Vance_Well Abandonment_20240301

1
WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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
3225-A wells abandoned:"'A 1
7b.Approximate volume of water i remaining ainin in well(s): 96.65 al
NC Well Contractor Certification Number pP g � )
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:n
Company Name 7c.Type of disinfectant used: N/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:'N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout . : ' II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grt iitti ' -= 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout N`'.`,tl i ij DT Cuttings
❑irrigation 0 Specialty Grout MAN A i r i vet
Non-Water Supply Well: ❑ Bentonite SjEry1: y I. , 4 0 Other(explain under 7g)
PIMonitoring 0 Reco very rietad ,,7�p,.,,�;;
injection Well: 7f.For each material s a T�� mount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-12s
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Water-15.0 gallons
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer j
❑Geothermal(Heating/Cooling Return) ❑other(explain under 7g) Slowly added bentonite chips and ensured there was no bridging
taking place.Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 01.17.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway 8669 026978
Facility/Owner Name Facility iDi/(if applicable) 8.Certification: I.
1640 N. Garnett Street, Henderson, 27536 i�/- .- ""-
Ph Physical Address,City,and ZipII✓o• y
Y Signature of Certified Well Contractor or Well Owner Date
Vance ' 0044 06010 By signing this form, I hereby ceriify that the well(s)was(were)abandoned in
County Parcel Identification No.(PiN) accordance with 75A 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 la/long is sufficient) 9.Site diagram or additional well,details:
36.342234 N -78.394423 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 ABANDONEDSUBMITTAL INSTRUCTIONS'
Attach well construction record(s)tfavailable.For multiple injection or non-water supplywells
ONLY with the same construction/abandonment,you can submit one form.
It A 10a. For All Wells: Submit this form within 30 days of completion of well
V'6a.Well m#: ' W-8 abandonment to the following: I
Division of Water Resoiiices,Information Processing Unit,
6b.Total well depth: 80.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For injection Wells: in addition to sending the fora to the address in 10a
6c.Borehole diameter: 6.0 (in.) above, also submit one copy of tills'form within 30 days of completion of well
abandonment to the following: f
6d.Water level below ground surface: 14.20 (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.) 10e.For Water Supply&injection Wells: in addition to sending the form to the
address(es)above,also submit on copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): 68.O (ft.) abandoned.
6g.Screen length(if known): 12.0 (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
Frank Beecher 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 GWL 30 is needed. indicate TOTAL NUMBER of
3225-A wells abandoned: '
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.60 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLSONLY:
Company Name N/A
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known •
7d.Amount of disinfectant used: N/A
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 r,Qpt,}"� .„.�,,,1 0 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout I L I-•,'d ill Cuttings
❑Irrigation 0 Specialty Grout MA p , _ ;ravel
Non-Water Supply Well: 0 Bentonite Slurry H►1V 11024 024 0 Other(explain under 7g)
U Monitoring ❑Recovery M1fic7rTP , a
injection Well: 7f.For each material s tcOA aa6o1Ptif v amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite ChIpS 77;ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
Water-1.0 gallons
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description oLthe abandonment procedure:
❑Geothermal(Closed Loop) OTracer Slowly added bentonite chips'and ensured there was no bridging
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
taking place.Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 01.17.2024 The well was abandoned!in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway 8669 026978 1,
Facility/Owner Name Facility iD#(if applicable) 8.Certification:
1640 N. Garnett Street, Henderson, 27536 9 "a"` 2,1G,vi
i.
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Vance 0044 06010 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 A100 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:
36.342189 N -78.395029 `,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 welt construction record(s)!I-available.For multiple injection or non-water supply wells
ONLY with the same construction/abamdonment,you can submit one form.
10a. For All Wens: Submit this form within 30 days of completion of well
6a.Well ID#: M W-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 27.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For injection Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (in.) above, also submit one copy of this,'form within 30 days of completion of well
abandonment to the following: j
6d.Water level below ground surface: 17.70 (ft.) Division of Water Resources,I,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
6L Inner casing/tubing length(if known): 12.5 (ft.) abandoned.
6g.Screen length(if known): 15.0 (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:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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
3225-A wells abandoned:"'^ I 1
NC Well Contractor Certification Number 7b.Approximate volume of water ire aining in well(s): 1•70 (gal.)
