WI0700199_Permit (Completion)_20240920 (2)

CECS SOUTHEAST, LLP "Setting the Standard for Service
�s1. Geotechnical • Construction Materials • Environmental • Facilities ND R"st�,J Enyjoc t r
NC Regtsteaed Geoioc,,,t: JC.
SC Regtste,ed EnTn—%g rui
December 13, 2017
Mr. Hassan Osman
NCDEQ, Division of Waste Management, UST Section
1646 Mail Service Center
Raleigh, North Carolina 27699-1646
Reference: Report of Monitoring Well Abandonment Services— Midway Motors
2139 US Highway 17 North
Merry Hill, Bertie County, North Carolina
NCDEQ Incident No: 12418
NCDEQ Contract No: N17006
ECS Project No: 49:2847-A
Dear Mr. Osman:
As authorized by your acceptance on October 24, 2017 of ECS Southeast, LLP (ECS) Task
Authorization Request Number (TAR No. 1) dated October 20, 2017, ECS has completed Report
of Monitoring Well Abandonment for the above referenced site.
On November 8 and 9, 2017, ECS personnel and Quantex, Inc. (Quantex) (NC Well Contractor
Certification #3106-A) located twenty seven (27) monitoring wells: MW-39 (43 feet), MW-38 (43
feet), MW-37 (43 feet), MW-36 (46 feet), MW-28 (35 feet), MW-26 (15 feet), MW-25D (75 feet),
MW-25 (30 feet), MW-24 (15 feet), MW-23 (30 feet), MW-23D (75 feet), MW-22 (15 feet), MW-27
(30 feet), MW-21 (15 feet), MW-12 (12 feet), MW-33 (40 feet), MW-32 (40 feet), MW-31 (40 feet),
MW-29 (40 feet), MW-20 (15 feet), MW-18 (15 feet), MWA3 (12 feet), MW-9R (15 feet), MW-1R
(15 feet), MW-2R (15 feet), MW-35 (30 feet), and MW-5 (12 feet). After locating the monitoring
wells with a metal detector, ECS personnel observed and documented the abandonment of each
monitoring well by Quantex. The monitoring well abandonment records (Form GW-30) are
attached. The former locations of the groundwater monitoring wells are shown on Figure 1.
Photographs depicting abandonment activities are included in the attachments.
ECS appreciates the opportunity to provide our environmental consulting services to you on this
project. If you have any questions concerning this report or this project, please contact us.
Sincerely,
ECS SOUTHEAST, LLP
_ VA CARD•.
•�'i"'"` � , ��•�`•1�' �%,C�N��d�j may
�srirah I�ordon
Jo S. Lair, P.G.
Environmental Scientist Pr. ipal Geologist: C_ Sr��
..
2075 •
[e-mail] [e-mail]% Sps_•p �.
[phone] [phone] sFO(p�,1
Attachments— Form GW - 30 Monitoring Well Abandonment Records 0 911*1
Figure 1 - Monitoring Well Location Map
Field Notes & Photograph Log
FCS Capita!Services,PLLC • ECS Flodda.LLC • ECS Mid-Atlantic.LLC • ECS Midwest LLC • _CS Southeast,LLP • ECS Texas.LLP
www.ecslimited.com

WELL ABANDONMENT RECORD For lntcnml Use ONLY:
I his lomr can be used for single or multiple well.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned Multiple
Well Conimcior Nance(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply welts ONi Y with the same
construchoniabandonment you can submit one form.
3106-A
7b. Approximate volume of water remaining in well(s): NA (gal.)
NC kkell Conimcior Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
List all applicable twit construction permits(i.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
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) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri gation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other("plain under 7g)
0 M on i tori ng ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 50 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility ocaner Nam, Facility IDd(if applwablel 8.Cerlrfication:
2139 US Highway 17, Merry Hill, NC 27957 ate 11/22/17
Physical Address.City,and/ip Signattze of Certified Well Contractor or Well Owner Da:,
Bertie NA By signing this form, l hereby certify that the wells) was(were) abandoned in
ount} 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 deg rees/mi n utesiseconds or decimal degrees:
hfwell field,one lat'long is sufficient) 9.Site diagram or additional well details:
36.036250 N 76.778317 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)ii available. For multiple injection or non-water supply
wells Oft Y with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well ID#: MW-24 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b. Total well depth 15 (It ) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
VC 2° above, also submit one copy of this form within 30 days of completion of well
6C.Borehole diameter: p l abandonment to the following:
6d. Water level below ground surface: _ 7.96t (II.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center, Raleigh,NC 27699-1636
NA 10C. For Water Supply & Iniection Wells: In addition to sending the form to
6e. Outer casing length(if known) (ft.) 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
6f. Inner casing/tubing length(if known): NA VI.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONL Y with the same
constructionvabandonment,you can submit one form.
