Durham_Well Abandonment_20240910

WELL ABANDONMENT RECORD �jv
I',r kaernal Ure ONLY
This form can be used for single or multiple Wells
I.11c11('nntraemr Information: WELL ABANDONMENT DETAILS
Chris Buffer 7a.Number of wells being;abandoned: 1
Weil Contractor Nance at emit aeuar petxnully abandoning amid on hinder prawnsI lei. mulnifrr nifrarlwr ry rMN/-Malr<'r supply wells ONLY with the sane
r',r1-011k/1.Nr.rhrarfAMIAti't/r,LiN..Ur.uhnrtt rest. A,rat
4223
7b.Approximate volume.t'w ater remaining an„tilts): (Ra1,)
NC Well Contractor Certification Nnmber
SASD1iCC0 FOR WATER SUPP1_l V.ELLS ONLY:
Conwei+)Name 7c Type of disinfectant used:
2.Wdl Construction Penislt
List adi'rlcd::.thlr weft pvrm,l8 rte.Ciaw$.Vale.t ortance.Ineectinn.rIl-. ,f Alrnwu
7d.Amount of disinfectant used:
3.Well use(check Well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agnzulninl ❑Municipal:Publre ❑ Neat Cement Croon DI Bcmonile Chips or Pellets
❑Geothen al(Heanrig+Cooling Supply) ❑Rcsidctiial Water Supply isingle) ❑Sand('enter Grote ❑Dn Clay
❑Indttstrtal,Comntcrcial OResidentral Water Supply(shared) El Crnurclr Grout ❑Drill Cuttings
❑Imgatiou 0 Swanky Grout 0 Gravel
Non-Water Suplmlf vt..iI ❑Bentonite Slurry' U Other(explain under 7g)
ISIMutittonng ❑Recovery
Injection Wcll: 7f.For each material selected above,preside amount of materials used:
❑Aquifer Recharge ❑Groundwater Rentedianon
❑Agniler Stonier and Ko a en ❑Salinas Darner
Bentonite.:501b ,Wtr:gal.
❑Aquifer Test ❑Storms sire Drainage
❑Expetinnetual Technology ❑Subsidetrce Control 7g,Provide a brief description of the abandonment procedure:
❑Geothentai(Closed Loop) OTracer
Pulled temporary well and backfilled borehole w/ hydrated
❑Geothemnl lHeating+Cooling Return) DOtherlexplain under 7g)
bentonite chips
4.Date wellty ahandlincd: 8/15/24 ."4aLe 1��f
a
5a.Well lunation: J
Catsburg Country Store r 0 ��
Facili)�Qartet v.,•ra Facility ifasplicabk) R.Certification;
Chris Ruffer e�d �..d
1110 Old Oxford Rd, Durham, NC 27704 44/21/2024
Phssteal Address.(is.and Zip Signature of C,tlf.cd Well Contractor or Well(aver Dann
Durham lie signing then form, 1 hereby cern/y that the well(s)was(werer rrhartdoned or
Comm Parcel Identification No.MINI accordance with 15.4.'VAC 02C.0100 or 1C.0200 Well Construction.Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in dcgrees;niinures;seconds or decimal degrees:
or wcll field,one lavtmig e.alre.ew) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
N W abandonment details. You now also smelt additional pays if necessary
essart
CONSTRUCTION DET.AII.S OF W ELI AS)BEING AB.ANDQNga ,SUBMITTAL.INSTRUCTIONS
Attack weR ruaelr/./ow nn,rd'a+U of white. 1,.r m tifipre ultra Warr or non-t tuor simeey
wedsOlsLY with the:OW awrar/e cuo,r atarrA trncrrt_lot)can when(are from. lila. For All Welly: Stihmu this form within:0 days of completion of well
6a Well ID/:3DC-5 abandonment to the following
Division of Water Rewrarces.Information Processing twit.
1617 Mail Sem ice Center.Raleigh.NC 27699-1617
6h.Total well depth: 20 (ft.)
DM.For Inlrylion Weill: In addition lu s i,Jmg lie form to the address in lba
6c.Borehole diameter:1 tip.) above.also submit one copy of this tern cithni iI)days of completion of Well
abandonment to the following
6d Water lend below Division of Water Resources,L ndergnund Injection Control Program.
ground surface: (ft.) 1636 Mail Service('cater.Naki2h,N('27699-1636
15 Inc.For Water Sunnis& Injection Weill: in addition to sending the form to
oe.Outer casing length Iif lamina): (�) the address(esl above. also submit one copy of this form Within all days of
completion of well abandu nrent to the counts health dep:innuent of the county
Where abandoned
of.loner easing/tubing length lif known): (ft.)
o_.Screen length of know nl:5 (ft.)
