Cabarrus_Well Abandonment_20241025

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WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-Lo�p'jGeothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 1is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4'9 (gal.)
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J.
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name -
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
•
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 C Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout , ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: • ❑Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring •Recovery
r
Injection Well: If.For each material selected above,provide amours.of ma.terl is;i it :; t -.
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite
❑Aquifer Storage and Recovery 0 Salinity Barrier f 1 ( 6 2024
❑Aquifer Test ❑Stormwater Drainage `F
❑Experimental Technology ❑Subsidence Control I1-,'.G,,:,; i rnr;q -J
7g.Provide a brief description of the abandonment procedut,.OGeothermal(Closed Loop) OTracer
ut.ur �
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 a) ' 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Wt11 Owner Date
Cabarrus 2851 I •
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.0I00 or 2C.0200 Well Construction Standards
and that a copy of this record has been'.provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 You may use the back of this page to provide additional well site details or well
N -80.561402 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED •
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: AS-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
•
6b.Total well depth: 45 (f•) 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: I
I
6d.Water level below ground surface: 14.42 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I. ;
6e.Outer casing length(if known): (g•) 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
6E Inner casing/tubing length(if known): (fi•) abandoned.
6g.Screen length(if known): 2 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY: •
is
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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
3110 wells abandoned:•
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3'7 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name I.
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 ❑Neat Cement Grout a Bentonite Chips or Pellets
['Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay •
❑Industrial/Commercial ['Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
[Monitoring ®Recovery w '" .it--
Injection Well: 7f.For each material selected above,provide amount of materials-d&e l: : a ;: ,i
['Aquifer Recharge ['Groundwater Remediation 25 lbs bentonite
❑Aquifer Storage and Recovery ['Salinity Barrier OCT ' t4 6024
❑Aquifer Test ❑StormwaterDrainage Irk-:,: :, , >'s. 4 ; o t
['Experimental Technology ['Subsidence Control �;9?
7g.Provide a brief description of the abandonment procedure: C''1'ti•�'Zf i�.G
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned:'9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable)
8.Certification:
2825 Lane Street, Kannapolis 28083 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W 1 Owner Date
Cabarrus 2851
By signing this form, I hereby certify;that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AS-2 abandonment to the following:
1.
Division of Water Resources,Information Processing Unit, '
6b.Total well depth: 42 (g) 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: (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: 18.85 (ft) Division of Water Resources,Underground Injection Control.Program,
1636 Mail Service Center,,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g•) 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 t health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
' 6g.Screen length(if known): 2 (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: ,ir
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-Lol p: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
3110 wells abandoned:1 '
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4'0 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY: •
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 I 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 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other,(explain under 7g)
•'
OMonitoring ©Recovery , : ;"-•- .
Injection Well: 7f.For each material selected above,provide amount 7if'litaterfals.used' ?,_,
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite Q C T `L _. 20-
7m.
❑Aquifer Storage and Recovery ❑Salinity Barrier �`
❑AquiferTest ❑StormwaterDrainage Ir,`:-:;::,-.,r' ',i--..., .. ,,'.
❑Experimental Technology 0 Subsidence Control O" Cd;2O;3
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot,Travel Centers, LLC 0-011084 •
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 Gi)dL 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Wit Owner Date
Cabarrus 2851
By signing this form, I hereby certify)that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beenprovided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
i
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i'
Attach well construction record(s)if available. For multiple injection or non-water supply wells I,
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 m# AS-4 abandonment to the following: I'
Division of Water Resources,Information Processing Unit,
6b.Total well depth 45 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: (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: 20.16 (R) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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): (t•) abandoned.
6g.Screen length(if known): 2 (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 DETAILSI I
William Ewing 7a.For Geoprobe/DPT or Closed-Lo I: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
3110 wells abandoned:1 I I
15.6
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name i
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iifknown I -
7d.Amount of disinfectant used: 1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
1.
['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
❑Irrigation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring dRecoveiy
Injection Well: 7f.For each material selected above,provide amoupti f mat rill used5
❑Aquifer Recharge ❑Groundwater Remediation 100 lbs bentonite
❑Aquifer Storage and Recovery - ❑Salinity Barrier O C T 2 ;� 2024
['Aquifer Test ❑Stormwater Drainage -
['Experimental Technology ❑Subsidence Control � ,t 1.;,1�•.