3106-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): NA (gal.)
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
List all applicable welt constructionpermih(l.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Benionite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 100 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
[]Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned: 1 1/9/17
5a. Well location:
Midway Motors NA
Facility'OwnerName Facility lD#(if applicable) B.Cer fication:
2139 US Highway 17, Merry Hill, NC 27957 _I a� 11/22/17
Physical Address.City,and Zip Sisnalre of Certified Well ContractorOwner Date
or Well Ow Date
Bertie NA By s(pninp this form, /hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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 laclong is sufficient) 9.Site diagram or additional well details:
36.036250 N 76.778317 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 wall construction record(s)it available. For multiple injection or non-water supply
tells ONL Y with the same construetionlabandonment you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-23D abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth:
60 (ft.) 1617 Mail Service Center, Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
2" VC above, also submit one copy of this form within 30 days of completion of well
6C.Borehole diameter: p (in.) abandonment to the following:
6d.Water level below ground surface: — 23.80t (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center, Raleigh,NC 27699-1636
6e. Outer casing length(if known): NA (ft) 10c. _For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f. Inner casing/tubing length(it known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONL Y with the same
constructionlabandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
List all applicable well construction permits(i.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
m Monitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 65 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility'Owner Name Facility ID#(if applicable)
B•rer fiCatlOn: /,-)
2139 US Highway 17, Merry Hill, NC 27957 _1 11/22/17
Physical Address.City.and Zip Signlm of Certified Well Conawtor or Well Owner Date
Bertie NA By signing this form, l 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:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)it available. For multiple injection or non-water supply
wells ONL Y with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-38 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 43 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in l0a
vc 2° above,also submit one copy of this form within 30 days of completion of well
6c. Borehole diameter: p (in.) abandonment to the following:
6d.Water level below ground surface: " 17.75' (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply & Infection Wells: In addition to sending the form to
6e. Outer casing length(if known): NA (ft.) 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
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
I his turm can be used for single or multiple well,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
well l ontractor Name(or%%ell owner personally abandoning%sell on his her property) For multiple injection or non-water supply wells ON Y with the Jame
3106-A conslruchoNabandonment,you can submit one form.
NC Well Comractor C rnificauon Number 7b. Approximate volume of water remaining in well(s): NA (gal.)
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#): NA
List all applicable ws/lcomfiuctionpermils(i.e.County,State, Variance,etc.)itknown 7d.Amount of disinfectant used: NA
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
mMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 66 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 1 1/9/17
5a. Well location:
Midway Motors NA
Facihty'Owner Name Facility ID#(if applicable) 8-Ce70.:,_
fication: }2139 US Highway 17. Merry Hill, NC 27957 // 11/22/17
Physical Address.t c, .: d/q, Signan.re of Certified Well Conawwr or Well Owner f .:i
Bertie NA By signing this form, l hereby cerlify that the well(s) was(were) abandoned in
County Parcel Identiticanon 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 laClong is sufficient) 9.Site diagram or additional well details:
36.036250 N 76.778317 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 WELLS) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)If available. For multiple injection or non water supply
wells ONL Y with the same construcfiorVabandonmenf,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a Well I Dk MW-36 abandonment to the following:
Division of Water Quality. Information Processing Unit,
6b. Total well depth: 46 01.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2rr VC above,also submit one copy of this form within 30 days of completion of well
6C. Borehole diameter: P Un.J abandonment to the following:
6d.Water level below ground surface: - 19.92 If1.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center, Raleigh,NC 27699-1636
NA 10c. For Water Supply & Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (f[.) 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
611. Inner casing/tubing length(it known). NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1. Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONL Y with the same
constructioWabandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
Ustall applicable well construction permits(i.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
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) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
0 Monitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 60 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility'Owner Name Facility ID✓:(if applicable) B.CO fiC8tlon: l
2139 US Highway 17, Merry Hill, NC 27957 _ I 11/22/17
Physical Address.City.and Zip Sigoaque of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l hereby certify that the wett(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:
(ifwell field,one lationg is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anach will cortstruction records)if available. for multiple injection or non-water supply
wells Oft Y with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1 D#: MW-35 abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 40 (ft.)