Fort GW-3u Noah Carotins Department of Ens ironnicnt and Natural Resotntres-DR mow of Water Resources Rcs Ned August 2011

WELL ABANDONMENT RECORD For Itn(nel)I v ONI F
This form can be used for single or multiple wells
I.Well Contractor Information: WELL.ABANDONMENT DETAILS
Chris Ruffer 7a.Number of wells being abandoned: 1
N'.II(�•!mootNameforwellownerpersonalhabandoningwellonhealerpropert r�u• muJuplr OWE?Iar rw rww-avatar smpptx cells 17\'t.Y with Me sonic
enorreirrh.ii tbornhutmnrn,rylf/CNr'WIWU(Isle((Irnt
4223
NC WetlClnharactclrCenifiationNitt#Ice 71o.Approximate xnlume of water remaining in wrllisr (Xal.l
SA16D11CC0 41)R M ATER SIJPPI.I'WELLS ONLY:
Convoy Name 's.Type of disinfectant used:
2.Well Couatruction Permit 0:, ,
LW Id/trjrludL&well wrmax rt.e.('LrM.Var.1'undmre lrryettirm,etc t Ijkmrrr,
7d. Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(cheek all that apply):
❑Agricultural ❑MunkipalrPublic 0 Neat Cement Graft N Ben tonite Chips or Pclkts
❑(kothermal(Heating/Cooling Supply) ❑Restdetmal Water Supph!single) O Send Cement Grout ❑ Dry Clay
❑irtdusttaUCommcrcial ❑Rcsidctit:d Water Supph'!shared) Cl Concrete Grout 0 Dull Cuttings
❑!mllation ❑ Specialty.Grout ❑Gras el
Non-Water Supply Melt: ❑Bentonite Shiny LI Other(eApiam under 'g)
NMotionog ❑Rnunery
Injection Well: 7f.For each material selected ahomr,punide amntmt of materials used:
❑Aquifer Recharge ❑Oiro,iusd )ter Remtediatiom
❑Agmiler Storage and Reccnrn ❑Salom limier
❑Aquifer"Pest ❑Slontmatcr Drainage
Bentonite.:501b ,Wtr:gal.
❑Eyxnmerual Technology OSttbudenre(mimI 7g.Provide a brief description of the abandonment procedure:
OGeothernal(Closed Loop) OTracer
Pulled temporary well and backfilled borehole w/ hydrated
OGeathentnl(Heating+Cooling Return) 0O1ber(eWplam under
bentonite chips
4.Date nellty abandoned: 8/15/24
5a.Melt Location: ( vv
Catsburg Country Store S`� 0 �24
Facilm.OunerNam Facility MNOf aryl eabk)
S.Cenifkatioh:
1110 Old Oxford Rd, Durham, NC 27704 Chris Ruffer Chi o 8/21/2024
Physical Address.Cm.and Zip \resWan of Caulk('Welt('awewlar ut W'etl Ouster Dow
Durham lit.'swum thee form, 1 hereby certify that the well(sl was(were)abandoned in
Comic t'tt:ai Wean katlonNo.(PlNi acrvnlnnce with ISA.VCAC 02C.01011 or 2C 0200 Well Cons7ruction Stvndarib
and that a copy of this record has been provided to the well owner.
Sb.Latitude and Imgituck in ckgr'crs,rminutrvsccnnds ordadmal domes:
(if welt field,one lat lotig a*mil toot) 9.Site diagram or additional well details:
You may me the back of this page to provide additional well site details or Well
W' abandonment details. You may.also attach additional pages if necessary.
CONSTItUC11ON DETAILS OF 5 ELIASt BEING ABANDON El) SUBMITTAL.INSTRUCTIONS
.trklch well cunfrri/min n'cordlsl!J dt eitkge. I cr ncn:ry,k''d ee AI"rem-n a:rr atpl,ii
IC elk ONLY w1h the come ecsrcosao,c akordrmmna'nt ice c do nciN it one term. 10a. Fur All \%ells: Submit this form within 10 days of completion of well
6a Well ID/:3DC-6 abandonment to the following.
