WI0500242_Permit (Completion)_20241015 (2)

ARCAD IS Design&Consultancy
fornaturaland
builtassets
Mr. Blake Butcher, Hydrogeologist Arcadis G&M of North Carolina,Inc.
North Carolina Department of Environmental Quality 175 Regency Woods Place
Division of Water Resources Suite 400
UIC Program Cary
1636 Mail Service Center North Carolina 27518
Raleigh, NC 27699-1636 Tel [phone]
Fax [phone]
www.arcadis.com
Subject: ENVIRONMENT
Recission of Permit W10500242
UPS Rocky Mount Center
1108 Instrument Drive Date:
Rocky Mount, Nash County, North Carolina September 18, 2024
NDEQ Incident#5019
Contact:
Denise Dixon
Phone:
Dear Mr. Butcher: 770.289.3261
On behalf of United Parcel Service (UPS), Arcadis G&M of North Carolina, Inc.
Email:
(Arcadis) is submitting the attached documentation to close Permit No. [e-mail]
W 10500242.
On May 16, 2016, Arcadis submitted a Notice of Residual Petroleum to Ms. Our ref.
30208183
Barbara Hafshejani at the North Carolina Department of Environmental Quality
(NCDEQ). NCDEQ subsequently issued a Notice of No Further Action on July 8, ARCADIS G&M of North Carolina,Inc.
2016. Both documents are attached for reference. The monitoring and injection
wells were abandoned as indicated in the attached May 16, 2017, NC Engineering License#C-1869
NC Surveying License#C-1869
correspondence to NCDEQ.
As requested in your correspondence dated September 17, 2024, Arcadis has
completed the attached Status of Injection Well(s)/Permit Recission Request
Form GW-68. Please close the permit and provide a Permit Completion Letter.
Page:
1/2

NCDEQ
September 18, 2024
If you have any questions or need further information, please contact the undersigned.
Sincerely,
Arcadis G&M of North Carolina, Inc.
Denise Dixon, P.G.
North Carolina Professional Geologist
Copies:
Friedhelm Otto,2535 Edward Babe Gomez Ave.,Omaha,NE 68107
File
arcadis.com
Page:
2/2

04 ARCAD IS Design&Consultancy
fornaturaland
built assets
Ms. Brenda Hafshejani Arcadis U.S.,Inc.
North Carolina Department of Environmental Quality 1000 Cobb Place Blvd.
Raleigh Regional Office Bldg.500-A
1628 Mail Service Center Kennesaw
Raleigh, North Carolina 27699 Georgia 30144
Tel [phone]
Fax [phone]
Subject: www.arcadis.com
Notice of Residual Petroleum
UPS-Rocky Mount Center ENVIRONMENT
1108 Instrument Drive
Rocky Mount, Nash County, North Carolina
NCDENR Incident#5019 Date:
May 16, 2016
Dear Ms. Hafshejani: Contact:
On behalf of United Parcel Service (UPS), Arcadis U.S., Inc. (Arcadis) is Margaret Geganto
presenting the attached certified copy of the Notice of Residual Petroleum (NRP) Phone:
for the above-referenced facility. The NORP was filed with Nash County on May 404.952.1610
6, 2016. Additionally, Arcadis initiated public notice on May 6, 2016. Letters
transmitting a copy of the Conditional Notice of No Further Action were sent via Email:
certified mail in accordance with North Carolina Department of Environmental Margaret.Geganto@arcadis.
Quality correspondence dates April 18, 2016. com
If you have any questions or require any additional information, please contact us Our ref:
at 404.952.1610. Please send any correspondence regarding this site to Mr. Paul B0038382.0015
Harper of UPS at the address provided below, with a copy to Arcadis.
Sincerely,
Arcadis U.S., Inc.