7g.Provide a brief description of the abandonment procedtrreflit J"q to G
❑Geothermal(Closed Loop) ❑Tracer
['Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location: i'
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:''"" ,
2825 Lane Street, Kannapolis 28083 Gt9 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or WE11 Owner Date
Cabarrus 2851
By signing this form, I hereby certify;that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100.or'2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)iifavailable. For multiple injection or non-water supply wells - i
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#: AS-6 abandonment to the following:
Division of Water Resource,Information Processing Unit,
6b.Total well depth 44 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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: I
I'
20.16 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (g•) g
1636 Mail Service Center,Raleigh,NC 27699-1636
, 1 ,
6e.Outer casing length(if known): (g•) IOc.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): (g,) abandoned.
6g.Screen length(if known): 35 (ft) '
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources } Revised 2-22-2016
•
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-Lol pGeothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-301is heeded. Indicate TOTAL NUMBER of
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4•0 (gal.)
!
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
Unknown
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 ❑MunicipalPublic ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout I 0 Drill Cuttings
❑Irrigation ; 0 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 amou t ofmaterials,used:
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite ` ` "'`za w r 'x 4,„L W-
❑Aquifer Storage and Recovery 0 Salinity Barrier _
❑Aquifer Test ❑StormwaterDrainage OCT l 2024
❑Experimental Technology ❑Subsidence Control ,Et
7g.Provide a brief description of the abandonme' dce Jui
❑Geothermal(Closed Loop) ❑Tracer 7 t�•.:3s•i�'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pelretS''tC) 59eet
below ground surface. completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
. Facility/Owner Name Facility ID#(if applicable) S.Certification:
2825 Lane Street, Kannapolis 28083 t 2u L 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or w 1 Owner Date
Cabarrus 2851
By signing this form, I hereby certify'that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100,or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N �'Ir abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)tf available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# AS-7 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (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: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
20.00 Division of Water Resources,Unde round In ection Control Program,
6d.Water level below ground surface: (ft) I g +
1636 Mail Service Center,'Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g•) 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): (g•) abandoned.
6g.Screen length(if known): 2 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-Lol pGeothermal 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3'8 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY: •
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 El Neat Cement Grout l9 Bentonite Chips or Pellets
['Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explan undei 7g) s r -.--
['Monitoring Recovery ^�t:' s...,; •
Injection Well: 7E For each material selected above,provide amount of matefialsusgd: �}
❑Aquifer Recharge ❑GroundwaterRemediation 25 lbs bentonite UC IT 2 2024
❑Aquifer Storage and Recovery ❑Salinity Barrier lG'i,:rnb.i'.F;. �'!•r,. ,-^N �;t ?,:.
[Aquifer Test ❑Stormwater Drainage r ,<,•,,.:�.. `"`
['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) Mixed-potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:'
2825 Lane Street, Kannapolis 28083 09z � 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W 1 Owner Date
Cabarrus 2851
By signing this form, I hereby certify;that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: AS-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 44 (ft,) 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: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 20.25 (ft.)
1636 Mail Service Centr,Raleigh,NC 27699-1636
6e.Outer casing length(if known):- (it. 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): (g,) abandoned.
I ;
•
6g.Screen length(if known): 2
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
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-L lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30I is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3.1 (gal,)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 0 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) .0 Sand Cement Grout 1 0 Dry Clay
❑Industrial/Commercial :Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 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 amours ofmaterials used:- ,..'_,
❑AquiferRechazge ❑Groundwater Remediation 25 lbs bentonite 't-^; •f' ?,.,:t..%
❑Aquifer Storage and Recovery ❑Salinity Barrier T
❑Aquifer Test ❑StormwaterDrainage Q� I G i) 2024
❑Experimental Technology ❑Subsidence Control t 1�.� 4�-
7g.Provide a brief description of the abandonmeniFprdeedure _.a,j 1
❑Geothermal(Closed Loop) ❑Tracer Mixed potable water with bentonite pellets to
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 Gt ( 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W l Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been,provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: AS-9abandonment to the following:
.
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 39 (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this for within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface 19.70 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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): ( ) abandoned.
6g.Screen length(if known): 2 (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
William Ewing 7a.For Geoprobe/DPT or Closed-Lol p 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'8 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 0 Neat Cement Grout I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring •Recovery rr _
Injection Well: 7f.For each material selected above,provide amouti't'qf niateria)s used: '.';
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite f I"
❑Aquifer Storage and Recovery ❑Salinity Barrier O C T 2 ;. 1024
m❑Aquifer Test ❑StorwaterDrainage 't
❑Experimental Technology ❑Subsidence Control lr.: ,-—,L 'ter �= :a3;}ram
7g.Provide a brief description of the abandonment pro ced
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 wd � 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W I Owner Date
Cabarrus 2851
By signing this form, 1 hereby certi( t that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS •
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: AS-10 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 39 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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: 21.42 (R•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g•) 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): (IL) abandoned.