10b. For Infection Wells: In addition to sending the form to the address in 10a
vc 2° above, also submit one copy of this form within 30 days of completion of well
6C. Borehole diameter: p (in.) abandonment to the following:
6d.Water level below round surface: — 16.08' (ft Division of Water Quality.Underground Injection Control Program,
g ) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e. Outer casing length(if known): NA (ft) 10c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or nth-water supply wrIls ONL Y with the same
construction/abandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in weli(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA NA
List al/applicable well construction permits(i.e.County,State, Variance,etc.)ilknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
O Monitoring ❑Recovery
njection ell: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 59 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwaler Drainage
❑Experimental Technology []Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility Owner Name Facility IDrr(ifapplicable) B.Cer�l fieation:
1
2139 US Highway 17, Merry Hill, NC 27957 11/22/17
Physical Address.City,and Zip SignaW re of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l 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 deg rees/m I nutes/seconds or decimal degrees:
(if well field.one IaL'long is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Adach well construction record(s)it available. for multiple injection or non-water supply
wells ONL Y with the same construction/abandonment,you can submit one form. 10a. For A I I Wells: Submit this form within 30 days of completion of well
6a. Well I Da: MW-31 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 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 pVc (in.) abandonment to the following:
6d.Water level below round surface: 19.96' (ft.) Division of Water Quality,Underground Injection Control Program,
g 1636 Mail Service Center,Raleigh,NC 27699-1636
68. Outer casing length(if known): NA 10c. For Water Supply & Iniection Wells: In addition to sending the form to
(ft.) 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
61. Inner casing/tubing length(if known): NA (it.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONL Y with the same
construclioalabandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
List all applicable well construction permits(i.e.County,State, variance,Vic.)ilknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout O Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approximately 59 lbs. Neat Cement
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9117
5a.Well location:
Midway Motors NA
FacilitylOwner Name Facility ID#(ifapplicahlc1 8.Cer�.fieatlon:
2139 US Highway 17, Merry Hill, NC 27957 Qt _ �J l �1..� 11/22/17
Physical Address.City,and Lip Sigma"of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l 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 latllong is sufficient) 9.Site diagram or additional well details:
36.036250 76,77$317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atach*v//construction record(s)//available. for multiple injection or non-wafer supply
wells ONL Y wiM the same constructionrabandonment,you can submit one form. 10a. For A I I Wells: Submit this form within 30 days of completion of well
6a.Well I DA: MW-32 abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: '40 If
10b. For Injection Wells: In addition to sending the form to the address in 10a
vc 2° above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: p (in•) abandonment to the following:
6d. Water level below ground surface: 16.31 r (ft) Division of Water Quality.Underground Injection Control Program,
1636 Mail Service Center, Raleigh,NC 27699-1636
NA 10c. For Water Supply b Infection Wells: In addition to sending the form to
6e. Outer casing length(if known): (it.) 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
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (tit.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONL Y with the same
constructioniabandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
List all applicable wall construction permits(i.a.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
mMonitoring ❑Recovery
njection a 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 53 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA I !
Facility'Owner Name Facility ID#(ifapplicable) B.Cer fieation: I L �t—2139 US Highway 17, Merry Hill, NC 27957 0*1� , 11/22/17
Physical Address.City,and Zip Si of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN. ) accordance with 15A NCAC 02C.Of00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the the//owner.
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one latlong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record($)it available. for multiple injection or non-water supply
wells ONL Y with the same constructioalabandonmenl,you can submit one form. 10a. For A I I Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-28 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b. Total well depth: 35 (ft.) 1617 Mail Service Center, Raleigh,NC 27699-1617
10b. For Iniection 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 pVC (in.) abandonment to the following:
6d.Water level below ground surface: 21.69' (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply & Iniection Wells: to addition to sending the form to
6e. Outer casing length(if known): NA (ft.) 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
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor:Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells 01111 Y with the same
constructionlabandonmenl,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit k: NA
List all applicable well construction permits(i.e.County,State. Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approximately 59 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility'Owner Name Facility ID#(if applicable) 8.Cer�lfieatlon:
2139 US Highway 17, Merry Hill, NC 27957 . j _ 11/22/17
Physical Address.City,and Lip Siombim ofCettified Well Coaaactor or Well Owoer Date
Bertie NA By signing this form, l hereby certify that the wall(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:
(ifwell field.one lat1ong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with Me some constructioniabandonmerit,,you can submit one form. 10a. For All Wells: Submit this forth within 30 days of completion of well
6a. Well I D#: MW-29 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 40 (it.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
2r' above, also submit one copy of this form within 30 days of completion of well
6C. Borehole diameter: pvc (In.) abandonment to the following:
19.25t Division of Water Quality,Underground Injection Control Program,
6d. Water level below ground surface: (it.) 1636 Mail Service Center.Raleigh.NC 27699-1636
10c. For Water Supply & Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): NA (ft.) 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
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple infection or non-water supply wells ONL Y with the same
construction/abandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
Listal/applicable well construction permits Ae.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
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) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
m Monitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approximately 62 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 1119/17
5a.Well location:
Midway Motors NA
Faciliry'OwnerName Facility lD#(ifapplicable) 9•Cer fieation:
2139 US Highway 17, Merry Hill, NC 27957 11/22/17
Physical Address.City,and Zip Si of Certified Well Contactor or Well!Tuner Date
Bertie NA By signing this torn, l 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 laLlong is sufficient) 9.Site diagram or additional well details:
36.036250 76778317 You may use the back of this page to provide additional well site details or well
N . W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Apach well construction record(s)it available. For multiple injection or non-water supply
wells ONLY with Me same constructioalabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-27 abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 37 (ft.)