Dix ision of N ater Resourees,Information Processing Unit,
6b,Total well depth: 20 (D.) 1617 Mail Service Carter,Raleigh.N(•2 7699-16 1 7
nob.For Inkytion Web: In addition to sending the folio to the adducss nI Io;,
or. 'Thole diameter 1 tin.) abuse.also submit one copy of this fonn within ;1 loos of completion of hell
abandonment to the lollultmng
Dhision of Water Resources,Underground Injection Control Program.
od,W'ater level helms guossNt surface: (ft.) 1636 Mail Service Center,Raleigh,N('2 7 699-1 636
1510c.For Water Bunt'& Injection Web: In addition to sending the form to
(ft.)
6c.Outer casing length(if know n 1: the addresses) abuse. also submit one copy of this form within to days of
completion of hell abandonment to the county health department of the county
where abandoned
6f.Inner easing.+taping length(if known is (ft.)
og,Screen length(if knots nI;5 (R.)
Fenn GW-311 Non C'anhrct Department of Ens'rummer!'and Natural Rcs usees-Ent tsnn of Water Resources Res used August 20t t

WELL ABANDONMENT RECORD Forintcntl ON1Y
This form can be used for single or multiple wells
I.Well('nntracmr Information: WELL ABANDONMENT DETAILS
Chris Ruffer 7a.Number of wells being abandoned: 1
lt'c II I..ire:,our Name ice Nell°Niwi pnissialls abandoningn well on hes.ln i proven!,t f,a n lopk rn1ettaur ry Mm-skirt', >igrph rrlis f)\f I
c',5orrocncMi,tJaamAu,e,'nt item tin,+WlWllr.Nt.'Irian,
4223
71p.Approthnate volume of w aui•remaining in welled: Ixal.l
NC Well Conlni:tor Certification Nnn#,cr
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Cowan!,Name 7c.Ts pc of disinfectant used:
2.Well Construction Permit 0:, ,
l ee11;/tuna.e6&4r✓1J permits nor.I'wnn,1LMr.1%name e.byechart etc.,rl known
?d. Amount of disinfectant used:
3.Well use(check in ell use):
Water Supph Well: 7e.Sealing materials used(cheek all that apply):
❑Agnenlrural ❑Municipal:Publie O Neal Cement Grout IN Ben tomtc Chips or Pellets
❑Gmthemral(Hcantt_gl'ookng Supply) ❑Rcsidcratal Water Supph ;single) ❑Sand Comes Gtnnt ❑ Dn Clay
❑IidustffaliComntcrcial ❑Residenntial Water Supph;shared) O C(1rder°Grout ❑ DnI1 Cuttings
❑Impsuroti ❑Specialty Grout 0 Gras el
Non-Water Supply Well: ❑Bentonite Skirts Ll Other(esplaia under 7g)
I9Munuonne ❑Recosrn
lajeetion Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Nemeth...twin
❑Aquifer Siotage and Recosen ❑Saluun Barnet
Bentonite.:501b ,Wtr:gal.
❑Aquifer Test ❑Stonow er Drainage
—.
❑Etpenmemal Tecbiwbgy ❑St s.ideisx Control 7g Pnis ide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Pulled temporary well and backfilled borehole w/ hydrated
❑Geothemnal(Heating+Cooling Return) I.lttherlesplain under 7g)
bentonite chips
f.hate well(%)abandoee(k 8/15/24 ? `.... r t. r
Sa.y1 ell l„eanon: SE 1 0 tfJ24
Catsburg Country Store
Nolo)(h,ler Nam IDN(if apple abk r i.Cel'Nfkathn:
IrJO :Nbf 'le-.^y+ac:g U:71t
1110 Old Oxford Rd, Durham, NC 27704 Chris Ruffer Wi: S` " 8/21/2024
Physical Addles.Ca..and Zip signature of Certified Well Cannock)?in Well Owner Dose
Durham Ili signing this form. 1 hereby certif.).that the wells) was(were,abandoned is
Count" I'n.a Ik;,a,t:..nt,ni N,. :PIN, accordance with IS.4 Nr-ICO2C.0100or:C 0200 Well Construction Srandarilx
and that a crape of this record has been provided to the well owner.
5h.Latitude amd hnngitutie in degreeslmimrtrs,sounds sir decimal degrees:
iifwell fold.ow Lu:{,net r.wllrceryl 9.Site diagram or additional well details:
You may use the back of this page to pros de additional well site details or well
W' abandonment details. You nun'also attach additional pagcs if necessary
('ON STRI C LION DETAILS OF WELLISI BEING ABANDONED 11'BMITTAL INSTRUCTIONS
.,t„tair ac Cl curLs:rn.lr:,u tn..rd');1:J,W11A.!l' t'd mnitrf,ir uy<t elm/ry r,r.n neat?:Am!!:‘
we&ONLY With the stare Swtltrettthor,A.ord warn! tore cam what; N.,rm ltla, For All Wells: Subunit this form within '30 days of completion of well
6a.Well Ifni:
SDC-8 abandonment to the following
Division of Water Resources,Information Processing Unit.