6g.Screen length(if known): 2 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1

i '
WELL ABANDONMENT RECORD For Internal Use ONLY: I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-Lol p 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining aining in well(s): 4'1 (gal.)
;
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: ' _-_
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known j
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 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustriaUCommercial El Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
0 Monitoring ®Recovery r' ;'• - ,
y a Injection Well: 7f.For each material selected above,provide amount of matels'tled: a% j,e;3„.
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite 2 OCT :• 2Q?4
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage IG.,,,,..,,'.�.. .;,, _.. , �
0 Experimental Technology 0 Subsidence Control G''iuti.a.`wtJG
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification: ,
2825 Lane Street, Kannapolis 28083 . (,{Jc,1 r1. (----� 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W l Owner Date
Cabarrus 2851
By signing this form, 1 hereby certiji that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N �I abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells ,
ONLY with the same cansrruction/abandonment,you can submit one jorm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AS-1 1 abandonment to the following: •
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 45 (ft.)
10b.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: (in.) above, also submit one copy of this forin within 30 days of completion of well
abandonment to the following:
19.40 Division of Water Resources Undc round In ection Control Pro ram,
6d.Water level below ground surface: (g,) +Underground J g
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (t1,) 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 i health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 2 (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
William Ewing 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining aining in well(s): 4.0 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if blown
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 S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
0 Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ®Recovery
Injection Well: 7f.For each material selected above,provide amount of niaterrals used: fi
DAquifer Recharge ❑Groundwater Remediation
25 lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier O C T C Ix n 1 A
0 Aquifer Test ❑StormwaterDrainage L`F
❑Experimental Technology ❑Subsidence Control
OGeothermal(Closed Loop) OTracer 7g.Provide a brief description of the abandonment procedure:::r t o.: 0
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 GtAi �t;l 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W I Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100.or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)!I-available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AS-12 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 45 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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 19.93 M.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
6e.Outer casing length(if known): l L) 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
6E Inner casing/tubing length(if known): (ft.)
abandoned.
6g.Screen length(if known): 2 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j . Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-Lol p 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3'4 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 I Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring uRecovery
Injection Well: •
7f.For each material selected above,provide amount of materials used:r; ':,
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite O ff'T 2
❑Aquifer Storage and Recovery ❑Salinity Barrier 024
❑Aquifer Test ❑StormwaterDrainage i,_�- ;_ �____ _. t,'3
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: 'L� rJ
OGeothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility IDt1(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 �' 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or WL'll Owner Date
Cabarrus 2851
By signing this form, I hereby certifil that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: AS-13 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 43 (g•) 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:_ (in.) 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 21.54 (tt) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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): (g.) abandoned.
6g.Screen length(if known): 2 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-L lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-301 is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'2 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 ®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 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry (explain-under 7
❑Other g),
❑Monitoring ®Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:" ' r --=.-:J
❑Aquifer Recharge ❑Groundwater Remediation 2024
25 lbs bentonite (I I:I 2
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage t}x_+t
❑Experimental Technology ❑Subs idenceControl U•°''`Cc r-''
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 02el . 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W l Owner Date
Cabarrus 2851
By signing this form, 1 hereby cent(that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)favailable. 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#: AS-14 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (B,) 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:
21.08
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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): (g,) abandoned.
6g.Screen length(if known): 2 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD ForintemalUseONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
W Iliam Ewing 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water re Lining aining in well(s): 2'8 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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) 0 Sand Cement Grout • 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ! ❑Drill Cuttings
❑Irrigation ❑Specialty Grout 1 ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ®Recovery
Injection Well: 7f.For each material selected above,provide amount,pfinatersals aksedr c•�'�•.,
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite n
❑Aquifer Storage and Recovery ❑Sal inity Barrier U CT 2 2024
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control IG"'"'t� "^ "„
7g.Provide a brief description of the abandonment pro cedurg' iic,,:q;13
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084 --
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 Gt'Aigca 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W 1 Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15)1 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 You may use the back of this page to provide additional well site details or well
N -80.561402 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: AS-15 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 38 at) 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: (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 20.51 (R) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g•) 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 i health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
•
6g.Screen length(if known): 2 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-Lol p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-301 is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:i I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3'6 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 ❑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: El Bentonite Slurry ❑Other(explain under 7g)
:Monitoring URecovery _
Injection Well: 7f.For each material selected above,provide amounrof niaterials:us4-,
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite
❑Aquifer Storage and Recovery Cl Salinity Barrier . ~
U �024
❑Aquifer Test ❑Stormwater Drainage
�� � ��
IC Experimental Technology ❑Subsidence Control If 'tD Y C: ;; Pcr...trvq_h,t, �,
7g.Provide a brief description of the abandonment proced g:•.._ .�: .� '.0
❑Geothermal(Closed Loop) ❑Tracer �t•c'=+}
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5-feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 (94ae 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W8f1 Owner Date
Cabarrus 2851
By signing this form, I hereby certi that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: •
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: AS-16 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 43 (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: (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: 20.74 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
6e.Outer casing length(if known): at) 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): (ft.) abandoned.
