Robeson_Well Abandonment_20240119

1
WELL ABANDONMENT RECORD For Internal Use ONLY: i' i
•
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 7a.For Geoprobe/DPT or Clos IdLoop 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
4548 A wells abandoned: II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.51 (gal.)
I'
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):
. Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public 0 Neat Cement Grout Ill Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑igation 0 Specialty Grout I e Gravel
Non-Water Supply Well: 0 Bentonite Slurry j 0 Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation 22.5 lbs of Bentonite Pour
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Storniwater Drainage I1
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Finished with gravel and native soil
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 09/.28/2023
5a.Well location: 0._6„f, ur n� a �, > I
JAN 1 9 2024
Johns Citgo Service 00-0-0000021055
V
Facility/Owner Name Facility ID#(if applicable) 8.Ceraiticati (Vr 4�'>v�'.:5�.:1�•ti�^
I' r.
211 N Main Street, Red Springs, NC 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contmctorlor r Date
Robeson 9348-583-9600 By signing this form, I hereby certfy that the well(s) was(were) abandoned in
County •Parcel Identification No.(PIN) accordance with 15A NCAC 02C,.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has'been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.49664 N 79.105445 .Rr 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.
1
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record(s)if available.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
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 m#• G M V V-1 abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 16.08 (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:
ji
6d.Water level below ground surface: 12.95 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service enter,Raleigh,NC 27699-1636
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): 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

ii
WELL ABANDONMENT RECORD For Internal Use ONLY:
P
II
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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 GVJ I30 is needed. Indicate TOTAL NUMBER of
4548 A wells abandoned: 'I
NC Well Contractor Certification Number 7b.Approximate volume of water I remaining in well(s): 0.56 (ga )
I'
Geological Resources, Inc. FOR WATER SUPPLY WELIS ONLY:
P Y 1
Cora an Name A 7c.Type of disinfectant used: 0
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):
I.
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 1 !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) 0 Concrete Grout , ❑Drill Cuttings
❑lrrigatian 0 Specialty Grout I 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 ❑GroundwaterRemediation 22 lbs of Bentonite Pour
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage II
❑Experimental Technology 0 Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer 1
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Finished with gravel and native soil
09/28/2023 :. (1.,R \/,--`y'
4.Date well(s)abandoned: 1
JAN 1 9 '202-
5a.Well location:
Johns Citgo Service 00-0-0000021055 '
Facility/Owner Name Facility ID#(if applicable) 8.C
NC =''
er tit iC n: I: 10120.G~
211 N Main Street, Red Springs,
10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or wt Date
Robeson 9348-583-9600. 1,
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.
1.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one►st/long is sufficient) 9.Site diagram or additional well ll'details:
34.49664 N 79.105445 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.
�+ ,A I 10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID#: G M V V-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.70 (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 Om)
above, also submit one copy oflthis form within 30 days of completion of well
abandonment to the following:
•
6d.Water level below ground surface: 12.29 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
P' l
(ft 10c.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): n/a
address(es)above,also submit ode copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
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 ResourcesI Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY: •
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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
4548 A wells abandoned: I i
NC Well Contractor Certification Number 'M.Approximate volume of waterremaining in well(s): 1.13 (gal.)
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: 1!
2.Well Construction Permit#: N/A i'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 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 0 Neat Cement Grout •Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout I ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout I 0 Drill Cuttings
❑Irrigation 0 Specialty Grout •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 ❑GroundwaterRemediation 28 lbs of Bentonite Pour
❑Aquifer Storage and Recovery 0 Salinity Barrier ,
❑Aquifer Test ❑Stormwater Drainage 1
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer j
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Finished with gravel and native soil
4.Date well(s)abandoned: 09/28/2023
1 JAN a 9,2024
5a.Well location:
Johns Citgo Service 00-0-0000021055 qn,_ .<i'-' i-.
Facility/Owner Name Facility ID#(if applicable) 8.Cer.• a ,n: I. D',0"-'0G
211 N Main Street, Red Springs, NC .,/
10/6/2023
Physical Address,City,and Zip Signature of Certified Well Con ,ell O • Date
Robeson 9348-583-9600
By signing this form, I hereby cert 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:
34.49664 N 79.105445 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)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IN: G M W-3 abandonment to the following: • ,
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19.75 (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 tliis'form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 12.81 (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.) 1Oc.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): 10 (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
Matthew Steele 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
4548 A wells abandoned: I 1
NC Well Contractor Certification Number 7b.Approximate volume of wat R remaining in well(s): 1.15 (gal.)
' Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: i
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 , 0 Neat Cement Grout ! e 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) s Concrete Grout 0 Drill Cuttings •
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
IMonitoring ❑Recovery ,
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 26 lbs of Bentonite,
❑Aquifer Storage and Recovery ❑Salinity Barrier �;
❑Aquifer Test ❑Stormwater Drainage 10 lbs of concrete
❑Experimental Technology ❑Subsidence Control
• 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Pour
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
4.Date well(s)abandoned: 09/28/2023 JAN 1 9 22024
5a.Well location: - - :, „ 1
lsl"ivir' :�Tl :.7,•-:=i ..: ,](Jfti'il
Johns Citgo Service 00-0-0000021055 _ u<d�:,°`-:�-0
Facility/Owner Name Facility ID#(if applicable) S.Cetitleatio.. I'
211 N Main Street, Red Springs, NC 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contractor:or e Date
Robeson 9348-583-9600 i'
By signing this form,I hereby certt&that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 020:0100 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:
34.49664 N 79.105445 `1, You may use the back of this page to provide additional well site details or well
abandonment details. You may alsoattach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED I'
Attach well construction record(s)if available.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
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#: G M W-4 abandonment to the following:
I
• Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 8.30 (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:
•
;11 .23 Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service renter,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): 10 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.)
Form GW-30.. North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016

