Carteret_Well Abandonment_20241022

4 .
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
f
Trevor Mizelle 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple itjection or non-iratersuppl t wells ONLY with the same
eonslrucliomubandonntenl,you can submit one form.
4629C
7b.Approximate volume of water remaining in well(s): N/A (gal.)
NC Well Contractor Certification Number
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:' N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
■Monitoring 0 Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets —5 lbs.
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test 0 Stommwater Drainage
❑Experimental Technology 0 Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) All well material removed and boring backfilled with
bentonite to ground surface.
4.Date well(s)abandoned: 9/11/2024 � '''
Sa.Well Location: OCT ti LOCLr
NCDEO 32885 :�, f..-ter. rg ll=s'x'
8.Certification: `G: ''t
Facility/Owner Name Facility ID#(if applicable) hn :/die` :�
1030 Seashore Dr,Atlantic, NC 28511,Atlantic, NC 28511 •
September 25.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CARTER ET 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 Well Construction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
34.8824998 N -76.3377835 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
well ONLY with the sane 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-01 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 2 (in.) I0a 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: 7.75(ft.) Division of Water Resources'
Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 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
6f.Inner casing/tubing length(if known): 10(ft.) county where abandoned.
6g.Screen length(if known): 5(ft.)
P:\2021\221160 DEQ SLP WINSTON HILL&SONS GROCERY ID 32885\WELL ABANDONMENT 221160.02_GINT.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 7a.Number of wells being abIai doned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple irjeclion or non-water supply ivells ONLY with the same
construction'abandonment,you con submit one form.
4629C
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used; N/A
2.Well Construction Permit#: N/A
List all applicable well pennits(i.e.County,Stale,Variance,Injection,etc.)if known 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ElBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout OD)/Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets ^•5 lbs.
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stommwater Drainage
O Experimental Technology D Subsidence Control
❑Geothermal(Closed Loop) ❑Tracei 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed well pad; alrother well materials abandoned in
~,T iriR•��.w
place. b. �. >
4.Date well(s)abandoned: 9/11/2024 4r T ? ti 2021
5a.Well Location:
NCDEO 32885 Ir e;;. ;: ..¢•:d r;
8.Certification:
Facility/Owner Name Facility ml1(if applicable) Q'i s.o J 13
1030 Seashore Dr,Atlantic, NC 28511,Atlantic, NC 28511 September 25.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CARTERET By signing this form I hereby certifil that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C Well Construction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.8825997 N -76.337732 W You may use the back of this page to provide additional well site details or well
abandonment details. You may.also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple it jection or non-water supply
well ONLY with the scone construction abandonment,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MVV-02 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: III addition to sending the form to the address in
10a above,also submit one copy of this form within 30 days of completion
6c.Borehole diameter: 2(in.) of well abandonment to the following:
6d.Water level below ground surface: 7.86 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service;Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 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
6f.Inner casing/tubing length(if known): 10(ft.)
county where abandoned.
6g.Screen length(if known): 5(ft.)
P:12021\221160 DEQ SLP WINSTON HILL&SONS GROCERY ID 32885\WELL ABANDONMENT I221160.02_GINT.GPI
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