6g.Screen length(if known): 2 (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
William Ewing 7a.For Geoprobe/DPT or Closed-L lop 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.1 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ 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 f materialsused::,
❑Aquifer Recharge ❑Groundwater Remediation l .', .� ,
25 lb bentonite a
❑Aquifer Storage and Recovery ❑Salinity Barrier T ,f
DAquifer Test ❑StormwaterDrainage Or' I 2 5 202`F
❑Experimental Technology ❑Subsidence Control lr r:•
7g.Provide a brief description of the abandonment pNdcMure• :• r • • ;.,hi r
❑Geothermal(Closed Loop) ❑Tracer i ,r;
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pelle s t(�5-feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 t Dear lt, 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or we l Owner Date
Cabarrus 2851
By signing this form, I 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
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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# DMW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (g) 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: (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 22.07 (R) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):- (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): (ft) abandoned.
6g.Screen length(if known):
(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
William Ewing 7a.For Geoprobe/DPT or Closed-Lot p 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
3110 wells abandoned:t
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4'2 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.UIC,County,Stale,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 0 Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(ex lain under 7g)
®Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of nta1tet ials'u`sed:.:
❑Aquifer Recharge ❑Groundwater Remediation 50 lbs bentonite (,(n 2 0
A
❑Aquifer Storage and Recovery ['Salinity Barrier ll �� � �,
❑Aquifer Test ❑Stormwater Drainage s,
❑Experimental Technology ['Subsidence Control ovv7g.Provide a brief description of the abandonment procedure: ca:2hu❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ['Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 GtAi � 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We 1 Owner Date
Cabarrus 2851
By signing this form, I hereby certify'that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100.or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/ong is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: DMW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 46 (Lt.) 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: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: i.
20.35 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (el) g g
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (f-) 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
abandoned.
6f.Inner casing/tubing length(if known): (IL)
;
6g.Screen length(if known):
(fr-)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD ForintemalUseONLY: ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-L top Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30j is heeded. Indicate TOTAL NUMBER of
3110 wells abandoned:1 }
NC WellConttactorCertificationNumber 7b.Approximate volume of water remaining in well(s): 5.0 (gal.)
I.
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 ❑MunicipaUPublic ❑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: ❑Bentonite Slurry ❑Other ex la ii under? _
®Monitoring ❑Recovery I' t;,T;4, _ , i .:, _, --'
Injection Well: 7f.For each material selected above,provide amount of materials used: ' t' ..r'
❑Aquifer Recharge ❑Groundwater Remediation 50 lbs bentonite OCTO 1 2 t'S 2024
❑Aquifer Storage and Recovery ❑Salinity Barrier
111;C;:r':'_.i.E' 1:•r:r — .C1 ,V
❑Aquifer Test ❑Stormwater Drainage • _
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) U Other(explain under 7g)
Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
II
Facility/Owner Name Facility ID#(if applicable)
8.Certification:
2825 Lane Street, Kannapolis, 28083 (,{)ui. z �r 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We 1 Owner Date
Cabarrus 2851
By signing this form, I hereby cert/that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been.provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells ,
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# D M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 50 (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: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: 1
I
6d.Water level below ground surface: 19.03 (B) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636 .
6e.Outer casing length(if known): _ (ft.) • 10c.For Water Supply&Inflection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county`health department of the county where
6f.Inner casing/tubing length(if known): (g,) abandoned.
. I '
6g.Screen length(if known):
(B.) •
•
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
William Ewing 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-36 is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:t
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'4 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 0 Neat Cement Grout " Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
"Monitoring ❑Recovery (
Injection Well: 7f.For each material selected above,provide amountrn'f naterials
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite ,r n
't❑Aquifer Storage and Recovery ❑Salinity Barrier 01: I 2 tw 20L
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedurP.A:Ca•- 'G
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 02,11;a0r, � 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or ell Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 N -80.561402 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.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-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 27.5 (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: (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 18.70 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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 i health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS ,
William Ewing
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-3 i is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water rem dining in well(s): 3'6 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if/mown
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 ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
®Monitoring ❑RecoveryInjection Well: 7E For each material selected above,provide amount of i tei ials i sed: ' e
❑Aquifer Recharge ID Groundwater Remediation
25 lbs bentonite
❑Aquifer Storage and Recovery ❑Sal inity Barrier O f,T 2 ; 2 U24
❑Aquifer Test ❑Stormwater Drainage •
❑Experimental Technology ❑Subsidence Control lI • " ..t" t� �'
7g.Provide a brief description of the abandonment procedureO':`t/ .