1
WELL ABANDONMENT RECORD For Internal Use ONLY: ' ' '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele ' 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
4548 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water Iemaining 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
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 s 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) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
S Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 27 lbs of Bentonite •
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 10 lbs of concrete •
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer Pour
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) j r.7.7.7 i ' `',.. v 117 c"-)
• g 'cs...° .-ii V 'd-1,.,1
4.Date well(s)abandoned: 09/28/2023 JAN 1 9 6?4
5a.Well location: P!-:- ;:g i,
vitie.r'.' �il . ... _.. ri:i
Johns Citgo Service 00-0-0000021055 r`1
`:;--1r-1,
Facility/Owner Name Facility ID#(if applicable) 8.C ti11er aan:
211 N Main Street, Red Springs, NC =f'" 10/6/2023
Physical Address,City,and Zip Signature of Cei2ified Well Contras ,or' I er Date
Robeson 9348-583-9600 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:
34.49664 N 79.105445 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
Attach well construction record(s)if available.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
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#: G M W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 9.1 0 (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 thus form within 30 days of completion of well
abandonment to the following: j !
Division of Water Resourcesl,Underground Injection Control Program,
6d.Water level below ground surface: 12.97 (ft.)
1636 Mail Servicei Center,Raleigh,NC 27699-1636
(ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): n/a
address(es)above,also submit mile copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tnbing length(if known): 10 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft) I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
•
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele
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
4548 A wells abandoned: 1
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s):0'97 (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 0 Neat Cement Grout In 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) IR Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ 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 27 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
Aquifer Test CI 10 lbs of concrete
❑
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �.,- .,-a •„�,.
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour `s- l .,f I 1 f„n,y.
P .. ua
4.Date well(s)abandoned:
09/28/2023 JP, i 1 9 2024
5a.Well location: DWC:i15 y v
Johns Citgo Service 00-0-0000021055
Facility/Owner Name Facility ID#(if applicable) 8..certl6c.,:on:
211 N Main Street, Red Springs, NC _• 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contras ,or' er Date
Robeson 9348-583-9600 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:
34.49664 N 79.105445 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
Attach well construction record(s)if available.For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS •
ONLY with the same construction/abandonment,`A you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• G M V V-6 abandonment to the following:
,t
Division of Water Resources,Information Processing Unit,
Ob.Total well depth: 19.40 (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 form within 30 days of completion of well
abandonment to the following:
I ;
1344 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): 1 0 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
I. ' -
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