AECOM Technical Services of North Carolina,Inc. "FOR WATER SUPPLY WELLS IONLY:
Company Name N/A
7c.Type of disinfectant used:
2.Well Construction Permit 11: N/A
List all applicable well construction permits(i.e.UIC,Colony,State,Variance,etc.)if known
7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout , ti 1 l3eptcgtite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout t 1" � •
••r .:I.`ko frZyjy
❑lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout MAK I 1 Cuttings
['Irrigation 0 Specialty Grout 1 �T]Gravel
Non-Water Supply Well: 0 Bentonite Slurry bitervVevi jc^a'l P;r.^,,-•. .(t t)rei(explain under 7g)
u Monitoring ❑Recovery Ot Q/ of
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-46 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Water-1.0 gallons❑Aquifer Test ❑Stormwater Drainage
. ❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description ofth'e abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Slowly added bentonite chips!and ensured there was no bridging
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
taking place.Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 01.17.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway 8669 026978
Facility/Owner Name Facility TIN(if applicable) 8.Certification: �----)
1640 N.Garnett Street, Henderson, 27536 fi•-�. -`,.`�` 2_i 6.2.`1
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Vance 0044 06010
By signing this form, 1 hereby certtb,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:
36.342424 N -78.394410 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS,, '
Attach well construction record(.$)ifavailable. For multiple injection or non-water supplywelts 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 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 23.0 (ft)
10b.For injection Wells: in addition to sending the form to the address in i0a
6c.Borehole diameter: 2.0 (in.) above, also submit one copy of tins form within 30 days of completion of well
abandonment to the following: 1 ',
I ,
I
6d.Water level below ground surface: 12.60 (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): 13.0 (ft.) abandoned. I
6g.Screen length(if known): 10.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

1
I
WELL ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS!
Frank Beecher 7a.For Geoprobe/DPTorClosed-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
3225-A wells abandoned:"rn ii I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.46 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)(([!mown
7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout , 7.. te Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout V-_'l„r il (
, C y
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout (��Cuttings
❑Irrigation ❑ Specialty Grout MAN �' 1 `"15Y;ravel
Non-Water Supply Well: ❑ Bentonite Slurry lr,Drn-hsue.n t tJr(explain under 7g)
"Monitoring ❑Recovery DWOOG
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips-24 'Os
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Water-1.0 gallons
❑Experimental Technology ID Subsidence Control i'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Slowly added bentonite chip and ensured there was no bridging
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
taking place. Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 1.17.2024 The well was abandoned,in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway 8669 026978
Facility/Owner Name Facility TD#(if applicable) 8.Certification:
1640 N. Garnett Street, Henderson, 27536 ' •''.` ' 2.16.24
Physical Address,City,and Zip Signature of Certified Well Contractor or,Well Owner Date
Vance 0044 06010 By signing this form, I hereby certfr 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: r I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well!details:
36.342424 N -78.394161 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(.$)rfavailable.For multiple injection or non-water supplywells
ONLY with the same construction/abandonment,you can submit one form. t I
MW-1(MA) 10a."For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: 1 ,
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 12.0 (fl)
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (in.) above, also submit one copy of tliis!form within 30 days of completion of well
abandonment to the following: `
9.15 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 Sunolv&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
6L Inner casing/tubing length(if known): 7.0 (ft.) abandoned.