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ['Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 09a,11rL � 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We l Owner Date
Cabarrus 2851
• 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.0I00 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 42 (g•)
10b.For Injection 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 19.75 (ft•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g•) 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 r health department of the county where
6f.Inner casing/tubing length(if known): (ft-) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS '
William Ewing 7a.For Geoprobe/DPT or Closed-L lop'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
3110 wells abandoned:1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'7 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.U/C,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):
DAgricultural ❑Municipal/Public ❑Neat Cement Grout III Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
0 Industrial/Commercial 0 Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry i ❑Other(explain under 7g)
®Monitoring ❑Recovery ...
Injection Well: 7f.For each material selected above,provide amount of materialstised ;; y,•;,j
❑Aquifer Recharge ❑GroundwaterRemediation 25 lbs bentonite
❑Aquifer Storage and Recovery ❑Sal inity Barrier Q C l l.?. E 2024
❑Aquifer Test ❑Stormwater Drainage
a,. ,, "r ':':?1:
❑Experimental Technology ❑Subs idence Control
r'r:'dti.u'ri-•a-
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 C-a� .biz C-� 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We 1 Owner Date
Cabarrus 2851
By signing this form, I hereby cert j 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
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 Iat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells '
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-10 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (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: (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: 18.45 (g) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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):- (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIIS
•
VVilliam Ewing 7a.For Geoprobe/DPT or Closed-LI op 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 i§needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water rt maining in well(s): 1.6 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 B Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
uMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,;provide amount'ofmaterials.used•- ----._._
l'. i
❑A uiferRechar Recharge ❑GroundwaterRemediation 25 lbs bentonite " ''"- •
❑Aquifer Storage and Recovery ❑Salinity Barrier U(, I :` 2024
❑Aquifer Test ❑Stormwater Drainage -
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the•abandonmentlirrotedtire:
❑Geothermal(Closed Loop) ❑Tracer Mixed potable water with bentonite pellets to'5-feet
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 (,f9di 1r' c: 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We I Owner Date
Cabarrus 2851
By signing this form, I hereby certify,that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been,provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)rfavailable. 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-1 1 abandonment to the following: i
Division of Water Resources,Information Processing Unit,
6b.Total well depth 30 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 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 20.10 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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 county where
6f.Inner casing/tubing length(if known): (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.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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
3110 wells abandoned:t
NC Well Contractor Certification Number • 7b.Approximate volume of water remaining in well(s): 1.6 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 !9 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: 0 Bentonite Slurry ❑Other(explain under 7g)
BMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amounCotttuaterials usred:
❑Aquifer Recharge ❑GroundwaterRemediation 25 lbs bentonite
❑Aquifer Storage and Recovery ❑Sal inity Barrier '— Q(.T 2024
[Aquifer Test ❑Stormwater Drainage
❑Experimental Technology U Subsidence Control
7g.Provide a brief description of the abandonment procecitliWQrIir_ J
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ['Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 Gf�a� nz �` 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We I Owner Date
Cabarrus 2851
By signing this form, I hereby certifrithat the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# M W 12 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft) 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: (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 20.22 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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
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): 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.Well Contractor Information: WELL ABANDONMENT DETAILSI
William Ewing 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.7
(gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ON,LY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if/mown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout II Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
IMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of matterial§•used:�, y',u`^
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite n
0 Aquifer Storage and Recovery ❑SalinityBarrier 1'� l 2024
❑Aquifer Test ❑StormwaterDrainage !n`- -,-- .
❑Experimental Technology ❑Subsidence Control i C:`erir.`:3i:ri p
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothemtal(Heating/Cooling Return) DOther(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 G/}e �� 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We I Owner Date
Cabarrus 2851
By signing this form, I hereby certify'that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been'provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)tfavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-13 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 30 (g) 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: (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: 19.90 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Off-) IOc.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):- (tt-) abandoned. i
1
6g.Screen length(if known): 10 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 .