Margaret Geganto
Project Manager
Copies:
Paul Harper—UPS Corporate Plant Engineering, 55 Glenlake Pkwy NE,Atlanta, GA
30328
Page:
G:\COMMON\U P S\North Carolina\Rocky Mount\2016\Public Notice\UPS Rocky Mount Center-certified NRP transmittal.docx
1/1

Page i of 4
IllllilllllllllllllllllllllllllllllillllllllllllliNilllllilll�lll�lllilillll
Doc ID: 006980140004 Tvoe: CRP
Recorded: 05/06/2016 at 02:41:55 PM
Fee Amt: $26.00 Paoe 1 of 4
Nash Countv North Carolina
Anne J. Melvin Resister of Deeds
BK2824 PGi116V-1 /7 2
NOTICE OF RESIDUAL PETROLEUM
UPS-Rocky Mount Center,Nash County,North Carolina'
The property that is the subject of this Notice(hereinafter referred to as the"Site")contains
residual petroleum and is an Underground Storage Tank(UST)incident under North Carolina's
Statutes and Regulations,which consist of N.C.G.S. 143-215.94 and regulations adopted thereunder.
This Notice is part of a remedial action'for the Site that has been approved by the Secretary(or
his/her delegate)of the North Carolina Department of Environment and Natural Resources(or its
successor in function),as authorized by N.C.G.S. Section 14313-279.9 and 143B-279.11. The North
Carolina Department of Environment and Natural Resources shall hereinafter be referred to as
"DENR".
NOTICE
Petroleum product was released and/or discharged at the Site.Petroleum.constituents remain on
the site,but are not a danger to public health and the environment,provided that the restrictions
described herein,and any other measures required by DENR pursuant to N.C.G.S. Sections 14313-
279.9 and 14313-279.11,are strictly complied with. This"Notice of Residual Petroleum" is composed of
a description of the property,the location of the residual petroleum and the land use restrictions on the
Site.The Notice has been approved and notarized by DENR pursuant to N.C.G.S. Sections 143B-279.9
and 143B-279.11 and has/shall be recorded at the Nash County Register of Deeds'office
Book ,Page
Source Property
BT OH LL.0 of Atlanta,Georgia is the owner in fee simple of all or a portion of the Site,which is
located it)the County of Nash,State of North Carolina,and is known and legally described as:
Parcel: 018297, PIN:385216832 785,Address: 1108 Instrument Drive,Description: 192 3; 2 AC, SUB
I RD FARM; UNITED PARCEL SERVICE AC IC 1112 WSTRUMENT
Pa,rccl. 0.32759, PiW.-38521683A721, Description:192 2Z 0 50 AC, INSTRUMENTDR
el
Parcel: 032757 PIN:385216836616, Description: 192 20, 0 93 AC, 1 BKA KILSON
Revised January 15,2013
1
Book: 2824 Page: 169 Seq: 1

Page 2 of 4
/ 7a
For protection of public health and the environment,the following land use restrictions required by
N.C.G.S.Section 143B-279.9(b)shall apply to all of the above-described real".property.These restrictions
shall continue in effect as long as residual petroleum remains on the site in excess of unrestricted use
standards and cannot be amended or cancelled unless and until the Nash County Register of Deed receives.
and records the written concurrence of the Secretary(or his/her delegate)of DENR(or its successor in
function).
PERPETUAL LAND USE RESTRICTIONS
Groundwater: Groundwater from the site is Prohibited from use as a water supply. Water supply wells
of any kind shall not be installed or operated on the site.
ENFORCEMENT
The above land use restHetion(s)shall be enforced by any owner, operator,or other party
responsible for the Site. The above land use restriction(s)may also be enforced by DENR through any of
the remedies provided by law or by means of a civil action,and may also be enforced by any unit of local
government having jurisdiction over any part of the Site. Any attempt to cancel this Notice without the
approval of DENR(or its successor in function)shall be subject to enforcement by DENR to the full extent
of the law. Failure by any party required or authorized to enforce any of the above restriction(s)shall in no
event be deemed a waiver of the right to.do.so thereafter as to the same violation or as to one occurring
prior or subsequent thereto.
Revised January 15,2013
.2
Book: 2824 Page: 169 Seq: 2

Page 3 of 4
IN WITNESS WHEREOF,United Parcel Service has caused this No�ice to be executed pursuant
to N.C.G.S. Sections 143B-279.9 and 143B-279.11,this ��day of l ,2016.