10b. For Infection Wells: In addition to sending the form to the address in 10a
6C. Borehole diameter: 2 p
" above, also submit one copy of this form within 30 days of completion of well
VC (in.) abandonment to the following:
17.91' Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center, Raleigh,NC 27699-1636
10c. For Water Supply & Infection Wells: In addition to sending the form to
6e. Outer casing length(if known): NA (ft.) 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
611. Inner casing/tubing length(if known): NA (ft,) where abandoned.
6g.Screen length(if known): NA (it.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 200

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1. Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONLY with the same
constructionlabandonment,you can submit one form.
3106-A
7b. Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
List al/applicable wr//construction permits(i.e.County,State,Variance,etc.)ilknown 7d.Amount of disinfectant used: NA
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public O Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industriat/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
election a 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 65 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) []Other(explain under 7g)
4.Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility'O"ner Name Facility ID#(if applicable) B.Cer flCatlOn:lr
2139 US Highway 17, Merry Hill, NC 27957 QtM-A— L11/22/17
Physical Address.City.and Zip Sig alm of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l 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:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach w7r//construction record(s)it available. for multiple injection or non-water supply
wells ONL Y with the same constructionlabandonment.you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well I D#: MW-39 abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center. Raleigh,NC 27699-1617
6b.Total well depth: 43 (it.)
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 pVc (in.) abandonment to the following:
round surface: 17.7' (ft Division of Water Quality,Underground Injection Control Program,
6d. Water level below
g ) 1636 Mail Service Center, Raleigh,NC 27699-1636
68. Outer Casing length(if known): NA 10c. For Water Supply & Iniection Wells: In addition to sending the form to
(ft.) 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
61. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 'North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-crater supply Mulls ONL Y With the same
3106-A constructionlabandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): NA (gal.)
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
Listall applicable well construction permits(i.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
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) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
01ni ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 27 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility/Owner Name Facility ID#(if applicable) B.Cer fleation:
2139 US Highway 17, Merry Hill, NC 27957 11/22/17
Physical Address.City.and Zip Signatyre of Certified Well Conhacmr or Well Owoer Date
Bertie NA By signing this form, l hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0f00 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 latlong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W 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 ONL Y with the same constructiotvabandonment,you can submit one form. 10a. For A I I Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-26 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
vc 2" above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: p (in.) abandonment to the following:
6d.Water level below round surface: " 7.66' (ft) Division of Water Quality,Underground Injection Control Program,
g 1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c. For Water Supply & Infection Wells: In addition to sending the form to
6e. Outer casing length(if known): (ft.) 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
61. Inner casing/tubing length(it known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONLY with the same
comtructionlabandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
List al/applicable well construction permits(i.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial El Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Grotmdwater Remediation Approximately 65 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility'OwnerName Facility ID#(ifapplicable) B.Gert.fication:
2139 US Highway 17, Merry Hill, NC 27957 1 Q,k*tA- 6, I 11/22/17
Physical Address,City,and Zip Sigrati of Certified Wet!Contractor or Well Owner Date
JJ
Bertie NA By signing this form, l 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 latlong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W 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 ONL Y with the same constructioWabandonment,you can submit one form. 10a. For A I I Wells: Submit this form within 30 days of completion of well
6a.Well I Da: MW-37 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth: 43 (f1.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2" yC above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: p (in.) abandonment to the following:
6d. Water level below round surface: — 19.08t (ft.) Division of Water Quality,Underground Injection Control Program,
9 1636 Mail Service Center, Raleigh,NC 27699-1636
10c. For Water Supply & Infection Wells: In addition to sending the form to
6e. Outer casing length(if known): NA (f1•) 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
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONLY with the same
3106-A construchon/abandonment you can submit one form.
NC Well Contractor Certification Number 7b. Approximate volume of water remaining in well(s): NA (gal.)