William Ewing 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water relmaining in well(s): 1•7 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 ❑MunicipaUPublic ❑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 0 Drill Cuttings
❑Irrigation 0 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'5riate ial's used: _
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite n
❑Aquifer Storage and Recovery ❑Salinity Barrier l l l'T tx ��
❑Aquifer Test ❑StormwaterDrainage �- •;•< - :.- t
❑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) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 (& 1l �r r e • 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We l Owner Date
Cabarrus 2851
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
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: MVV-14 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 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: (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 19.61 (R) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g•) 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): (ft-) abandoned.
6g.Screen length(if known): 1 0 (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Intemal Use ONLY:
• I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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-36 is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'5 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: .
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)flmawn
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 • e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial :Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other.(explaip under 7g)-
BMonitoring :Recovery - . > -
Injection Well: 7f.For each material selected above,provide amount of materials used: ~
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite OCT fi t` 20?4
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage I y,,.,t
❑Experimental Technology 0 Subsidence Control �'''+i•c''�i»°a v
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility IDl/(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
•
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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-17 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (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: 19.50 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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): (ft.) abandoned.
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Internal Use ONLY: •
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-Lloop 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
3110 wells abandoned:r I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.7 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name I.
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)tflaiown
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 ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
❑Irrigation ❑Specialty Grout r ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ under
Other(ex lain der 7g)
p
®Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide a t•oiiiitrof materials usedt.2
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite n l•I 2
[Aquifer Storage and Recovery ❑Salinity Barrier •
2074
❑Aquifer Test ❑StormwaterDrainage l :"-
v..c
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the,abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 • a}di 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We I Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been,provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
—N •- W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this foim within 30 days of completion of well
6a.Well ID# MW-20 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 30 (fr,) 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: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 19.75 (ft.)
1636 Mail Service Center;Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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 county where
6f.Inner casing/tubing length(if known): (g•) 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
1

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.7 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use): - -,
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout II 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 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
®Monitoring ORecovery
Injection Well: 7f.For each material selected'above,provide amount of•materials.used;_• ..
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite 4 •'.i-=. y i, ,;'
❑Aquifer Storage and Recovery ❑Sal inity Barrier O iJ I j B ;, 2024
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonYnent,proced"ure':7 r'r,�•"-- Fes„
❑Geothermal(Closed Loop) ❑Tracer ..•;.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Mixed potable water with bentonite peltets•to=5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned:_9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 (,fAg urr, C--1 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We l Owner Date
Cabarrus 2851
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
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 Iatllong is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-21 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 30 (B•) 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: (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 19.34 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 1Oc.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (g•) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20(6

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS '
William Ewing 7a.For Geoprobe/DPT or Closed-Loin)Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-3d is'needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water rem aining in well(s): 1.6 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown •
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 III Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ; ❑ Drill Cuttings
❑Irrigation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
®Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount.of.materialsirkedf
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite •ri j ')
❑Aquifer Storage and Recovery ❑Salinity Barrier [Jr—I z 2014
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology Subsidence Control Itr.` ;, .t'." ''^.r•sre;<<, �J�,
7g.Provide a brief description of the abandonment proc ur :, .y
❑Geothermal(Closed Loop) ❑Tracer ' :-4-`
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 0941-n. �' 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor owner Date
Cabarrus 2851
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.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS •
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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-22 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 30 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Inflection 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:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 20.26 (ft)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g.) 10c.For Water Supply&Inflection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (g,) 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 Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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
3110 wells abandoned:1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.7 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: 1
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)(known
7d.Amount of disinfectant used:
3.Well use(check well use): • i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I II Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout I ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
❑Irrigation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ! ❑Other(e plain:under:7g)
®Monitoring ❑Recovery
Injection Well: 7f.For each material selected above;provide amount of materials used:' 1 Li.
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite OCT 2 ;i 2074
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage irifu: 1.:i ;'-•�.r",:,,::„,,L t„
❑Experimental Technology ❑Subsidence Control
G} VCi/2 0 Z
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geotheral(Heating/Cooling Return) ❑Other(explain under7g) Mixed potable water with bentonite pellets to 5 feet
m
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID##(if applicable) 8.Certification: !