United Parcel Service
(name o ponsible party if agent is signing)
By: IV/ e����
(signahlre of responsible party.attorney or other agent if there is oae)
CuRLOIL4-76 gcME0iAr(dv MA•NALrE�
Mfie of agent for responsible parry if there is one)
Signatory's name typed or printed: PA lit L L
G- 1
COUNTY
(Name of coo-uupnty inII which acknosviedgment was taken)
I, n 3v N(1 L��-� otary Public for said County and State,do hereby certify that
Ar - personally came before me this day and acknowledged that he is
Corp --k f2ernYl me of UP", and acknowledged,on behalf of
i the grantor t e due execution of the foregoing instrument.
WITNESS my hand and official seal,this the day o �rllf
V `1! Vgre
1 , 204
(Official Sam4ALCQ� t Pub
• (t
(- r
`. �0'TA
/� q • 01 p printed or typed Wane of Notary Pubfie).
J zS .,.• M/,� �•j�• to Notary Public
I : yam,.
t'� • �� L� C� My commission expires: • f
`f�0 •�. dune �,:�• �?�.i
4L
i\\
Revised January 15,2013
3
Book: 2824 Page: 169 Seq: 3

Fage I4 of 4 /
Approved for the purposes of N.C.G.S. 143B-279.11
(signature of Regional Sitpery sot)
M.42k �d�,/C/1 S ,Regional Supervisor
(printed name of Regional Supervisor)
12AL /Gh� Regional Office
UST Section
Division of Waste Management
Department of Environment Quality
NOR CAROLINA
<-�- COUNTY
(Name ofcount)i in which acAwowledgmeni was taken)
I certify that the following person(s)personally eared befl re m this day,each acknowledging to me
that he or she signed the foregoing document: lC� Znaregional supervisor)
Date: q l
`���-�fti r,e r r rage
(Officie'� l)Z• CA/�nt Ofa Pub
0 �, .
printed or typed n ne ofNoiory Public)
iA pUB��G Notary Public
e
� �'_��� My commission expires:
s�B�'fljCQuN, :e•
I hereby certify that the foregoing is a true and
accurate copy as taken from and compared with the
original on record in this office.
Witness my hand a official seal.
This C_ _day of-
a;6e,.n._Pcw_R Groodc l I
RegWdr of Deed- 11r co_d i S
r6ol Corp. CerN�er �r;vt
5uiAe 300
Revised January 15,2013
4 l�alet54. rvc 27(oa'7
Book: 2824 Page: 169 Seq: 4

co
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
Waste Management MICHAEL SCOTT
ENVIRONMENTAL QUALITY Director
July 8, 2016
Mr. Paul Harper/Mr. Mario Valdes
UPS Inc, Plant Engineering
55 Glenlake Parkway,NE
Atlanta, GA 30328
Re: Notice of No Further Action
15A NCAC 2L .0407(d)
Risk-based Assessment and Corrective Action
for Petroleum Underground Storage Tanks
UPS—Rocky Mount
1108 Instrument Drive, Rocky Mount
Nash County
Incident Number: 5019
Risk Classification: Low
Ranking: L 67 R(5/23/2012)
Dear Sir:
The Comprehensive Site Assessment Report received by the UST Section, Division of Waste
Management, Raleigh Regional Office on January 15,2010 has been reviewed. The review indicates that
groundwater contamination meets the cleanup requirements for a low-risk site but exceeds the
groundwater quality standards established in Title 15A NCAC 2L .0202.
The UST Section determines that no further action is warranted for this incident. All required
actions have been completed. On April 11, 2016, the UST Section received a certified copy of the Notice
of Residual Petroleum which is filed with the Register of Deeds. On June 27, 2016, the UST Section was
provided with proof of receipt of the conditional Notice of No Further Action letter or of refusal by the
addressee to accept delivery of the letter or with a description of the manner in which the letter was
posted.
This determination shall apply unless the UST Section later finds that the discharge or release
poses an unacceptable risk or a potentially unacceptable risk to human health or the environment.
Pursuant to Title 15A NCAC 2L .0407(a)you have a continuing obligation to notify the Department of
Environmental Quality of any changes that might affect the risk or land use classifications that have been
assigned.
Be advised that as groundwater contamination exceeds the groundwater quality standards
established in Title 15A NCAC 2L .0202, groundwater within the area of contamination or within the area
where groundwater contamination is expected to migrate is not suitable for use as a water supply, as
stipulated in the Notice of Residual Petroleum.
Interested parties may examine the Incident files by contacting this regional office and may
submit comments on the site to the regional office at the address or telephone number listed below.