66.Total well depth: (h.)
20 1617 Mail Sen ice Center,Raleigh.N('2 7699-1 6 1 7
!Ob.fur Iniecdon Wells: Iu addition to sending the fonn to the address in Ina
aboYe. also submit one cops of tins form within ut dais of completion of rsell
tee.Borehole diameter:1 tin.) abandonment to the following
Din Won of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.l 1636 Mail Scnice Center,Raleigh,NC 1 7 699-1 636
6c.Outer casing length lif know nl: 15 (ft.) Ilk.fur Water Sunuli& Inkctuin Welly In addition to sending the fomi to
the address(esl above. also submit one copy of this fomi within II) dais of
completion of well abandonment to the counts health department of the counts
where abandoned
6f.Inner casing/tulsine length(if known): (ft.)
fig.Screen length(if taros n l:5 (ft.)
Fours GW-to Non Carolina lkpanimalr of En.moment anti Nantual RCsMUCCS-DP!Man of Water Rcsowcee Res led August 21)1I

WELL ABANDONMENT RECORD For Internal UseONI.Y•
This form can be used for single or mdliple wells
I.Well contractor Information: WELL ABANDONMENT DETAILS
Chris Ruffer 7a.Number of wills being abandoned: 1
Well t'onite.ion NaneLL Ina well ONIie peruvulh abandoning well on hwiher propcm i For nvulaplr u)ler/rwr or w n-x suer xxlrplr wells Mitt w;,b the UAW
r',iforr,fre/J•Ut,k,nfrlon,n t,f ,*rf.r r,rt+Jll•,rl Jf VI.•4w,,,
4223
lb.A1g11.i,tint.ntt-,1.III II Itl n.ltcr Itiu:un,m,ni (gai)
NC Well ConmiciorfenifiC:amn Nonbei
SASDI►CCO FOR WA'IERSI PPI.Y NELL'.t)'tl \:
Company Nanic t.Tr lw of disinfectant used:
2.Wdl Ctwatnctisn Permit
list di applicable well pernutr li e.('wM.Mile.)ar,we-e hyetilan,etc'..0/worn
d, )mount of disinfectant used:
3.WdI use(chedc well note):
Water Supply Well: 7e,Sealing materials used teheek all that apply):
❑Agrwnitural ❑hlumcipal.'Ptnhlrc 0 Neat Cement Groin W Bentonnc Chips or Pellets
10(;rnthcrmil(HcanIu('ogling Supph t ❑Residctatal Water Supph' singlet ❑Sand Cement Grout Cl On Clay
❑Irdustruil'Coninicreial ❑Residential Water Supply i shared) 17 Cotx rein Gram ❑ Dull Cuttings
❑Irngat,un ❑ Specialty Grout ❑Gratel
Non-Water Supp is \\ 0 Bentonite Slurry 11 Other(explain under 7g)
i9Munuonng ❑Rccosen
Injection W'en: 71.For each material selected arose,prrnidc atanmt of materials used:
❑Aquifer Recharge ❑Groundwater Remedimion
El Aquifer Storage and Recovery ❑Saloon Darner
Bentonite.:501b ,Wtr:gal.
❑Aquifer Test ❑Stommatcr Drainage
❑Espetmemal Teclmologs ❑Substdetse Control 7g.Provide a brief description of the abandonment pro(edure:
LJGeothennal ICbsed Loop) LlTracer
Pulled temporary well and backfilled borehole w/ hydrated
LlGeothermal(Heating+Cooling Return) IlOthcrtesplam under 7g)
bentonite chips
4.Date wellisi abandoned; F/15/24 s`•.1
«e)i location: SFP 1_ 2074
Catsburg Country Store
Ewilns IDrld4Captnrat)ka II.Certification: it'af$:i+ftet>;t•:iI P rr,.e;yazitd*Ulu
1110 Old Oxford Rd, Durham, NC 27704 Chris Ruffer Q0101120.' 8/21/2024
Ph.sical address.Cin.and Zip Alegi ore of Certified Well Columnar or Well Owner Dare
Durham ley swung this form, 1 hereby cernfy that the wellfs►was(were,abandoned in
('duel) P.ii.et kl;ni,tx'atrnu N•, ;1'1\I accordance with IS.-!NC-IC 02C.0100 or 2C 0200 win Construction Sfancianis
and that a copy of this record has been provided in the well owner.