I
6g.Screen length(if known): 5.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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 lis needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:" I 1
NC Well Contractor Certification Number 7b.Approximate volume of water I remaining in well(s): 1•17 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: N/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: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all;that apply):
❑Agricultural ❑Municipal/Publlc 0 Neat Cement[Giod"�'.,..,.•:. ,• j3_r E Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement'Grtbur + 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout M P1l( l) 1 2024 ❑Drill Cuttings
❑Irrigation 0 Specialty Grout i' i CJ C,ravel
Non-Water Supply Well: ❑Bentonite S r3fi^s�lt?41 or•-,' �1.11";
jpfhq 0 Other(explain under 7g)
uMonitoring 0 Recovery LWC.uO
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-36 lbs
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Water-1.0 gallons
❑Experimental Technology ID Subsidence Control '
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I
Slowly added bentonite chips and ensured there was no bridging
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
taking place.Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 01•17.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway 8669 026978
Facility/Owner Name Facility iDti(if applicable) 8.Certification:
ri 1640 N. Garnett Street, Henderson, 27536 . i; "ate
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Vance 0044 06010 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:
36.342089 N -78.394177 W You may use the back of this page io 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.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#: MW-2 abandonment to the following: ;
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For r injection Wells: in addition to sending the form to the address in 10a
6e Borehole diameter: 2.0 (in.) above, also submit one copy of this:form within 30 days of completion of well
abandonment to the following: 1
6d.Water level below ground surface 10.85 (ft) Division of Water Resources,jUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
N/A tOc.For Water Supply&lfniection 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
6E Inner casing/tubing length(if known): 8-0 (ft.) abandoned. I
6g.Screen length(if known): 10.0 (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
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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
3225 A wells abandoned:"'A I1
NC Well Contractor Certification Number 7b.Approximate volume of water iremaining in well(s): 1•30 (gal.)
AECOM Technical Services of North Carolina,lnc. FOR WATER SUPPLY WELLS ONLY:
Company Name N/A
7e.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)([known
7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout� •- I, 6. a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Ce� pro,,L i DO Dry Clay❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 1 ' 0 Drill Cuttings
❑irrigation ❑ Specialty GrcMAR 2024 ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry. 0 Other(explain under 7g)
(Monitoring ❑Recovery intorrfi.3ciFn ?r,gt "T:'y UFA
Injection Well: 7f.For each matcrinQAPAiloW,provide amount of materials used:
OAquiferRecharge ❑GroundwaterRemediation Bentonite Chips-46'Ibs
(]Aquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test ❑Stormwater Drainage Water-1.0 gallons
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer i. I
Slowly added bentonite chips!and ensured there was no bridging
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
taking place. Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: O 1.17.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113.
Speedway 8669 026978
Facility/Owner Name Facility TDII(if applicable) 8.Certification:
1640 N. Garnett Street, Henderson, 27536 �i.-f '' 2, rF.•z 4
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Vance 0044 06010 By signing this form, I hereby certlfr that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.6100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one latlong is sufficient) 9.Site diagram or additional well,details:
36.342258 N -78.394430 `,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(.$)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 m#: MW-2(MA) abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 23.0 (ft)
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (in.) above, also submit one copy of till§'form within 30 days of completion of well
abandonment to the following: ; 1
I
6d.Water level below ground surface: 15.05 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
N/A 10c.For Water Sunnly&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): 13.0 (ft.) abandoned.
6g.Screen length(if known): 10.0 (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
ii
Frank Beecher 7a.For Geoprobe/DPT or Closed-I I 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- 0 is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:Nth 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1•76 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known N/A
7d.Amount of disinfectant used.,
3.Well use(check well use): , 1
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Gr901, ,r .- .1 M.I1gntonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Gr(iiii i. �,t. i Spit t OClay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ' 1 D Drill Cuttings
202
❑irrigation 0 Specialty Grout i MAR 0 1 . Gravel
Non-Water Supply Well: 0 Bentonite Slurry " t :tF;1?r.^.:;SOaG':�
Q th r(explain under 7g)
ttKOfr
IMonitoring 0 Recovery
��,,��ee�
Injection Well: 7f.For each material sciccrcd°a9ovc?provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-42 lbs
❑Aquifer Storage and Recovery 0 Salinity Barrier
Water-1.0 gallons ; I
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 1
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer !
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Slowly added bentonite chips and ensured there was no bridging
taking place. Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: O 1.17.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113. I I
Speedway 8669 026978
Facility/Owner Name Facility TDff(if applicable) 8.Certification: '
1640 N.Garnett Street, Henderson, 27536 L1- ' ""-" H
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date ,
Vance 0044 06010 Bysigning thisform, I herebycerq that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) S
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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well details:
36.342160 N -78.394227 `,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 favailahle.Formula*injection or non-water supplywells
ONLY with the same construction/abandonment,you can submit one form. ' I
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well TD#: M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 21.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
-
1013.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: 2.0 (in.)
abandonment to the following:
6d.Water level below ground surface: 10.21 (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 Suualy&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
6L Inner casing/tubing length(if known): 1 1•0 (ft.) abandoned.