State of North Carolina I Environmental Quality I Waste Management
UST Section Central Office 11646 Mail Service Center I Raleigh,NC 27699-1646 1(919)707-8171

This No Further Action determination applies only to the subject incident; for any other incidents
at the subject site,the responsible party must continue to address contamination as required.
If you have any questions regarding this notice, please contact me at the address or telephone
number listed below. .
Sincerely,
Mark R. Powers
Supervisor
Raleigh Regional Office
UST Section, Division of Waste Management,NCDEQ
cc: Director,Nash County Health Department
Arcadis US Inc., Ms. Margaret Geganto, 1000 Cobb Place Blvd., Building 500-A, Kennesaw, GA
30144
RRO UST incident filesBRH
Raleigh Regional Office 11628 Mail Service Center I Raleigh,NC 27699-1628 1(919)7914200

94ARCADIS Design&Consultancy
fornaturaland
built assets
Ms. Brenda Hafshejani Arcadis U.S.,Inc.
North Carolina Department of Environmental Quality 1000 Cobb Place Blvd.
Raleigh Regional Office Bldg.500-ASuite 400
1628 Mail Service Center Atlanta
Raleigh, North Carolina 27699 Georgia 30339
Tel [phone]
Fax [phone]
www.arcadis.com
Subject:
Well Abandonment ENVIRONMENT
UPS-Rocky Mount Center
1108 Instrument Drive
Rocky Mount, Nash County, North Carolina Date:
NCDENR Incident#5019 May 16, 2017
Risk Classification: Low
Contact:
Denise Dixon
Dear Ms. Hafshejani:
Phone:
On behalf of United Parcel Service (UPS), Arcadis U.S., Inc. (Arcadis) is 770.289.3261
presenting this correspondence as notification of well abandonment completed
on May 1, 2017. EnviroCheck of Va, Inc. (EnviroCheck), a North Carolina Email:
licensed well driller, performed the abandonment activities. EnviroCheck will [e-mail]
transmit the original well abandonment forms to the Division of Water Resources.
Our ref:
If you have questions, please contact Ms. Denise Dixon at 770.289.3261 or Mr. B0038382.0015
Hugh Devery at 770.384.6576.
Sincerely,
Arcadis U.S., Inc.
1�GLc�ti �iw
Denise Dixon
Project Manager
Enclosures
Copies:
Mario Valdes—UPS Corporate Plant Engineering, 55 Glenlake Pkwy NE,Atlanta, GA
30328
Page:
G:\COMMON\U P S\North Carolina\Rocky Mount\2017\Well Abandonment 5-1-17\well abandonment letter to NCDENR.docx
1/1

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPTor Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: LINK
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a 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
11irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: N Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge @GroundwaterRemediation approx 50# of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20# of bentonite
❑Experimental Technology ❑Subsidence Control 7g.provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date wells)abandoned: 5-1-17
Sa.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC
Physical Address,City,acid Zip Si ' lure of Certifi ell Contractor or Well Owner Date
Nash
By signing th form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner_
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00' 27.36" N -77 47' 16.50 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)tfavailable.For multiple injection or non-watersupply wells
ONLY with The same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: IW-1 through IW-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 26 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 13 (it) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
be.Outer casing length(if known):
U n k (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 26.5 (fk) abandoned.
6g.Screen length(if known): 10 00
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: UNK
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irti ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: a Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GrotmdwaterRemediation approx 50#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20#of bentonite
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility iD#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC
Physical Address,City,and Zip Si of Certified Contractor or Well Owner Date
Nash
By signing this f I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one[at/long is sufficient) 9.Site diagram or additional well details:
36 00'27.76" N -77 47' 17.50 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-2 abandonment to the following:
23.25 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 13 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): un k (ft) 10c.For Water Suonly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 23.25 (ft.) abandoned.
6g.Screen length(if known): 10 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: UNK
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout S 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
01rrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: a Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑AquiterRecharge ❑GroundwaterRemediation approx 50#of grout
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20#of bentonite
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(if applicable) S.Certification:
1108 Instrument Drive Rocky Mount, NC Awl
Qom'` . , 2
Physical Address,City,and Zip Signat of Certified Well tractor or Well Owner Date
Nash
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00' 26.73" N -77 47' 17.14" 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(~)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction-abandonment,you can submit one form.