1
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 7a.Number of wells being aljarjdoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-watersnpllly wells ONLYwith the same
cmutntction'abandonment,you am submit one fornt.
4629C 7b.Approximate volume of water remaining in well(s): N/A (gal.)
NC Well Contractor Certification Number i,
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,Slate,Variance.Injection,etc.)ifknown 7d.Amount of disinfectant used: N/A
3.Well use(check well use): ,
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic 0 Neat Cement Grout ®Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout 1 ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GrouhdwaterRemediation Bentonite Pellets ~5 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
0 Aquifer Test 0 Stormwater Drainage
0 Experimental Technology 0 Subsidence Control
❑Geotlmer mal•(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All well material removed and boring backfilled with
bentonite to ground surface. p--.,7--.;-_,5 ,
4.Date well(s)abandoned: 9/11/2024 °" °t'' E""';- "_r'
-�,? t'-'Lr,
5a.WellLocation: OCT 2 4, '614
NCDEQ 32885 J <_. C -. ',,,-;:' lei 1.A/A
8.Certification: lri��•+ ''
Facility/O\vnerName Facility]D#(if applicable) 7-/6 G idi.C: ice'a
1030 Seashore Dr,Atlantic, NC 28511,Atlantic, NC 28511 � � September 25.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CARTERET By signing this form I hereby certt that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C We/I Construction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.8825529 N -76.33753205 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
well ONLY with the same construction abandonment,you can submit one form ''
10a.For All Wells: Submitthis form within 30 days of completion of well
6a.Well ID#: MW-03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 2(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: 6.99(ft.) Division of Water Resources,'Underground Injection Control Program,
1636 Mail Service Center,Raleigh,'NC 27699-1636
6e.Outer casing length(if known): N/A 1Oc.For Water Supply&Injection Wells: In addition to sending the form
to the address(es)above,also submit one copy of this form within 30 days of
completion of well abandomnent to the county-health department of the
6E Inner casing/tubing length(if known): 10 (ft.) county where abandoned.
6g.Screen length(if known): 5(ft.)
P:\2021\221160 DEQ SLP WINSTON FILL&SONS GROCERy ID 32885\WELL ABANDONMENI\221160.02_GiNr.GPI
Adapted from NCDENR DWR Form GW-30 North Carolina Department of Environment and Natural Resources=Division of Water Resources Revised August 2013

e
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Trevor Mizelle 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For nailrip/e irjecrion or non-water supp tow,e(is ONLY with the same
cotsstructionitbundonntenl,you can submit onejorm.
4629C 7b.Approximate volume of water remaining in well(s): N/A (gal.)
NC Well Contractor Certification Number
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State,Variance.Injection,etc.)ijknmrn 7d.Amount of disinfectant Used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ®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
0 Irrigation ❑Specialty Grout • ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: ' 7f.For each material selected above,provide amount of materials used:
Li Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets -5 lbs.
0 Aquifer Storage and Recovery 0 Salinity Barrier
0 Aquifer Test ❑Stomtwater Drainage _
❑Experimental Technology 0 Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g) All well material removed and botii rbackfillesl;with.
4,,...s..
bentonite to ground surface.
4.Date well(s)abandoned: 9/11/2024 0 LI y el L4
5a.Well Location:
NCDEQ 32885
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1030 Seashore Dr,Atlantic, NC 28511,Atlantic, NC 28511 (' .?zy September 25.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CARTERET By signing this form I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with/5A NCAC 02C.0100 or 2C Well Construction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.88257972 N -76.33746819 qr You may use back of this to provide additional well site details or well
abandonment the details. You maypage also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable. For multiple iyection or non-water supply
well ONLY with the same construction abandonment,you can submit one fonn 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MVV-04 abandonment to the following:'
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in
IOa above,also submit one copy of this form within 30 days of completion
6c.Borehole diameter: 2(in.) of well abandonment to the following:
6d.Water level below ground surface: 6.77(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
li
6e.Outer casing length(if known): N/A 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
6E Inner casing/tubing length(if known): 10(ft.)
county where abandoned.
6g.Screen length(if known): 5(ft.)
P:\2021\221 I60 DEQ SLP WINSTON HILL&SONS GROCERY ID 32885\WELL ABANDONMENTt221 I60.02_GINr.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

.
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I `
Trevor Mizelle 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injcrton or non-water supply wells ONLY with the same
cotrshrrclimr ubandonnrem,you can submit owes}
4629C I'
7b.Approximate volume of water remaining in well(s): N/A (gal.)
NC Well Contractor Certification Number
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)iifknown 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural 0 Municipal/Public 0 Neat Cement Grout El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 0 Groundwater Remediation Bentonite Pellets —5 lbs.
0 Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stomiwater Drainage
❑Experimental Technology 0 Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
s'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All well material removed and boring backfilled with
bentonite to ground surface. .
4.Date well(s)abandoned: 9/11/2024 V ` -.. ,� ;'' ` 't"—.
5a.WellLocation: OCT _ u CD?k
NCDEO 32885
Facility/Owner Name Facility ID#(if applicable) 8•Certitication: I...:.: ,:a�t7. ?-,•.^.•.,r4;!,- 1.,:t3:':
" ./-1. '.V i.0-'."ti i c:1
1030 Seashore Dr,Atlantic, NC 28511,Atlantic, NC 28511 September 25.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CARTERET By signing this form I hereby cert fy that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or.2C Well Construction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.88230904 N -76.33744856 q, You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple it jection or non-water supply
well 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-05 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 2 (in.) l0a 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: 5.17 (ft.) Division of Water Resourcles,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 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 of well abandonment to the county health department of the
6f.Inner casing/tubing length(if known): 10(ft.) county where abandoned.
1
6g.Screen length(if known): 5(ft.)
P:\2021\221160 DEQ SLP WINSTON HILL&SONS GROCERY ID 32835\WELL ABANDONMENT\221160.02_GINT.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
t I
i
I !