2825 Lane Street, Kannapolis; 28083 9d-Sam. -err 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We l Owner Date
Cabarrus 2851
. By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# M W-23 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 30 (g) 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: (in.) 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: 19'19 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g•) 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): (g,) 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
4

WELL ABANDONMENT RECORD For Internal Use ONLY:
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water reimaining in well(s): 1.8 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other expla in under 7g)
MMonitorin [Recovery
Injection Well: 7f.For each material selected above,provide amount of•materiaa 5Is•used'e
['Groundwater
a
❑Aquifer Recharge Groundwater Remediation 25 lbs bentonite OCT t r T 2 210 4
❑Aquifer Storage and Recovery ['Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage • ;�s,:a , a:. -�.r ;�,:•.: t� ,:
❑Experimental Technology ❑Subs idence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
['Geothermal(Heating/Cooling Return) ['Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Datewell(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility IDii(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 Gf&?zm � 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We l Owner Date
Cabarrus 2851
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS •
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# M W-24 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 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: (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 18.95 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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): (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
William Ewing 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
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water lemaining in well(s): 1'0 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 0 Neat Cement Grout I Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0 Irrigation ❑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 ampunt bffmateriars psi d:'
❑AquiferRechazge ❑Groundwater Remediation 25 lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier — 7
❑Aquifer Test ❑StormwaterDrainage Or 1 ZOZ4
❑Experimental Technology ❑Subsidence Control r ,,rx U.e:i
7g.Provide a brief description of the abandonriiiirt'f roi`eBui•e:.,.;
OGeothermal(Closed Loop) OTracer U' t.c':0t.7
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID(!(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 (,)edam. 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or mil Owner Date
Cabarrus 2851
By signing this form, 1 hereby certii that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 25 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 28 (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:
21.53
6d.Water level below ground surface: (ft.)
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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
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 For Internal Use ONLY: I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing •
7a.For Geoprobe/DPT or Closed-L i op 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
3110 wells abandoned:I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.6 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 G 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 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
(Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount'o, materials used
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite❑Aquifer Storage and Recovery, ❑Salinity Barrier O C 1T
2 2024.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control IGic.:' .'" � d�t` • l�?>
7g.Provide a brief description of the abandonment procedu :.'nCu .),r
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Datewell(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility IN(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 0.9e .un- ( i 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We l Owner Date
Cabarrus 2851
By signing this form, I 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
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
•
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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-26 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 28 (B,) 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: (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 18.34 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g•) 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): (g.) 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 Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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
3110 wells abandoned:r
NC Well Contractor Certification Number 7b.Approximate volume of water lemaining in well(s): 1.3 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name i .
7c.Type of disinfectant used:
Unknown i
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
• 7d.Amount of disinfectant used:
3.Well use(check well use):
:
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ❑Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial 0 Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
'"Monitoring ❑Recovery _--
Injection Well: 7E For each material selected above,provid,a ount of, ater:ials'used:,i
❑Aquifer Recharge ❑GroundwaterRemediation 25 lbs bentonite n
❑Aquifer Storage and Recovery ❑Sal inity Barrier 1 OUT 2 ,-. 2U24
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control II "'t�'� ' <r-�'`�- 1`
7g.Provide a brief description of the abandonment jioceduie=}a
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location: •
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID//(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 Gt)diZanz C' i 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or WO-I Owner Date
Cabarrus 2851
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
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'at/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
-N - W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells i
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-27 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
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: 22.14 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): • (ff-) 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): (ft.) abandoned.
6g.Screen length(if known): 15 MO
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For Intemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 7a.For Geoprobe/DPT or Closed-LI op 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
3110 wells abandoned:t
NC Well Contractor Certification Number 7b.Approximate volume of water relmaining in well(s): 1.7 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: I
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifkmwn
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 I Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout I ❑ Drill Cuttings
0 Irrigation ❑Specialty Grout I ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
®Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of4materiats used: •,•:
❑Aquifer Recharge ❑Groundwater Remediation 25 lbs bentonite
❑Aquifer Storage and Recovery ❑Sal inity Barrier 0(�! u [024
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ._
7g.Provide a brief description of the abandonment proOdure:' L
OGeothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
• below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis, 28083 a- � 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or We l Owner Date
Cabarrus 2851
By signing this form, I hereby cent that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS •
Attach well construction record(s)If available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 28 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (g,) . 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: (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 19.63 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): ((t) 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): (g•) abandoned.
6g.Screen length(if known): 15 (ft.) i •
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
• William Ewing 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-B0'is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:I .
NC Well Contractor Certification Number 7b.Approximate volume of water iemaining in well(s): 22.6 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflrnown
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 II Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation • 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring NI Recovery
Injection Well: 7f.For each material selected above,provide amounf'of.ma'terialsused:. a. c..
