Montgomery_Well Abandonment_20240624

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4630C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
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 ❑MunicipalIPublic 0 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry s Other(explain under 7g)
IMonitoring ['Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
[Aquifer Recharge ❑Groundwater Remediation Bentonite 50 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier --
❑AquiferTest ❑StormwaterDrainage Concrete _ 15Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer
['Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Hydrated bentonite used to fill to six inches below
land surface. Concrete used to cap casing and
4.Date well(s)abandoned: 6/6/2024
bring opening to grade. AllpoU_materia�s}
place i+
5a.Well location: �•• �/
.
Anthony Stanback (and others) 0-020410 JUN q �_ 2024
Facility/Owner Namc Facility ID#(if applicable) 8.Certification:
3653 NC Highway 73 West, Mount Gilead, NC 27306 F •, Iaae,• r-e.r. ,g that
� j0/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Montgomery 750100997156
By signing this form, 1 hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
35.172441 N -79.970146 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
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# M W-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 27 (It.) 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: 8.25 (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: 4.22 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 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): 12 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 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
4630C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.LIC,Count},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 ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry •Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 38 lbs
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 15Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer Hydrated bentonite used to fill to six inches below
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
land surface. Concrete used to cap casing and
4.Date well(s)abandoned: 6/6/2024
bring opening to grade. All well materials left in
5a.Well location: place. ; J' I
Anthony Stanback(and others) 0-020410 ..
8.Certification: 2024
Facility/Owner Name Facility lDit(iiapplicable) .i�JN J �•
3653 NC Highway 73 West, Mount Gilead, NC 27306
h mil ,'-�-,r4,;stlpkbeit
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner dry Q,{•Mate
Montgomery 750100997156
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.172441 N -79.970146 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)r/available. I.or multiple injection or non-water s 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#: MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 18 (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 8.25 (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 4.91 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Snooty&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): 3 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 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
4630C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Namc
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,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
❑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 El Gravel
Non-Water Supply Well: 0 Bentonite Slurry III Other(explain under 7g)
EMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 50 lbs
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 15Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) Hydrated bentonite used to fill to six inches below
land surface. Concrete used to cap casing and
4.Date well(s)abandoned: 6/6/2024 bring opening to grade. All well materials left in
5a.Well location: place. + .•
Anthony Stanback (and others) 0-020410 �� ���-• � '
Facility/Owner Name Facility lD#(if applicable) 8.Certification: JUN 2 42024
3653 NC Highway 73 West, Mount Gilead, NC 27306 2i2 r 1.6
6/20/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Wel f r C ',yr r� . B
Montgomery 750100997156 D'h(.� G"
By signing this form, I hereby certIb7 that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.172441 N -79.970146 You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 30 (ft 1 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 8.25 (in 1 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: 11.15 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 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): 15 (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.N ell Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
;', c,, tractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4630C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine Powder
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)if known 1.5 oz
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apple):
❑Agricultural ❑Mumicipal/Public ❑Neat Cement Grout • Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
❑Irrigation ❑Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry IN Other(explain under 7g)
PIMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 850 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 501bs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geotheral(Heating/Cooling Return) ❑Other(explain under 7g) Hydrated bentonite used to fill to ten feet below
m
land surface. Concrete used to cap casing to the
4.Date well(s)abandoned: 6/6/2024 level of the surrounding grade. All well materials
5a.Well location: left in place. '/
Anthony Stanback (and others) 0-020410 '�1 �l..P
Facility/Owner Name Facility ID#(if applicable) 8.Certification: ,�(,lN ���4
r��
3653 NC Highway 73 West, Mount Gilead, NC 27306 .
p.� •
6/20/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner DiA.4 j e>[LM
Montgomery 750100997156
By signing this form. 1 hereby certify that the well(s) was (were) abandoned in
Count, Parcel Identification No.(PIN) accordance with 1SA 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/tong is sufficient) 9.Site diagram or additional well details:
35.172441 N -79.970146 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 firm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: WSW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6h.l oral viell depth: 35 (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 Unknown (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: 12.25 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if knobs n): Unknown (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): Unknown (II) 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:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 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
4630C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine Powder
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.(I/C,County,Slate, Variance,etc.)if known
7d.Amount of disinfectant used: OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout • Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout El Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry P Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 300 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier -
❑AquiferTest ❑StowaterDrainage Concrete 251bs
rm
❑Experimental Technology ❑Subsidence Control 7g. Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Hydrated Bentonite used to fill to one foot below
land surface. Concrete used to cap casing to the
4.Date well(s)abandoned: 6/6/2024
same level as the surrounding grade, All well plegriais
5a.Well location: left in place.
Anthony Stanback (and others) 0-020410 JUN 9 4 2024
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3653 NC Highway 73 West, Mount Gilead, NC 27306 �� 70.t'arwix P'T•^.11041,2 Ufa
'�t� r&oza
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Montgomery 750100997156
By signing this form. 1 hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.172441 N -79.970146 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 nun-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#: WSW-1 A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 21 (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: Unknown (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 0.76 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if knos)it): Unknown (ft) 10c.For Water Suooly&Inflection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Nathaniel Newman 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
4630C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorine Powder
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,County,State, Variance,etc.)if known 1.5 oz
7r1.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) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: El Bentonite Slurry a Other(explain under 7g)
U Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite 150 lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete 18Ibs
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Hydrated bentonite used to fill to six inches below
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
land surface. Concrete used to cap casing and
4.Date well(s)abandoned: 6/6/2024
bring opening to grade. All well materials left in
5a.Well location: place. ` '
Anthony Stanback (and others) 0-020410
Facility/Owner Name Facility ID#(if appl[cable) 8.Certification: JUN 9 • 2024
3653 NC Highway 73 West, Mount Gilead, NC 27306
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner D itCy sg
Montgomery 750100997156 By signing this form. I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat'long is sufficient) 9.Site diagram or additional well details:
35.172441 N -79.970146 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)(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#: WSW-1 B abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24.52 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
Unknown above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
abandonment to the following:
6d.Water level below ground surface: 11.45 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft.) lk.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.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

wsw-1
_ N
_ _
i s
',,, \ i
1
.b
- . 0 1tWSW-IA
•
, illikkilt4\14,7- L?
1` „co .ik, m
I. ,, A) 1
IA.,. FORMER
0- 3 \ DISPENSER
ISLAND
MW-3
MW-2
FORMER ��0� ►:�
OUT-HOUSE
D `y��i UST-1
FORMER MW-1
FORMER STANBACK ►•� °
t
HYDRAULIC UST.5
LEGEND '►� STORE(r
1.► -", UST-6 ,�c).—UST 2
W
® Abandoned Monitoring r
Well (Type II)
Abandoned Potable — - ®
• 1•. Water Supply Well : v
DApproximate Location 1...
of Former UST System
r
EDParcel Boundary ' + •
w 1. mmti
.O I ce E ll,iul. tw,Ktitigoi '-acraAIN,:]46fteg1U. .-70e ITunity.
NOTE: Well and tank locations were obtained from previous reports
prepared by other consultants and are approximate. 40 20 0 40 80
ini
Feet
PROJECT TITLE FIGURE
STANBACK STORE
CATLIN 365MT GIL AD3 CEST SITE MAP
Engineers and Scientists 1
INCIDENT NO. JOB NO DATE SCALE DRAWN BY/CHECKED BY
29584 220207 JUNE 2024 AS SHOWN KMC/SJO