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
List al/applicable well construction permits(i.e.County,State, Variance,etc.)if known NA
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic 0 Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ORecovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 50 lbs. Neat Cement
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility'Owner Name Facility ID#(if applicable) B•Cer cation:
2139 US Highway 17, Merry Hill, NC 27957 ,I _ 11/22/17
Physical Address,City,and Zip Signi t m of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l 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:
(ifwell field,one IaUlong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. for multiple injection or non-water supply
wells Oft Y with the same conatructionlabandonment,you can submit one form. 10a. For A I I Wells: Submit this form within 30 days of completion of well
6a. Well ID#:
MW-23 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
yC 2" above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: p (in.) abandonment to the following:
19.04' Division of Water Quality, Underground Injection Control Program,
6d. Water level below ground surface: (ft.) 1636 Mail Service Center, Raleigh,NC 27699-1636
NA 10c. For Water Supply & Infection Wells: In addition to sending the form to
6e. Outer casing length(if known): (ft.) 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
611. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use I)NL1
This form can be used for single or multiple wells
1. Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply tells ONL Y with the same
constructionlabandonmenl,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.County,State, Variance,etc.)ilknown 7d.Amount of disinfectant used: NA
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) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well. ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
njection ell: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 26 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility�Owner Name Facilitv ID#(ifapplicable) 6.rert.fieati0n:
m j
2139 US Highway 17, Merry Hill, NC 27957 Q,+t J 11/22/17
Physical Address.City,and Zip Si of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l 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:
(ifwell field,one IaLlong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allach well construction record(s)if available. for multiple injection or non-water supply
wells ONL Y with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well 1 D#: MW-22 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
vc 2" above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: p (in.) abandonment to the following:
6.82' Division of Water Quality,Underground Injection Control Program,
6d. Water level below ground surface: (ft.) 1636 Mail Service Center, Raleigh,NC 27699-1636
10c. For Water Supply & Iniection Wells: In addition to sending the form to
6e. Outer casing length(if known): NA (ft.) 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
61. Inner casing/tubing length(if known): N (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1. Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on hisihcr property) for multiple injection or non-water supply wells ONL Y with the same
3106-A constructiorYabandonment,you can submit one form.
NC Well Contractor Certification Number 7b. Approximate volume of water remaining in well(s): NA (gal.)
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#t: NA
Listal/applicable well construction permits(i.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial El Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
M Monitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approximately 25 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility Owner Name Facility 1D#(ifapplicable) B.Cert.:fication:
2139 US Highway 17, Merry Hill, NC 27957 Q,t _ 11/22/17
Physical Address.City.and Zip Si of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l hereby certify that the wall(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 latlong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Affach well construction record(s)if available. for multiple injection or non-water supply
wells ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well I D#t: MW-21 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
vc 2° above, also submit one copy of this form within 30 days of completion of well
6c. Borehole diameter: p (in.) abandonment to the following:
6d. Water level below ground surface: 5.65' (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center, Raleigh.NC 27699-1636
10c. For Water Supply & Infection Wells: In addition to sending the form to
6e. Outer casing length(if known): NA (ft.) 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
61. Inner casing/tubing length(if known): NA (ft.) where abandoned.
69.Screen length(if known): NA (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Infernal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
3106-A constructlon/abandonmem,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well($): NA (gal.)
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.County,State, Variance,stc.)ifknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 23 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control 7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
FacilitylOwner Name Facility ID#(ifapplicable) 8.Cert.fication:
2139 US Highway 17, Merry Hill, NC 27957 _j At-tL 0, 1,_:?L11/22/17
Physical Address.City.and Zip Signalm of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l 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:
(ifwell field.one lat1ong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anach well construction record(s)if available. For multiple injection or non-wafer supply
wells ONL Y with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-20 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth: 15 (it.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the forth to the address in 10a
vc 2° above, also submit one copy of this form within 30 days of completion of well
6c. Borehole diameter: p (in.) abandonment to the following:
6d.Water level below ground surface: NA (ft,) Division of Water Quality,Underground Injection Control Program.