10s. For All Wells: Submit this form within 30 days of completion of well
69.Well ID#• MW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 21.50 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniecton Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: approx 14 00 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6£Inner casing/tubing length(if known): 21.50 (ft.) abandoned.
6g.Screen length(if known): 10 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: LINK
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout 19 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: C Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 50# of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20# of bentonite
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain order 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) &Certification:
1108 Instrument Drive Rocky Mount, NC w & - �r_7,7 7
Physical Address,City,and Zip Sigi; of Certified Vontractor or Well Owner Date
Nash
By signing this form,1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00' 26.31" N -77 47' 16.19" 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
Auach well construction record(s)ifavailable_Formuthple injection or non-watersupply wells
ONLY with the some 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-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 24.50 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: approx 14 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unk (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy ofthis form within 30 days ofcompletion
2450 of well abandonment to the county health department of the county where
.
6E Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): 10 (ft)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: UNK
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)tf known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout N 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: a Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 50#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 20#of bentonite
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC
Physical Address,City,and Zip Sigma of Certified Well o tractor or Well Owner Date
Nash
By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
36 00' 25.73" N -77 47' 16.42" 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
Arlaclr well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same eonstructionlabandonmeni,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-5 abandonment to the following:
2348 Division of Water Resources,Information Processing Unit,
.
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (in_) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: approx 14 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k 4) 10c.For Water Suonly&lniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 23.48 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal,)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2,Well Construction Permit#: U N K
List all applicable well construction permits(t.e.UIC,County,State,variance,eta)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 N Neat Cement Grout N 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 ❑Drift Cuttings
OIrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: a Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 50#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20#of bentonite
❑Experimental Technology Cl Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapphcable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC
Physical Address,City,and Zip Si ertified P11 Contractor or Well Owner Date
Nash
BY signing this forth, I 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field one lat/long is sufficient) 9.Site diagram or additional well details:
36 00' 27.31" N -77 47' 16.24" 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)ifavallable.For multiple injection or non-water supply wells
ONLY with the some constructionlahandonment,you can.submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-6 abandonment to the following:
23.10 Division of Water Resources,Information Processing Unit,
lib.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 8 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface, apprOx 14 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k (ft) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
2310 of well abandonment to the county health department of the county where
.
6f. Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD r Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hisiher property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
N CWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used:
2.Well Construction Permit#: UNI<
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a 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: a Bentonite Slurry ❑Other(explain under 7g)
sMonitoring ❑Recovery
Injection Well: 7E For each material:selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 40#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage 20#of bentonite
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, Cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) &Certification:
1108 Instrument Drive Rocky Mount, NC GX -', Z
Physical Address,City,and Zip Sign of Certified W ontractor or Welt Owner Date
Nash
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one Wong is sufficient) 9.Site diagram or additional well details:
36 00' 26.98" N -77 47' 16.74" 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 records)ifavadable.Formultiple injection ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1114: MW-7 abandonment to the following:
26.30 Division of Water Resources,Information Processing Unit,
66.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 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: approx 14 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): unk (fL) 10c.For Water Suooly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 26.30 (ft.) abandoned.
6g.Screen length(if known): 5 A)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. R--7—hudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
N C W C-4229-B wells abandoned:NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit t#: U N K
List all applicable well construction permits(i.e.UIC,County,state,Variance,etc.)ijknwn
3.Well use(check well use): 7d.Amount of disinfectant used:
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
01ndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: @ Bentonite Slurry
@Monitoring ❑Recovery ❑Other(explain under 7g)
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 30# of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 15#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/CoolingReturn) ❑Othcr(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
Sa.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) &Certification:
1108 Instrument Drive Rocky Mount, NC ` 7
Physical Address,City,and Zip Si re of certi Well Contractor or Well Owner Date
Nash
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No_(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00' 26.80" N -77 47' 16.73" W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. Formultiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
MW-8 10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
1550 Division of water Resources,Information Processing Unit,
.