Sh.Latitude and Longitude in degrecsiminutcslscennds or decimal degrees:
IiiNcll frld.one bt 1nntg is.%on:scull 9.Site diagram or additional well details:
You may me the back of this page to pros date adddiliotral well site details or well
W' abandonment details. You may.also:mach atklituoital paws if,recessan
('ONSIRE( ION DETAILS OF W ELL4St BEING ABANDONED SUBMITTAL INSTRUCTIONS
(tat it xali. . 1,!l:ail fl'1r�r.r'�-;;Jt all•W:a. l'a<r nr1,1(,'•ia 0I,i1.flin .1 al t tV te.n• 1<T sonde),'
wx llr ONLY t:r1ith the mime Conorli'tion Id,u,n/wiaa'nr.14.40 ca,n',thmlt tore Pint!. 10*.For AD Weds: Submit the font within +() days of completion of well
6a.Well ID/
8DC-10 abandonment to the following
Die isktn of Water Resources.Information Processing limit.
sb,Total well depth:
20 1617 Mail Serike Center,Raleigh.NC'27699-1617
(fl.)
lob.For(niceties Wet: In addition to sending the form to the address in 111a
abode.also subunit one copy of this fonn within 30 days of completion of well
ore,Borehole diameter;1 (le.) abandonment Io the following
Di%islon of Water Resources.(ndergnlund Injection((mind Program.
sat.Water kid below mound%irefuie: (R,) 1636 Mail Sen ice Center,Raleigh,NC 2'o99-106
tie.For Water Sunni%& !election Wells: In addition ro sending the font to
6c.Outer casing length(if(mown): 15 (ft.) the address(es) above. also submit one Copt A this fond within 30 days of
completion of well abandonment to the count health dcpannien of the county
where abandoned
(if.Inner easing.+tslting length(if known): (ft.)
sg.Screen length(if talon n1:5 (h.1
Foma GW-31) North C'amliru Deism went of Eat imnn•cnt and Natural Resources -Dis isms of Water Rcsourcss Reseed August N)(t

WELL ABANDONMENT RECORD For lnknulUscONIN
This form can be used for single or multiple wells
I.Well('nntraemr Information: WELL ABANDONMENT DETAILS
Chris Ruffer 7a.Number of wills being abandoned: 1
Well C'ouracror Nan:.lot Null tot wi penal full!,alunIoiuii Nell an hasher propels) wuJnlllr rnk'ttiwr w non-outer supply arils () t.F u..
['immo.to MI,twkAUTA,tY,t 1r.ry t(In VidV,t,t tytY i�rrpl
4223
7h.Approximate surlume of water remaining in wribs): Igat.)
NC Well Contractor Certification Number
csw.naCCO FOR WATER SUPPLY WELLS ONLY:
Conpam Name 7c.'Iy pc of disinfectant used:
2.Well Construction Penult tit,
1,1.n,dl uipt,eoblr welllrrmtn o.r.('wlnh.Sher.l'unnerve.lnfraixr,etc..I!known,
711.Amount of disinfectant used:
3.WdI use(check well use):
Wester Supply Well: 7e.Sealing materials used(check all that apply):
❑.Agricultural ❑MunicipalTublic ❑Neat Cement Grout ® Bcnttonne Chips or Pellets
❑tkothertnal(Hcatanu (poling Supply i ❑Residential Water Supply isingle) ❑Sand Cetneni Gm"' ❑ Dn Clay
❑Irmdustrtal'Comniereial ❑Rcsidetttal Water Srtpph(shared) ❑Concrete Gtow ❑ Dnll Cuttings
❑ImgatIon ❑ Specialty Grout ❑Gras el
Non-Water Supply Well: ❑ Betionite Slum a Other(explain under 7g)
i klulutonug ❑Recosen
Injection Well: 7f.For each material selected above,prsnidc amount of materials used:
❑Aquifer Recharge ❑Grtnindwuer Reinedianon
❑Aquifer Storage and Recovers ❑Salinity Hamer
Bentonite.:501b ,Wtr:gal.