t
I
WELL ABANDONMENT RECORD For Internal Use ONLY:
.
• 1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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-30 is needed. Indicate TOTAL NUMBER of
4548 A wells abandoned: I 1
NC Well Contractor Certification Number 7b.Approximate volume of wate I remaining in well(s):0.96 (gal.)
i •I
Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: I •
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 0 Neat Cement Grout U 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 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 27 lbs of Bentonite .
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lbs of concrete.
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Pour
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) - _ __
'�"LL,;
4.Date well 09/28/2023
s)abandoned: JA N 1 9 2024
5a.Well location:
Johns Citgo Service • 00-0-0000021055 ` in'v"'.,'zn `i ti,:i
. ., .�..
OW/ 0/3
Facility/Owner Name Facility ID#(if applicable) F'l re i esti°
211 N Main Street, Red Springs, NC �� :✓G 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contract° r . Owner :Date
Robeson 9348-583-9600 By signing this form,I hereby cent(that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C'.0100 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:
34.49664 N 79.105445 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)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit tliis form within 30 days df completion of well
•
6a.Well ID#: G M W-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19.50 (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 form within 30 days of completion of well
abandonment to the following: I
I
6d.Water level below ground surface: 13.58 (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): 10 (ft) abandoned.
6g.Screen length(if known): 1 0 (ft.)
( I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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
4548 A wells abandoned: I 1
11
7b.Approximate volume of water remaining in well(s): 1.1 8 • (gal.)
NC Well Contractor Certification Number i
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 0 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) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout In 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 26 lbs of Bentonite Pour
:Aquifer Storage and Recovery ❑Salinity Barrier
•
:Aquifer Test ❑Stormwater Drainage
:Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer
Finished with gravel and.,n.ativesoilr_,�. •
0 Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) ({ _
F'�'ta L.`L.5,:::is V If_ ,../
4.Date well(s)abandoned: 09/28/2023 JAN 1 9 2024
•
5a.Well location: lP.ivir'ir-5i. ?�"-, ,• , -3 tin
.^..1
Johns Citgo Service 00-0-0000021055 �"
Facility/Owner Name Facility ID#(if applicable) 8.Cee.`iciiii
211 N Main Street, Red Springs, NC '� 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contras e 1 U ,_ Date
Robeson 9348-583-9600
By signing this form, I hereby certJ that the wells)was(were) abandoned in
County Parcel Identification No.(PII`) 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:
34.49664 N 79.105445 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)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,' you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID# G M V A V-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1892 1617 Mail Service Center,Raleigh,NC 27699-1617
.
6b.Total well depth: (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
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 ,
1
6d.Water level below ground surface: 1 1 .68 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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): 1 0 (ft.) abandoned.
6g.Screen length(if known): 1 0 (ft.) i
1
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,
h
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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
4548 A wells abandoned: I i
NC Well Contractor Certification Number 'Th.Approximate volume of water remaining in well(s):2.02 (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 0 Neat Cement Grout •Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial 0 Residential Water Supply(shared) • Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slu
rry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 37 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier 10 lbs of concrete
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) "i r, `, tt� ;
4.Date well(s)abandoned: 09/28/2023 JA>> 2024
1
.
5a.Well location: 1 in13n .:;:rc l ..., -c;.•'3 Linn
G
Johns Citgo Service 00-0-0000021055 ` '°DQIIS`�
Facility/Owner Name Facility ID#(if applicable) 8.2^:[ideas
211 N Main Street, Red Springs, NC . / 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or R !^ .-r Date
Robeson 9348-583-9600 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.49664 N 79.105445. 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)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID#: M W-2 abandonment to the following:
•
•
Division of Water Resources,Information Processing Unit,
6b.Total well depth 26.59 (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 form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 14.22 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail ServiceiCenter,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): u n kn own (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

WELL ABANDONMENT RECORD For Internal Use ONLY: I.
1i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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 G1V-30 is needed. Indicate TOTAL NUMBER of
4548 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wat I r i emaining in well(s): n/a (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.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout a 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) I Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slu
rry ❑ Other(explain under 7g)
•
(Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 27 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lbs of concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
•❑Geothermal(Heating/Cooling Return)' ❑Other(explain under 7g) Pour t. `'� .r' P.
,
J4.Date well(s)abandoned:
09/28/2023 •
"'r� 1 2024
•
5a.Well location: cat�,,-,..- ��r-• ..,...:..,;:2 ,,,,:.,.D
QG
Johns Citgo Service 00-0-0000021055 • " ''y
Facility/Owner Name Facility ID#(if applicable) 8.f ertlftea n:
211 N Main,Street, Red Springs, NC 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or ler Date
Robeson 9348-583-9600 By signing this form, I hereby certj 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:
34.49664 N 79.105445 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)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
A' 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M V V-3 abandonment to the following:
I,
. • Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19.40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2 (in.)
abandonment to the following: 1
- ,t I '
6d.Water level below ground surface: 13.43 (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&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): unknown (ft.) abandoned.
6g.Screen length(if known): unknown (ft.)
I
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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
4548 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water i emaining in well(s): 3.91 (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.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a 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) a Concrete Grout •0 Drill Cuttings
- ❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
IMMonitoring ❑Recovery
Injection Well: • 7f.For each material selected above,provide amount of materials used:
:Aquifer Recharge ❑GroundwaterRemediation 51 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lbs of concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour �^ :'•-�r---, , r P'-,A_,.
4.Date well(s)abandoned: 09/28/2023 JAN 1 9 2024
5a.Well location: I In:,r;,^< io•n P,- .9 IJ,1
Johns Citgo Service 00-0-0000021055 n<`:^::J,-,-
Facility/Owner Name Facility ID#(if applicable) 8.Ce 'Itt Cl 8t20n:
211 N Main Street, Red Springs, NC •• 'G f
10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contra'. .I r ell , r Date
Robeson 9348-583-9600 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 hasi 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:
34.49664 N 79.105445 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)tfavailable.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-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 36.75 (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 form within 30 days of completion of well
abandonment to the following: 1 '
12.74 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface (ft.) 1636 Mail Service;Center,Raleigh,NC 27699-1636
I `
6e.Outer casing length(if known): n/a (ft.) 10c.For Water Suntdy&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): unknown (ft.) abandoned. I
li
6g.Screen length(if known): unknown (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
Matthew Steele 7a.For Geoprobe/DPT or Closed)-L000p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4548 A wells abandoned: I I
NC Well Contractor Certification Number • 7b.Approximate volume of water remaining in well(s):4.46 (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): •
DAgricultural ❑Municipal/Public 0 Neat Cement Grout •Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply): ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Conrmercial 0 Residential Water Supply(shared) •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 55 lbs of Bentonite
•
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lbs of concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer -1 --.-,,.
o-.r.,_.
Pour ,�.:;4_ti_ .,,°~ a,F•.-�
0 Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 09/28/2023 I NQ 2024
5a. •
D Well location: ;1-,,,J„ -:.. , -..;:.. .. , '' ur,..i
;lj t DG',.
• • Johns Citgo Service " 00-0-0000021055
Facility/Owner Name Facility ID#(if applicable) 8...Cef if on
211 N Main Street, Red Springs, NC , 7-G= 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contra..or N i vner Date
Robeson 9348-583-9600 By signing this form, I hereby cert0 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:
34.49664 N 79.105445 `,It 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)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: •Submit this form within 30 days of completion of well
6a.Well ID#: M V VA'-5 abandonment to the following:
,t
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 39.44 (ft.) 1617 Mail Service i Center,Raleigh,NC 27699-1617
•
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 1 2.1 0 (ft.) Division of Water Resources, •
Underground Injection Control Program,
1636 Mail Service i 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)mown): (ft.) address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the 'minty 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