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c. For Water Supply & Iniection Wells: In addition to sending the form to
68. Outer Casing length(it known): (ft.) the address(es) above. also submit one copy of this forth within 30 days of
completion of well abandonment to the county health department of the county
6f. Inner casing/tubing length(if known): NA (it.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1. Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-Water supply wells ONL Y With the same
constructionlabandonment,you can submit one torn.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
List al/applicable wel/construction permits(i.e.County.State,Variance,etc.)if known 7d.Amount of disinfectant used: NA
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) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
mMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 24 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
I acdny Owner Name Facility ID#(ifapplicable) B.Car fication:
2139 US Highway 17, Merry Hill, NC 27957 Q,+t _ r 11/22/17
Physical Address.City,and Zip Si of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l 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:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach Well construction records)if available for multiple injection or non-Water supply
wells ONLYWIth the same constructlow4bandonment,you can submit onetorm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well I D#E: MW-18 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center, Raleigh,NC 27699-1617
10b. For Inleetion Wells: In addition to sending the form to the address in 10a
6c. Borehole diameter: 2 p
" above,also submit one copy of this form within 30 days of completion of well
Vc (in.) abandonment to the following:
6d.Water level below ground surface: 6.18 ((t.) Division of Water Quality.Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
fie. Outer casing length(if known): NA (ft.) 10c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
completion of well abandonment to the county health department of the county
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD I For Internal Use ONLY:
I his form can be used for single or multiple wells
1. Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned. Multiple
N ell Contractor Vamc(or"ell unner personally abandoning%cell on his,her property) for multiple inlrction or non-water supply wells ONLY with the same
3106-A construchoWabandortmenL you can submit one form.
7b.Approximate volume of water remaining in well(s): NA
VC Well t ontractorCertificarion Number (gal l
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY
Company Name 7c. Type of disinfectant used: NA
2.Well Construction Permit#: NA
List all opplicable well construction permits 0.e.County,State,Variance,etc.)if known 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic 0 Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri gation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
0 Monitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 22 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility/Ow•nerName Facility lD4(if applicable) 8. Cert.flcation.
2139 US Highway 17, Merry Hill, NC 27957 11/22/17
Physical Address.City,and Zip Signavil ofCettified Well Contractor or Wcll Owner Dale
Bertie NA By signing this form, 1 hereby certify that the well(s) was(were) abandoned in
Count% Parcel Idcrui icauon 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 degreestminutes/seconds or decimal degrees:
(if%%ell field.one lat'long is sufficient) 9.Site diagram or additional well details:
36.036250 N 76.778317 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 WELLS) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. for multiple injection or non-water supply
wells ONL Y with the same consrruclion/abandonment you can submit one form. 10a. For All Wells: Submit this forth within 30 days of completion of well
6a. Well ID#: MW-13 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth 12 1617 Mail Service Center, Raleigh,NC 27699-1617
. (ft.)
10b. For Infection Wells: In addition to sending the form to the address in 10a
Vc 2" above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: p (in.) abandonment to the following:
— 6.13' Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center, Raleigh,NC 27699-1636
NA 10c. For Water Supply & I niection Wells: In addition to sending the form to
6e. Outer casing length(if known): (It.) 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
611. Inner casing/tubing length(if known): NA (II,) where abandoned.
69.Screen length(if known): NA (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1. Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONL Y with the some
constructioniabandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
(ompany Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
Listal/applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
mMonitoring ❑Recovery
Injection Well: 711. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 25 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility'Owner Name Facility ID#(if applicable)
B.Oer>(�fiC8ti0n:
2139 US Highway 17, Merry Hill, NC 27957 11/22/17
Physical Address.City,and Zip Sigoalm of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l 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 lat1ong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recofd(s)if available. for multiple injection or non-water supply
wells ONL Y with the same constructionlabandonment,you can submit one form. 10a. For A I I Wells: Submit this form within 30 days of completion of well
6a. Well IDd:
MW-9R abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b. Total well depth: 15 (f1.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection 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 pVc (in.) abandonment to the following:
6d.Water level below ground surface: " 6.05' (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center. Raleigh.NC 27699-1636
10c. For Water Supply & Iniection Wells: In addition to sending the form to
6e. Outer casing length(if known): NA (ft•) 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
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY
This forth can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONL Y with the same
constructionlabandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
List all applicable well construction permits(i.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mtrnicipal/Public la Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
0 Monitoring ❑Recovery
njection a 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approximately 23 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility'Owner Name Facility IDu(if applicable) 8.Cer fieation:
2139 US Highway 17, Merry Hill, NC 27957 J Q, _ 11/22/17
Physical Address.City,and Zip Si of Certified Well Contractor or Well Owner Date
Bertie NA 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 Wet/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 IaLlong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)it available. for multiple Injection or non-water supply
wells ONL Y with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-5 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b. Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Infection Wells: In addition to sending the form to the address in 10a
p
6c. Borehole diameter: 2�tV above, also submit one copy of this form within 30 days of completion of well
c (in.) abandonment to the following:
6d.Water level below ground surface: NA (ft,) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1Oc. For Water Supply & Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): NA (ft.) 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
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD for Internal Use ONLY:
I his toxin can be USCd for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a Number of wells being abandoned Multiple
w cll Contractor Name(or well owner personally abandoning well on Ins her propeny) for multiple injection or non-water supply wells ONL Y with the same
constructioWabandonment,you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal l
NC t\ell(;ntmctor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA NA
List all applicable wall construction permits(i.e.County,State,Variance,etc.)itknown 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 m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
OMonituri ng ❑Recovery
njection a 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 23 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
4.Date well(s)abandoned 1 1/9/17
5a.Well location.