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6c.Borehole diameter: $ 10b.For Infection 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
abandonment to the following:
6d.Water level below ground surface: u n k (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-16M
6e.Outer casing length(if known): u n k (ft) 10c.For Water Suonly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
15.50 of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): 10 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closcd-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal,)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.We11ConstructionPermit#: UNK
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public N Neat Cement Grout a 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: C Bentonite Slurry ❑Other(explain under 7g)
a Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 45 # of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20# of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC
S2—i7 Physical Address,City,and Zip Si®uatu of Certified Wet 'ontractor or Well Owner Date
Nash
By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel By
No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00' 26.91" N -77 47' 14.36" 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 ITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable ror multiple injection ornon-water supply wells SUBM
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.WellID#: MW_10 abandonment to the following:
25.00 Division of Water Resources,Information Processing Unit,
6b.Total well depth: at) 1617 Mail Service Center,Raleigh,NC 27699-1617
6c.Borehole diameter: 8 I0b.For Iniection Wells: In addition to sending the form to the address in 10a
(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k Vt) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unk (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 where
6E Inner casing/tubing length(if known): 25 (ft.) abandoned.
6g.Screen length(if known): 1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.11'ell Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.ForGeoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: UNK
List all applicable well construction permits(i.e.UIC,County,State,Yartance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public S Neat Cement Grout a 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: a Bentonite Slurry ❑Other(explain under 7g)
AMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation approx 80#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 50#of bentonite
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal Meating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
Sa."'ell location:
UPS Incident#5019
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC , `
U 5/2/17
Physical Address,City,and Zip Signature f Certified We C ntractor or Well Owner Date
Nash
By signing this form 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(i£well Geld,one tat/long is sufficient) 9.Site diagram or additional well details:
36 00' 27.36" N -77 47' 15.33" 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(SI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach weliconstructionrecord(s)ifavadable.For multiple injection ornon-watersupplywells
ONLY with the same construction/ahandonment,you can.submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.well ID#• MW-11 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 61.26 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k (ft-) 10c.For Water Sunoly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
61'.Inner casing/tubing length(if known): 61.26 (ft-) abandoned.
6g.Screen length(if known): 2 (ft)
F ore,G%V-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
N CWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.WellConstructionPermit#: UNK
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a 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: a Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation approx 45#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StorinwaterDrainage 25#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC I
Physical Address,City,and Zip Signals'' of Certified W ontractor or Well Owner Date ' r I
Nash
By signing this form, 1 hereby certify that the well(s)was(were)abandoned in County Parcel Identification No.(PIN)
accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00'24.88n N -77 47' 15.51" 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)ifavailable. For multiple injection or non-water supply wells
ONLY with the some construction/abandonment,you can submit one form.
MW-12 ]Oa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
26.33 Division of Water Resources,Information Processing Unit,
fib.Total well depth: at,) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: $ above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 26.33 (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): 26.33 (ft) abandoned.
6g.Screen length(if known): 10 (ft)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2
EnviroCheck of Val Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: UNK
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout a 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: S Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 45#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
Sa.Well location:
UPS Incident#5019
Facility/Owner Name Facility 1D#(if applicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC
Physical Address,City,and Zip aleikAl -
Signatu fCertified P611 Contractor or Well Owner Date
Nash
tifi BY signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Idencati N Identification o.(PtN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00 25.44 N -77 47' 14.52" 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)ifavailable.For multiple injection or non-watersupply 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 ID#: MW-13 abandonment to the following:
26.33 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fw) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 25.57 (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 where
6E Inner casing/tubing length(if known): 26.33 (ft) abandoned.
6g.Screen length(if known): 1 (fit)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wens abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: U N K
List all applicable well construction permits 6.e.U1C,County,State,Variance,etc.)if town
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑MunicipaUPubl is W Neat Cement Grout N 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: C Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation approx 45#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storrnwater Drainage 20#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, INC
Physical Address,City,and Zip Signature ertified , Il Contractor or Well Owner Dam
Nash
By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
36 00' 26.54" N -77 47' 13.16" `,l, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. Formuliiple injection ornon-watersupplywellc
ONLY with the same constructionlabandonment,you can submir one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDII: MW-14 abandonment to the following:
2571 Division of Water Resources,Information Processing Unit,
.
