-1617
• 10b.For Iniection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6 (in•) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface 8.32 (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 i health department of the county where
6E Inner casing/tubing length(if known): 3 (ft.) abandoned.
6g.Screen length(if known): 25.5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j : Revised 2-22-2016
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!

i' l
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 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
3270-A wells abandoned: i
•
NC Well Contractor Certification Number 7b.Approximate volume of water remaining i in well(s): 3.26 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS f ONLY:
Company Name
7c.Type of disinfectant used: r
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.)if known
7d.Amount of disinfectant used: '
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout P Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout i, 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) E Concrete Grout 0 Drill Cuttings
. ❑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:
❑Aquifer Recharge ❑Groundwater Remediation 250 lbs of Bentonite
0 Aquifer Storage and Recovery 0 Salinity Barrier 50 lbs Concrete
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
•
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) '' TM-
4
01/04/2024
4.Date well(s)abandoned: J,�N i 9 20?4
5a.Well location: 1p,or `;..,. .
Perrytown Service Center 00-0-0000022792 • • ;, ut,:(;:�� � �i:
Facility/Owner Name Facility ID#(if applicable) S.Certification:
526 Sand Hill Road, Colerain, NC ` 'j; , 01/05/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
I
Bertie 3801-1432-6555 Bysigning.this o m, I herebycerti 'that the wells was were abandoned in
.r .f� �� (were)
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) I'
9.Site diagram or additional well details:
36.138194 N 76.803389 `,l, You may use the back of this page to provide additional well site details or well
abandonment details. You may also atiach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: R�y�A�-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 28.91 (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
2 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: �•
,
iI
6d.Water level below ground surface 8'94 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,!Raleigh,NC 27699-1636
i
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 form within 30 days of completion
of well abandonment to the county thelalth department of the county where
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned. i
6g.Screen length(if known): 25.5 (ft.)
Fonn GW-30 l North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
I