Midway Motors NA
Facilitv,OwnerNamc Facility ID4 01'applicable i
B. fert.flcation:
2139 US Highway 17, Merry Hill, NC 27957 11/22/17
V:1­1r.i l \,IJ:c" J/q' Signattte of Certified Well Contractor or Well Owner Dxe
Bertie NA By signing this form, l hereby cerlify that the well(s) was (were) abandoned in
Couulr 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:
(ifwcll field.one lat1ong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)rf available. for multiple injection or non-water supply
wells ONL Y with the same constructio"bandonment you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 2 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth 12 Ifl ) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
Ell Borehole diameter: 2 pVC n above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d. Water level below round surface 6.60' (ft.) Division of Water Quality,Underground Injection Control Program.
I) 1636 Mail Service Center,Raleigh,NC 27699-1636
NA „ 10c. For Water Supply & Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): the addressles) above. also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f. Inner casing/tubing length(It known): NA where abandoned.
6g.Screen length(if known): NA (ft.)
Form G W-30 Nonh Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECURD For Internal Use ONLY:
'Ibis fomr can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well l ontractor Name(or well owner personally abandoning well on htsher property) for multiple injection or non-water supply wells ONLY with the same
constructiorYabandonment,you can submit one form.
3106-A
7b. Approximate volume of water remaining in well(s): NA (gal.)
Nc N ell(omraaor Cenification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Compam Name 7c.Type of disinfectant used: NA
2 Well Construction Permit A: NA NA
List all applicable wellconstruction Permits(i.e.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 m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ BentonitcSlurry ❑ Other(explain under 7g)
mMonitoring ❑Recovery
njection e : 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 25 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
4. Date will abandoned: 11/9/17
5a.Well location:
Midway Motors NA )
8. Cert.fication:
Facility/Owner Name Facility ID#(ifapplicablc) 1
2139 US Highway 17. Merry Hill, NC 27957 _ I 11/22/17
Physical Address.City.and/q, Signan.re of Certified Well Contractor or Well Owner I kuc
Bertie NA By signing this form, l hereby certify that the well(s) was (were) abandoned in
Count� 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:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELOS) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recordls)if available. for multiple injection or non-water supply
wells ONL Y with the same construction abandonment,you can submit one form. 1 Oa. For All Wells: Submit this form within 30 days of completion of well
sa. Well I D- MW-2R abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b. Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in IOa
6C. Borehole diameter: 2 pVC (In I above.also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6.41 r Division of Water Quality,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) NA 10c. For Water Supply & Iniection Wells: In addition to sending the form to
(1L) 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
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1. Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on histher property) For multiple injection or non-water supply wells ONL Y with the same
constructionlabandonment,you can submit one form.
3106-A
7b. Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
Listall applicable wit construction permits(/.a.County,State,Variance,etc.)if known 7d.Amount of disinfectant used: NA
3. Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public m Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout Cl Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approximately 25 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility'Owner Name Facility IDa(ifapplkable) 8.Certification: 1
2139 US Highway 17, Merry Hill, NC 27957 i _ , I 71 11/22/17
Physical Address,City,and Lip Si of Cc tified Well Contractor or Well Owner Date
Bertie NA By signing this form, l hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0f00 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 deg rees/miItutes/seconds or decimal degrees:
(ifwell field.one lat7ong is su(ficientl 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wv//construction record(s)it available. For multiple injection or non-water supply
wells ONL Y with Me same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-1 R abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth:
15 1617 Mail Service Center, Raleigh,NC 27699-1617
(ft.)
10b. For Injection Wells: In addition to sending the form to the address in 10a
2° VC above, also submit one copy of this forth within 30 days of completion of well
6c. Borehole diameter: p (in.) abandonment to the following:
6d.Water level below ground surface: — 6.13' (}t) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center, Raleigh,NC 27699-1636
NA 10e. For Water Supply & Infection Wells: In addition to sending the form to
6e. Outer casing length(if known): (it.) 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
6t. Inner casing/tubing length(it known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD fnrl,,,en,all eitul,
This lunn can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells ONL Y with the same
constructioWabandonment,you can submit one form.
3106-A
7b Approximate volume of water remaining in well(s): NA (gal.)