m❑Aquifer Test ❑Stons:aet Drainage
❑Expennie ual Technology ❑Subsodet>Le Control 7g.Provide a brief'description of the abandonment procedure:
❑Geothermal(Closed Loop) Li-racer
Pulled temporary well and backfilled borehole w/ hydrated
❑Geothermal(Heatingr'Cooling Return) DOther(explain under 7g)
bentonite chips
I.Date welled abandoned: 8/15/24 - t.-- : 'r , i,
SA.Wen lot Akin: FP 1 1') 214
Catsburg Country Store
raciln}•O nl et Neat Facility.IAN(it-applicable) B.Certification; Il.fv;7:reo.f ll rr'f; .-, U-rs
1110 Old Oxford Rd, Durham, NC 27704 Chris R u ffe r CoNr i3C,B/21/2024
Physical Address.Cry.and Zip cnd it nit:niiud lt:ll I Osliniclot or Well Owner Dote
Durham fir signing dots
X SY J6rts, 1 hereby comfy that the well{s)was/teno(abandoned in
n..l Llold:.atinn No.(PIN) accordance with 15A.SC-lc 0;C',0100 or_i- 0):00 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5h.Latitude and longitude in ikgrres;minutcs.secnnds or decimal degrees:
Of urn field,one LIE lung in uiltkzn) 9.Site diagram or additional well details:
You mas use the back of this page to pros ide additional well site details or ssell
N W abandonment details. You Min also attach additional pages if neCessara
(•(1NSTRU(TiON DE:rAILs OF W E:I_I 1S)BEING:ABANDONED SUBMITTAL.INSTRUCTIONS
.itLklr wed!torialr'n.!a„r rr.urbsr:1 at Wia't:C. :',lr nntlei,k•;Tea(in,.,r rYal,w i„er tuppir
wells O.%L)'with the mime tointmrnknr oharnkwenrm..I..w,car+.ithm.t roar•t„rwt. Isla. For All Wells: Submit this form within i() days of completion of well
6a.wen I D&
SDC 12 abandonment in the bmllnts'nil
Disisien of Water Resources.Information Processing Unit.
20 1617 Mail Service(cater,Raleigh.NC 27699-1617
61),Total nell depth: (ft.►
tub.For Ialection Wcljp: in addition to sending the(onn to the address in Ina
abuse. also submit one cops of this tonic ssnhnt it)days of completion of sell
Or.Borehole diameter:1 lin.) abandonment to the following
DRision of Water Resources,Undergnivad Injection Control Program.
(bd,Water level below :pound surface: (ft.) 1636 Mail titmice(•enter,Raleigh,N('27699-1636
6e.Outer casin Inn 15 (ft.) Ilk.For Water Sunolf & Injection Went: in addition to sending the form to
g length lid laownl: the address(esi abuse. also submit one cops of this form within 10 days of
completion of null abandonment to the counts- health depanmenl of the county
sshcrc abandoned
6f.Inner casing+tubing length Of known): (ft.)
6g.Scorn length(if knotsn1:5 (rt.)
Form GW-Aii Nona Carolina Depunnrn of Ens ironnien and Natural Resources-CNs isms of Water Rcsourccs Rc.nscd August 20I A

WELL ABANDONMENT RECORD rprlmtnellt:•ctiNl}'
This form can be used for single or mdtiple Neils
I.Well('nntraemr Information: WELL ABANDONh1ENT DETAILS
Chris Ruffer 7a.Number of walls beitg(abandoned: 1
II I'i•iii;k tOf Natrw for Neil outlet personalh ahaidnnug well on!MAIN propetw 1 1,w mlJoph' niter'ion ,v .nri-warm su/y!fr nelfs ("Lirrr♦r the swnie
['.4,1rtrt gsNn,r7,,lekkviMa.elf.1.,n t<lie,'Ntoo,
4223
N( Wall('nmmanrCenfficalion Namhcr 7h.Appmthnate volume of water remaining in waist:
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
(mignon Name 7e Type of disinfectant used:
2.Wdl Construction Permit M:
Li z d7 appikd(ile weft prrnuls ti.e.('mint,.Star.i uriwrce hiiedas,c ei.i if know(
741 Amount of disinfectant uxd:
3.Well use(check well rise):
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipalrPublic ❑ Not cement Gran 5 Bentonite Chips or Pellets
❑(i oihermal(Hcating.(•ooling Supply) ❑Reside tial Water Supply'single) ❑ Sand('emenl Grout ❑ Dry Clay
❑Iidustnal('omnicrcial ❑Residential W:atcr Supply'stared) ❑ Concrete Grout ❑DWI(•nitings
Irrigation ❑ Specialty Grout ❑Gravel
Non-Water\ilppl%Well: ❑ BentonneSlurry CJOther levplain under 7g)
BiNiointonng ❑Recoven
Injection W'cll: 7f.For each material stletter!above.provide ansorrnt of materials used;
❑Aquifer Recharge ❑Groundwater Rentediaticirl
❑Aquifer Storage and Recover ❑Sali,un Bather
Bentonite.:501b ,Wtr:gal.