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k (ft-) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
25.71 of well abandonment to the county health department of the county where
6t:In casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: UNK
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.)if known
3.Well use(check well use): I
7d.Amount of disinfectant used:
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public S Neat Cement Grout a 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: a Bentonite Slurry
❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation approx 45#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20#of bentonite
❑Experimental Technology [--]Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC
-'I
Physical Address,City,and Zip �
Nash Sign re ofCertilA Well Contractor or Well Owner ate
By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00' 27.39" N -77 47' 12.57" W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction records)ifavailable.Formultiple injection ornon-watersupply wells SUBMITTAL INSTRUCTIONS
ONLY with the same construchon/abandonment,you can submit one form.
MW-15 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
24.75 Division of Water Resources,Information Processing Unit,
66.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
tic.Borehole diameter: 8 lob.For Iniection Wells: In addition to sending the form to the address in 10a
(in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: unk (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unk (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
2475 of well abandonment to the county health department of the county where
.
6f.Inner casing/tubing length(if known): (ft) abandoned.
bg.Screen length(if known): 1 0
(ft)
Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: UNK
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.)iiftnown
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 a Neat Cement Grout N 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: a Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation approx 45#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20#of bentonite
❑Experimental Technology El Subsidence Control
Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date wells)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Same Facility ID#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC �
Physical Address,City,and Zip 2 1Sigma o Certified a Contractor or Well Owner Date
Nash
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel By
No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0100 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this retord has been provided to the well owner.
(ifwell field one lat/long is sufficient) 9.Site diagram or additional well details:
36 00' 27.80" N -77 47' 12.82" 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 records)rfavailahle.For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Weu lDtl: MW-16 abandonment to the following:
25.41 Division of Water Resources,Information Processing Unit,
6b."Total well depth: at.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6t Inner casing/tubing length(if known): 25.41 (ft.) abandoned.
6g.Screen length(if known): 1 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <2 (gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Constriction Permit#: U N K
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.)if own
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munieipal/Public s Neat Cement Grout a 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: N Bentonite Slurry
❑Other(explain under 7g)
RMonitoring ❑Recov
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 45#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 20#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name. Facility iD#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC 5-2 17
Physical Address,City,and Zip Signature o citified omtactor or Well Owner Date
Nash
By signing this fo , I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constriction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one tat/long is sufficient) 9.Site diagram or additional well details:
36 00'29.75" N -77 47' 15.14" W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonmeni,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-17 abandonment to the following:
2458 Division of Water Resources,Information Processing Unit,
.
6b.Total well depth: at.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: approx 14 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k (ft) loc.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
2458 of well abandonment to the county health department of the county where
6£ .
Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 8 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DET II S
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed_ Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <10 al.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: UNIC
List all applicable well construction permits 0.e_UIC,County,State,Variance,eta)ifknown
3.Well use(check well use): I
7d.Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout S 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: S Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovera'
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation approx 100#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 20#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
Sa.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC 5-2-17
Physical Address,City,and Zip espIgning
ell Contractor or Well Owner Date
Nash
orm, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel By
No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has been provided to the well owner.
(ifwell field,one Wong is sufficient) 9.Site diagram or additional well details:
36 00 27.05n N -77 47' 19.11" 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)ijavailable.lormul6ple injection or non-water supply wells
ONLY with the same constructiorJabandonment,you can submit one form.
109. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-18D abandonment to the following:
49.07 Division of Water Resources,Information Processing Unit,
fib.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in l0a
fie.Borehole diameter: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: unk (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unk (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 where
6f.Inner casing/tubing length(if known): 49.07 (ft.) abandoned.
6g.Screen length(if known): 5 (ft,)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <10 (gal,)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#: UNI{
7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iftnown
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 a Neat Cement Grout a 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
❑bri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: a Bentonite Slurry
❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation approx 60#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 25#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating(Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5s.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
e 1108 Instrument Drive Rocky Mount, NC /� 5-2-17
Nash .
Physical Address,City,and Zip Sigma of Certified 11 Contractor or Well Owner Date
CountyBy signing this form, I hereby certify that the well(s)was(were)abandoned in
Parcel By
No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00 27.15 N -77 47' 19.03" 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 canstrucnonrecord(s)ifavailable. Formultipleinjectionornon-water supply wells
ONLY with the same construction/abandonmem,you can submit one form.
MW-19S 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
24.90 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
6c.Borehole diameter. 8 10b.For Injection Wells: In addition to sending the form to the address in 10a
(ia) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: Unk (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unk (ft) 10c.For Water Suunly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
2490 of well abandonment to the county health department of the county where
6C .
Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 10 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resoraces Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rhud
Jacob L.- --7— III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <10
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#: lJ N K 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)rfknown
3.Well use(check well use); 7d.Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic s Neat Cement Grout a 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
Oh-rigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: a Bentonite Slurry eMonitoring ❑Recovery RY ❑Other(explain under 7g)
Injection Well: 7E For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation approx 120#of grout
[]Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑StormwaterDrainage 50#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(ifapphcable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC 5-2-17
Physical Address,City,and Zip Si^ofC—fidontractor or Well Owner
Nash Date
By signing this form, 1 hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00 27.26 N -77 47' 15.19" You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S BEING ABANDONED
Attach well construction record(s)ifavailable. Formultiple injection ornon-water.supply wells SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonment,you can submit one form.
MW-PT 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
34.85 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12.25 10b.For Injection Wells: In addition to sending the form to the address in 10a
tic.Borehole diameter. (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: unk (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
3485 of well abandonment to the county health department of the county where
.
6f.Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): 30 (ft.)
Form GW-30 North Carolina Department o£Environmental Quality-Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s). <10 gal.)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: UNK
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural OMunicipal/Public a Neat Cement Grout a 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
OIrrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: a Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring aRecovery
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge RGroundwater Remediation approx 300# of grout
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 50#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility[Dtl(ifapplicable) S.Certification:
1108 Instrument Drive Rocky Mount, NC 5-2-17
Physical Address,City,and Zip Signature ertified W onmactor or Well Owner Date
Nash
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel By
No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ofthis record has been provided to the well owner.
(ifwell field,one tat/long is sufficient) 9.Site diagram or additional well details:
36 00' 27.45" N -77 47' 14.18" 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 WE,LL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavadable.For multiple injection or non-watersupply wells —
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: RW-A abandonment to the following:
47.90 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: $ (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Link (ft) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
47.90 of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 40 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <10 (gal,)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#: UNK 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
3.Well use(check well use): I
7d.Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply);
PP y)•
❑Agricultural ❑Municipal/Public S Neat Cement Grout a 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:
s Bentonite Slurry ❑Other ex lain under 7❑Monitoring BRecovery ( P g)
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge RGroundwaterRemediation approx 300# of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑StormwaterDrainage 50# of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(if applicable) S.Certification:
1108 Instrument Drive Rocky Mount, NC ,� 5-2-17
Physical Address,City,and Zip Signa f ertified W C tractor or Well Owner Date
Nash
County By signing this fo hereby certify that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: an that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00 27.76 N -77 47' 15.71 e W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction record(s)ifavatlable.Formul6ple injection ornon-watersupplywells SUBMITTALINSTRUCTIONS
ONLY with the same construction/abandonment,you can submit one form.
RW-B 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well m#: abandonment to the following:
47.39 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6c.Borehole diameter: 8 10b.For Infection Wells: In addition to sending the form to the address in 10a
(in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Link (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
47.39 of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 40 00
Porm OW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016

WELL ABANDONMENT RECORD ForinrernalUseONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jacob L. Rhudy, III
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
N C W C-4229-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): <10 (gal,)
EnviroCheck of Va, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#: LINK 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.)iflmown
3.Well use(check well use): 7d.Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply):
PP Y):
❑Agricultural ❑MunicipaVPublic a Neat Cement Grout N 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:
e Bentonite Slurry
❑Other(explain under 7g)❑Monitoring BRecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge eGroundwater Remediation approx 110#of grout
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 50#of bentonite
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) add bentonite pellets, tremie grout to surface, cap
to match existing surface completion
4.Date well(s)abandoned: 5-1-17
5a.Well location:
UPS Incident#5019
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1108 Instrument Drive Rocky Mount, NC
5-2-17
Physical Address,City,and Zip Signature o ertified ell Contractor or We0 Owner Dare
Nash
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36 00 26.99 N -77 47' 16.77" 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 WELLIS)BEING ABANDONED
Attach well constructionrecord(s)favailable. For multiple injection or non-watersupplywells SUB MITTALINSTRUCTIONS
ONLY with the same constructionlabondonment,you can submit one form.
RW-C 102. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
19.23 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lnjection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: $ (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: u n k (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): u n k (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
1923 of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 40 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016