I.
1
I
WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1
1.Well Contractor Information: WELL ABANDONMENT I)ETAILS
I
Trevor Mizelle 7a.Number of wells being abandoned: N/A
i i
Well Contractor Name(or well owner personally abandoning well on his/her property) For nmlitple injection ornon-watersnpplywells ONLYsith the sonic
corstrucoon'ubandonment,you can submit one form.
4629C i
NC Well Contractor Certification Number 7b.Approximate volume of(water remaining in well(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
1
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State,Variance,Injection;etc.)if known 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ElBentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial DResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
•Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets —5 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
O Aquifer Test 0 Stormwater Drainage l' •
❑Experimental Technology ❑Subsidence Control
❑Geothertal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed well pad; all other well materials abandoned in
place. I ;-
I i.�,,,,-`:,.>'d.r a +r 4.,..„a...a'
4.Date well(s)abandoned: 9/11/2024
5a.Well Location:
UL i 2 cU[4
NCDEO 32885 F . 73- --; -fj Ui,et
8.Certification: 7 • ;
Facility/Owner Name Facility ID#(if applicable) D
/ -ii k:a.3 i-�G
1030 Seashore Dr,Atlantic, NC 28511,Atlantic, NC 28511 September 25.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
I'
CARTERET By signing this form I hereby certifi,that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C Well Construction Standards and
that a copy of this record has'been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.88251626 N -76.33776615 qr Y m the back of pe too apt ditnal well
abandonmentouay use details. Youthis rmlaay ag alsoo apttachovi additional io pages if
site necessadetailsry or well.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well costrnction records)lf available. For multiple injection or non-water supply
well ONLY with the sane construction abandonment,you can submit oneform 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MVV-06
abandonment to the following:.
Division of Water Resources,Information Processing Linit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 2 (in.) 10a above,also submit one'copy of this form within 30 days of completion
of well abandonment to the following:
I
6d.Water level below ground surface: 8.32 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
fie.Outer casing length(if known): N/A 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
6f.Inner casing/tubing length(if known): 10(ft.) county where abandoned.
6g.Screen length(if known): 5(ft.) '
P:\2021\221160 DEQ SLP WNSTON HILL&SONS GROCERY ID 32885\WELL ABANDONMENT\22I 160.02_GQhrr.GPI
Adapted from NCDENR DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

Y N
,0 WSW-7
. O-------500-GAL.
GASOLINE
UST
FORMER
_ '' PUMP s
'I qn--,' ISLAND -
lor
+4`,:, .
FORMER' .'-
KEROSENE
� UST
�OffEifki ,�, MW-41
en
4' �+-t. k ® MW-3
/ --4,44,
MW-6 0
MW-1 ® FoioO,RMER
W
UST BASIN
SW-1 AST PROPANE ,
AST
LEGEND
® Abandoned Monitoring �j MW-5
Well (Type II) � -
Potable
© Water Supply Well PASOPANE
T
Approximate Location
of UST/AST System
❑ Parcel Boundary
v fk, c u a� ],Maxaro[ fi§WP Geographies a d ilk; r IS U e -•omm nity'`
NOTES:
1 Well and tank locations were obtained from previous reports
prepared by other consultants and are approximate. 30 15 0 30 60
2.MW-4,5,&6 locations were obtained during field activities Feet
conducted by CATLIN on March 27&28,2023.
PROJECT TITLE
WINSTON HILL & FIGURE
CATLIN SONS GROCERY SITE MAP
1030 SEASHORE DR
ATLANTIC, NC
Engineers and Scientists
INCIDENT NO. JOB NO. DATE SCALE DRAWN BY/CHECKED BY
32885 221160 OCT 2024 AS SHOWN KMC/SJO