WELL ABANDONMENT RECORD For Internal Use ONLY:
•
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Matthew Steele 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 G7- 0 is needed. Indicate TOTAL NUMBER of
4548 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wat I lemaining in well(s): n/a (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 0 Neat Cement Grout a Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑lrrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
UMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 14 lbs of Bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lbs of concrete
❑Experimental Technology • 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
, 0 Geothermal(Heating/Cooling Return) DOther(explain under 7g) P-^ 2--' """ 7 , r.-,,-.
4.Date well(s)abandoned: 09/28/2023 . JAN 1 9 2G24
5a.Well location:
Johns Citgo Service 00-0-0000021055 I,,;�,Y, , .3 hF,:,
Facility/Owner Name Facility ID#(if applicable) 8 Cerlitic Son:
211 N Main Street, Red Springs, NC ''
10/6/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or of ner Date
Robeson 9348-583-9600 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:
34.49664 N 79.105445 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.
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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 k Vco�l»s`trAu'ction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID#: 'V t -6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9.98 (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'thi's form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: n/a (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): unknown (ft.) abandoned.
6g.Screen length(if known): unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016

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WELL ABANDONMENT RECORD For Internal Use ONLY: '
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1.Well Contractor Information: WELL ABANDONMENT DETAILS •
Matthew Steele 7a.For Geoprobe/DPT or Clos Id-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 f 30 is needed. Indicate TOTAL NUMBER of
4548 A wells abandoned: i �NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 5.78 (gal.)
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Geological Resources, Inc. FOR WATER SUPPLY WELLSONLY:
mP y
Co an 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: 17e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout a 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) a Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slu
rry 0 Other(explain under 7g)
IMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 66 lbs of Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 10 lbs of concrete
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pour
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ▪"•" v `p' +.
4.Date well(s)abandoned: 09/28/2023 JAN 1 9 ZU24
5a.Well location: r.;* `
Johns Citgo Service 00-0-0000021055 • •`'`�'
Facility/Owner Name Facility ID#(if applicable) ..e'ii fl etion:
211 N Main Street, Red Springs, NC 10/6/2023
Physical Address,City,and Zip Signature of Certified Well Con ..,or r W" er Date
Robeson 9348-583-9600 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:
• 34.49664 N 79.105445 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)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#•T V V`n, 1 abandonment to the following: 1
Division of Water Resources,Information Processing Unit,
47.50 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) 1
lob.For Inflection Wells: In addition to sending the form to the address in 10a
Borehole diameter: 2 above, also submit one copy of this form within 30 days of completion of well
6c.
(in.) abandonment to the following: 1
6d.Water level below ground surface: 1 2.03 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Inflection Wells: In addition to sending the form to the
address(es)above,also submit ono 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):45 (ft,) abandoned.
6g.Screen length(if known): 5 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016