6g.Screen length(if known): 10.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 7a.For Ceoprobe/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-30 is needed. indicate TOTAL NUMBER of
3225-A wells abandoned:WA I I NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4.85 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLY WELLS ONLY:
rnn
Company Name 7c.Type of disinfectant used: N/!~
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UK,',County,State,Variance,etc.)if known
7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Ceme rtnth ,; _C Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0Sand Cem t gout� v I.r irz Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete GroutIlA p 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 12,�Z4 0 Gravel
Non-Water Supply Well: 0 Bentonitg en wrr.r, ,,2 usa Other(explain under 7g)
UMonitoring 0 Recovery D•CCZOG I.
injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge, ❑GroundwaterRemediation Bentonite Ch ips-90 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier i
❑Aquifer Test ❑StormwaterDrainage Water-3.0 gallons; i.
❑Experimental Technology ❑Subsidence Control I ',
7g.Provide a brief description ofttie abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Slowly added bentonite chips and ensured there was no bridging
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
taking place.Then added:water to hydrate bentonite chips.
4.Date well(s)abandoned: 01.17.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113. ,
Speedway 8.66.9 026978 .
Facility/Owner Name Facility iD#(if applicable) 8.Certification:
1640 N. Garnett Street, Henderson, 27536 J 4- ' 2, I ' ?-y
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Vance 0044 06010 By signing this form, I hereby certjy 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 la/long is sufficient) 9.Site diagram or additional well details:
36.342248 N -78.394410 N, You may use the back of this page in 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. I
1tt� 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#.
M V V-4 abandonment to the following: •
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
45.0 (ft) Service Mail Sice Center,Raleigh,NC 27699-1617
10b.For iniection Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter: 2 0 (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: 15.28 (ft) Division of Water Resources,underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A l Oc.For Water Sunaly&iniecti nl Wells: in addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit onelcopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): 4.0 (ft.) abandoned.
6g.Screen length(if known): 41.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

1
i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 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 I30 is needed. indicate TOTAL NUMBER of
3225-A wells abandoned:WA i
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1•34 (gal.)
AECOM Technical Services of North Carolina,Inc. FOR WATER SUPPLYWELLS'IONLY:
Company Name 7c.Type of disinfectant used: NSA
2.Well Construction Permit#: N/A
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: N/A
3.Well use(check well use): I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural 0 Municipal/Public 0 Neat Cement Gif il)t 7-• .-. a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement tlrotltt-L,L..r�I I/�. D,y Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout Mm1 AR v 1 rill Cuttings
❑irrigation 0 Specialty Grout 1 2OZ4 ❑Gravel
Non-Water Supply Well: 0 Bentonite SId rtrksUen p,.�„ 0 Other(explain under 7g)
IN Monitoring 0 Recovery •
((;;•�**�'�"�•��b4:12 ufa
injection Well: 7f.For each material selecctedAiMA,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips-60'lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier i 1
❑AquiferTest ❑StormwaterDrainage Water-2.0 gallons , !
❑Experimental Technology ❑Subsidence Control I, I'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Slowly added bentonite chips land ensured there was no bridging
taking place.Then added water to hydrate bentonite chips.
4.Date well(s)abandoned: 01.17.2024 The well was abandoned i'n accordance with 15A NCAC
5a.Well location: 02C .0113. '
Speedway 8669 026978
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
I
1640 N. Garnett Street, Henderson, 27536 .7 ✓- f{`�, r
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Vance 0044 06010 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:
36.342434 N -78.394908 ,,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 supplywellr
ONLY with the same construction/abandonment,you can submit one form. , I
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For InjectionWells: in addition to sending the form to the address in 10a
6c Borehole diameter: 2.0 (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: 21.80 (ft) Division of Water Resources,;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft) 10c.For Water Supply&iniection,Wells: in addition to sending the form to the
address(es)above,also submit one dopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
150 abandoned.
( I
. aanone .
6L Inner easing/tubing length(if known): (ft.)
0
6g.Screen length(if known): 15. (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016