NC Nell C onlractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Compam Name 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA
Listall applicable wil construction permits(i.e.County,State, Variance,etc.)itknown 7d.Amount of disinfectant used: NA
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) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
0 Monitoring []Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 122 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed LA)-op) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility/Owner Name FacilitvlD++(if applicable) 8•Ce f
, iCStion: l
2139 US Highway17 Merry Hill, NC 27957 Q,U+� r 11/22/17
rY
Physical Address.City,and Lip Stgnamm of Certified Well Contractor or Well Owner Daze
Bertie NA By signing this form, l hereby certify that the well(s) was(were) abandoned in
CoumN Parcel Idenuticauon 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 deg rees/m i nutestseconds or decimal degrees:
(if well field.one lat'long is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W 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 ONL Y 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-25D abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth 75 Ill i 1617 Mail Service Center,Raleigh,NC 27699-1617
.
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: pVC (in.) abandonment to the following:
6d. Water level below ground surface: — 21.51' ift) Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c. For Water Supply & Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known) if I.) 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
61. Inner casingltubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a.Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) for multiple injection or non-water supply wells OWL Y with the same
construchoWabandwmen4 you can submit one form.
3106-A
7b.Approximate volume of water remaining in well(s): NA (gal.)
NC Well Contractor Certification Number
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Namc 7c.Type of disinfectant used: NA
2. Well Construction Permit#: NA NA
List all applicable well construction permits(l.v.County,Stale, Variance,etc.)it*no wn 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 lD Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
njection a 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approximately 50 lbs. Neat Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 11/9/17
5a. Well location:
Midway Motors NA
Facility Owner Name Facility ID#(ifapplicablc) 8.Car rfieation:
I
2139 US Highway 17, Merry Hill, NC 27957 J
QAM� 11/22/17
Physical Address.City,and Zip Signagre of Certified Well ContractorOwner or Well Date
Bertie NA By signing this form, l 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:
(ifwell field.one ladlong is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach*roll construction record(s)if available. for multiple injection or non-water supply
wells ONL Y with the same constructionlabandonment,you can submit one lorm. 10a. For A I I Wells: Submit this form within 30 days of completion of well
6a. Well I D#: MW-25 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in IOa
6C.Borehole diameter: 2 pVc above, also submit one copy of this form within 30 days of completion of well
(In.) abandonment to the following:
— 7 85' Division of Water Quality,Underground Injection Control Program,
6d. Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply & Iniection Wells: In addition to sending the form to
6e. Outer casing length(it known): NA (ft•) 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
6f. Inner casing tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
James D. Barker 7a. Number of wells being abandoned: Multiple
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wefts ONL V with the same
3106-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): NA (gal.)
Quantex, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: NA
2.Well Construction Permit#: NA
L ist all applicable well construction permits(f.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used: NA
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used (check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑hidustrial/Commercial El Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f. For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Approximately 59 lbs. Neat Cement
❑Aquifer Storage and Recovery El Salinity Barrier
El Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control 7g, Provide a brief description of the abandonment procedure:
El Geothermal(Closed Loop) ❑Tracer Neat Cement was placed - Bottom up
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
4. Date well(s)abandoned: 11/9/17
5a.Well location:
Midway Motors NA
Facility/Owner Name Facility fD#(ifapplicable) 8•dAt-t�
ication:2139 US Highway 17, Merry Hill, NC 27957 6, I 11/22/17
Physical Address,City,and Zip Signalre of Certified Well Contractor or Well Owner Date
Bertie NA By signing this form, l hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 20.0200 We/l 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.036250 76.778317 You may use the back of this page to provide additional well site details or well
N W 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 ONL V 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 I D#: MW-31 abandonment to the following:
Division of Water Quality, Information Processing Unit,
6b.Total well depth:
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
vC 2" above, also submit one copy of this form within 30 days of completion of well
6c.Boreholediameter: p (in.) abandonment to the following:
16.15' Division of Water Quality, 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): NA (ft) 10c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f. Inner casing/tubing length(if known): NA (ft.) where abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013

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SCALE CAROLINA
NCDEQ INCIDENT NO. 12418
ECS PROJECT NO.49.2847

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SOURCE: MIDWAY MOTORS
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GROUNDWATER MANAGEMENT ASSOCIATES, INC. MERRY HILL, BERTIE COUNTY, NORTH CAROLINA
ECS FIELD NOTES NCDEQ INCIDENT NO. 12418
ECS PROJECT NO. 49:2847-a

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MERRY NORTH CAROLINA
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Photograph 4: View of monitoring well MW-35 after grouting and abandonment activities.
SITE PHOTOGRAPHS
MIDWAY MOTORS
i-- 2139 NC HIGHWAY 17 N
MERRY HILL, BERTIE COUNTY, NORTH CAROLINA
_ NCDEQ INCIDENT: TF-12418
ECS PROJECT: 49:2847-A

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