❑Aquifer Test OStommatcr Drainage
❑E\peninenfal Teclinolog_v °Subsidcice Control
7g.Provide a brief description of the abandonment procedure:
❑Geothempl(Closed Loop, OTracer
Pulled temporary well and backfilled borehole w/ hydrated
❑G>othennat(Heating.coolitte Return) L)Ottlertesplam under g)
•
bentonite chips
- eL.. 1...
I.Date wcllist abandoned:
8/15/24 . . v 1./
SEP 1 02424
Sa.Wall Iq.c.Nion:
Catsburg Country Store (fr�ti:7ari
raeilns'OW earName FacihnIDMofappliablet t.CerlNicaUae: CYa�\.03c
1110 Old Oxford Rd, Durham, NC 27704 Chris Ruffer 8/21/2024
Physical Address.Can.and Zip Sigralnrc of Conned Well Contractor or Well Owner Dale
Durham nv.rifsrung this from, 1 hereby certify that the r•e11(sl was(were)diaeirior ed in
Count I°,,.<i Id.al t:,ns o No.(PINT accordance with ISA.hCAC OY'.O100 or.'C 02(10 Well Construction S7iincAnds
and that a acyis coffins record has been provided to the well owner.
5h.Latitude and longitude in tkgrcrs;minutrsrseoinds or daaintal dcYnvrs:
of well fad(tale hu Wig r.winicre,ai 9.Site diagram or additional well details:
You may the the back of this page to pros ide additional well site details or well
N W abandonment details. 1'ou may also attach:rklinoiral pages if uts:essan.
(Y)NiTRI'(TiON DETAILS OF%%FLI.iSI BEING ABANDONED $UDMiTTAi.INSTRUCTIONS
.Fred.It well,rnZstria)rm rr,,,rd.;it di allibk. l,v,mileptc r.{;.rh.,v,r lien-w alit?suppii
wear ONLY With the aver constreecruss akimioinnrnil_INN can si.t,mll(gee kiwi 10a. For A11 W ales: Submit this form within:0 days of completion of well
6L Well ID/:SDC-14 abandonment to the following
Division of Water Resources,Information Processing Unit,
1617 Mail Service(enter,Raleigh.NC 2 7 699-16 1 7
61i.Total well depth: 15
hub.for Inketion Wells: in addition to sending the form to the address in Ina
above_also submit one cop% of Iles fonn within ,o dins of completion of well
he.Borehole diameter:1 (in.) abandonment to the following
Division of Water Resources,Underground)Injection Control Program.
hd.Water level hrluw ground surface: (ft.) 1636 Mail Service('enter,Raleigh,N('27699-1636
10 Ilk.for Water Sue my& Ink'ctwtn Weill: in addition to sending the foram to
6c.Outer casing'suttee lif known): (D•) the addresses) above. also submit one copy of this form within il1 days of
completion of well abandonment to the comity health dcpannierl of the county
w hers abandoned
6f.Inner casing/tubing length at known): (ft.)
6g.Screen length lif known):5 (ft.)
Fono GW-ln Noah Carol=Depannteta of Ens Imnnlein and Natural Resources-Di%isan of Water Resources Re,eat August?oil t

WELL ABANDONMENT RECORD For!nem!Use ONLY
This form can be used for single or multiple Aelis
I.Well Contractor Information: WELL ABANDONMENT DETAILS
Chris Ruffer 7a.Number of wdIs being abandoned: 1
N'e11 l'Utaraciot None 10i Nell oaui 3ilifik1111111#well on haler proper, >v a mnlapk n,+vc?,.ur Ce n..n-rnfer supply wells (1Vf.t „�! �. •.�u��,
rrrfllfrift thin.#owheimenr.i,.,f true.r.hnuf,.wr farm
4223
NC Well ContractorCenifiation Monks
7h.Approshnate suluine•of water remaining in wilts): ital.)