❑Aquifer Recharge ❑GroundwaterRemediation 100 lbs bentonite OCT 2 702.4
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainageit
❑Experimental Technology ❑Subsidence Control (v roi;a• +aa
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC Q-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification: '
2825 Lane Street, Kannapolis 28083 aAleatilt, ( (t:a1 - 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W 1 Owner Date
Cabarrus 2851
By signing this form, I 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
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS •
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 55 (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: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
20.57 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft) g J g
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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 Ihealth department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 50 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD ForintemalUseONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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
3110 wells abandoned:t 1
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): 13.8 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: •
2.Well Construction Permit#: Unknown
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 IN Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ['Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ®Recovery
Injection Well: 7f.For each material selected above,provide atnount'ofrmateriafs used: 1
❑Aquifer Recharge ['Groundwater Remediation 75 lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier O C T 2 i` 2024
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment prof kdtiie:2,tla
['Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC . 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 (,{JG,i �� 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W I Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS • •
Attach well construction record(s)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#: RW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 40 (ft.)
10b.For Injection Wells: In additioh 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 19.05 (g•) -Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (IL) 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): (IL) abandoned.
6g.Screen length(if known): 30 (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
William Ewing 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-b0 is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
7b.Approximate volume of water remaining in well(s): 17.4 (gal.)
NC Well Contractor Certification Number
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
•
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 ❑Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain,u_nder
[Monitoring (Recovery • ..
Injection Well: 7f.For each material selected above,provide-Amon l"ofmaterials'ttsed:-
❑AquiferRecharge ❑GroundwaterRemediation 100 lbs bentonite ; 4A
❑Aquifer Storage and Recovery ❑Salinity Barrier n r T 2 i LO Z`t
❑Aquifer Test ❑Stormwater Drainage �, +a.. .i'i
❑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) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:2825 Lane Street, Kannapolis 28083 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W I Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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-6 abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 45 (ft.)
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 18.38 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (IL) 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 county where
6f.Inner casing/tubing length(if known): (g.) abandoned.
6g.Screen length(if known): 36 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

•
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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
3110 wells abandoned:!
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 26.0 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit ll: Unknown
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 ❑Neat Cement Grout II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ®Recovery
Injection Well: 7f.For each material selected above,provide amount.of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 100 lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier n r T 9 /117 4
❑Aquifer Test ❑Stormwater Drainage =•,!1„?:
❑Experimental Technology ❑Subsidence Control y�c i_r 3
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Retum) U Other(explain under 7g)
Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 a9de m � 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W 1 Owner Date
Cabarrus 2851
By signing this form, 1 hereby certt&that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 W You may use the back of this page to provide additional well site details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply wells
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#: RVV 8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 58 (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 18.27 (g) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): .(g) 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): (ft.) abandoned.
6g.Screen length(if known): 50 (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
William Ewing 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
3110 wells abandoned:I
7b.Approximate volume of water remaining in well(s): 22.0 (gal.)
NC Well Contractor Certification Number
Crawford Environmental Services FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 0 Neat Cement Grout ® Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring NRecovery
Injection Well: 7f.For each material selected above,provide amoint-of materials used•
:Aquifer Recharge ❑GroundwaterRemediation 100 lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier Ir T %074:�
❑Aquifer Test ❑Stormwater Drainage
❑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) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Date well(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) S.Certification:
2825 Lane Street, Kannapolis 28083 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or W 1 Owner Date
Cabarrus 2851
By signing this form, I hereby certify'that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SVE-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth 53 at) 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: (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 19.39 (}I,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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): (g•) abandoned.
6g.Screen length(if known): 45 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD For lntemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
William Ewing 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 J30 is needed. Indicate TOTAL NUMBER of
3110 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Crawford Environmental Services FOR WATER SUPPLY WELLS(ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: Unknown
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 II Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 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 at:rib—n tof materials used:-
❑AquiferRecharge ID Groundwater Remediation 50 lbs bentonite ...-
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 N-
❑Aquifer Test ❑Stormwater Drainage
O1,
❑Experimental Technology ❑Subsidence Control - • _c
7g.Provide a brief description of the abandontrStentpiocedurru.
OGeothermal(Closed Loop) ❑Tracer V'
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 7g) Mixed potable water with bentonite pellets to 5 feet
below ground surface. Completed remaining 5 feet
4.Datewell(s)abandoned: 9/27/24 with neat Portland Cement
5a.Well location:
Pilot Travel Centers, LLC 0-011084
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2825 Lane Street, Kannapolis 28083 (2a,1 n. ( 10/22/24
Physical Address,City,and Zip Signature of Certified Well Contractor or WLIl Owner Date
Cabarrus 2851
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.497968 -80.561402 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)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#: SVE-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (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: (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: Dry (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i '
6e.Outer casing length(if known): (g,) 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 county where
6E Inner casing/tubing length(if known): (f,) abandoned.
6g.Screen length(if known): 12 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016