SAZDACCO FOR WATER SLIPP1.4 44 FLL S ONLY:
Company Name lc.'type e of disinfectant used:
2.Wdl Comstrsction Permit
(1sf dt o;;n::ohlr w,•I/je•rrn is(i.e.Cwefi'.Sr.*.I amerce igrrOon.etc.,r/brown
7d.Amount of disinfectant used:
3.Wdl use(check n ell use►:
Water Sappis Well: Te.Sealing materials used(check all that apple):
❑Agra ultural ❑blunieipal;Public ❑Neal Cement Gmitt 1&Bentonite Chips or Pellets
❑(icother mal(Hcannt'('ooling Supply) ❑Rcstdctatal Water Supph isinglet ❑Sand Cement(;rout ❑ Un(la}
❑irdustrial,Comntcrcial ❑Residerital Water Supph•(shared) ❑Corinne Grout ❑ Unll('ulbngs
❑lmn:Muu 0 Specwlt}-Grout ❑Gras el
Nag-Water Supply Well: 0 Bentonite Slum I Other tesplain under 7g)
ISMouttontig ❑Rctosen
Injection Well: 7f.For each material selected above,puts ide ant,mint.,f matcrla s wed:
❑Aquifer Recharge ❑Gmundss-aler Reined iat ion
❑Aquifer Storage and Reern en ❑Saluuls Barer
❑Aquifer Test ❑Stomns ater Drumm:
Bentonite.:501b ,Wtr:gal.
❑Exprnmrdual Technology ❑Substdci a C'unatol 7g.Provide a brief description of the abandonment procedure:
t1Gcotlicrmal(Closed Loop) ❑Tracer
Pulled temporary well and backfilled borehole w/ hydrated
t'Geothermal(Healing•'Cooling Return) 00dsericsplant under'et
bentonite chips
I.Date n elks)abandoned: 8/15/24
Via.44ell location:
�tN10al124
Catsburg Country Store
Facia MNtifapplieabk) R.Ccnilkatian:
Irrf;,:rawit Prr.saw:l ulll
1110 Old Oxford Rd, Durham, NC 27704 Chris Ruffer dhCet O14 8/21/2024
Plo local Address.Con.and Zip Ctgrcpurc of Certified Well CnnnacYw or Well Parer Dare
Durham Bt..swung this J6rin, I hereby certify that the w•tllts!was(were,,thanik,iwd nu
Parcel Idemdicatinu No (PIN) accordance with 15.d.'CAC 02C,0101)or 2C 0:00 Well Construction..'tandem/s
and that a copy of this record has bean provided to the well owner.
Sh.Latitude and longitude in de•}(reeslminutrc seconds or decimal degrees:
difwell fold,one lantniyg n u irimerr 9.Site diagram or additional well details:
You Iluly me the back of tins page to pros Ide additianl well site details or well
N W abandonment details. You etas also attach aldttiunal pays if IletesSan
(Of RI(-f1O.N DI:1.AILS OF 44 ELl_AS'BEING ABAND()NEQ SURb1ITTAl.INSTRUCTIONS
TiONS
.trr,x lr sump ar,rnjrwalnar rented'., {1 m wht'h'. :-Or Arhlnpic oy t(,r.U,Or,Yln•WYlrer supple'
wells ONLY with the..unw,Vn,t/eirwer.ih uidiweacwu_tow can ahmi)curt N,enr Pia. For All Well',: Submit this form within .0 days of completion of well
6a Wet!IDf:SDC-17 abandonment in the following
Des(skin of Water Resources,Information Proem:ing Unit.
20 1617 Mail Sees ice('enter,Raleigh.I\('2 7699-16 1 7
6b.Total well depth: (ft.)
10b.For[election Wells: In adduion to settling the form to the edible III Ills
6e Batebakdianreter 1 (in.) abuse.also subunit one cops of his fonn suihni sn doss of completion of well
abandonment to the following
Division of Water Resources,Underground Injection Control Program.
6d.Water let*heltin •,fii,u (ft.)ad surface: 1636 Mail Service Center,Raleigh,N('17699-1636
15 10c.For Water Sunup& !election Well;: in addition to sending the fomi to
be.Outer easing length lit know a): (ft.) the addressfes( abuse. also submit one cops of this form within 10 day-s of
completion of sell abandonment to the court} health department of the county
of.Inner casing/Bahia length lit known): (ft.) where intoned
6 r,Screen length(if known1:5 (ft)
Fonts GW-In North Carolina DepMnrd of Eva freemen ani Watural Resources-DIs s10n of Water Rsources Rey wed Auguo 2011