Chatham_Well Abandonment_20220603

rrU�.i.�:t�,�1�11Ul��IYT�CORD • F��tualU�oN�Y: ���. 7,q
71ds fomt'can be used for single or rntiWpbe went
1-Well Co clor lorormationt
' _ • •><
11
11+ell Conueclor Name(or w 1 oweet personalty tbmdoel40 triUbnhit/httproptrty) For Nmultiple er°ttn/tel!If
ltbn ndan all r
W narrvetfc✓abondonmr spy 1rtNs ONL) oral: the aoma
eo
n4 you en au6ntrt om jonri.
NC lvelt Coelrtclor Cettlnettlou Number 7b.Approximate volume of Triter rtmAlning In neO(s); AI.
N.W. Poole Well & pump Co. ce )
Company Name FAmoun
FFLY WLLd,5 UNLYt
Z,1veU ConttrncUon.Ptrmlt ff:��� thnt nsedr l
L!at all applicable N rl!prrmrra(f.e,Cmanry,......Varratre't,IrVtcHoK Ile)(/anown
nfestsnt Wald:
3."'Ell use(checkn•ell use):
FgriSupply1ve117a Seaiing material,cued(cheek■ll Ihel a Igrleulttual 13Munlalpel/publlo 13 Neat Cement grout fTp"y)tcoUtcnnal C7{eeling/Covlln supply) cnlonl►e Chips or Pellets
8 PP Y) *a1dentlsl Water Supply(single) 13 Send Cement grout
❑Industrial/Comniercl:il _ ❑RaldendAl Wales Supply(eltuhxl) ❑Dry Clay
Clbri a(loll ❑Con Grout 0 Drill Cuttngs
Non-wit(er Supply t5'tll: ❑'Specialty grout Gtavcl
0Mgnfluring U 13tntonile Slurry
Injection! ell: CI Other(explain under 7g)
❑Recov
OAqulCcr Recharge 7f.For saeli rlaltx "y pm
lde amount bf materiels used:
❑Aquifer Bturege and Recovey ❑Salinity Buda medlnllrnh
❑Aquifcr'fest ❑Slortnwa(ctDmUga
Technology °" '1�� ®
By 11Subsldenco Control
❑Gcolllcnnal(Closed Loop) OTrecer 7 Prorlde a brlef dtacrlptlon of the abandonment procedure:
l C1l3coUlcmlel cello Coolln Roltim ❑t)lhor lain undcr7 }
J 7V
4,Unlc ireli(s)abandoned: / "' ••,
��7� .•—ram
s'
38.Well locn(iurl: /
FaeiUlylO ner Neme ,.
olUtylI)f(IfappUtable) B.Cerl1lfeaUonf
Phyl fee Ad&-' 1,City,and Zip
/ 81sas `of cetdDid U Cc Itraotor or We owner y bile
ouut� Y ny,lgnin Ihtt. rr
Parcel ldoetl g. I h frpDy cerf(fY Afat Aft wells mar by r llcadorlNo, W � (J ( e eJ°G°lfAontd!n
J dCCO �t tblth ls�(..,YNC 01C.010o or 2C.010O WtIl Corulniction Srarfdnrda
3b.LAU(udb nti lonlitUUe la degrber/ritlhnteUaecondr or deelmaldegrees; and that a
Cepl'ell4tr record her been provided to the well otrner,
(Ifn•eil'11eIJ,ooe IeUlting li iuFgelsi,l) .
9.Site iilagrttm:ar adltlUbnrl neU deUhUs:
17 You mky:itsda6e, `adk of hits page to provide addilionl tivcll silt Jctaib or Nell
�' abarldotiMMI d'.Wia: YOu mttp also attach addilionl pages Unccessary.
ifrfBFll�tS 1 t.. '
+rrr!}b In efl/i} 'tfltii[�a '' '"':' .,-I Z 6a non lratir'ngrply
olshlkldhrtiifif,jrJli tdn turnHtf n)nt jorm,
tin,lveil wfi! 10a, l Submit Uds farm witidn 3U days of complcUon of well
per, 6'sndadffilsrht to Ul'o'following:
`bt Total well depth; bivill°b ollyalerReaources,Information Processlug Unit,
(f4) JA 0 3 2022 1611 Null Berrtce Center,Heleigh,NC Y7699.16I7
lob,Fot Ieiec InN!Nat. �.
5c.Borehole dlntneiee:. ,v t In:addiilon to 6cri&g Ole form to Ufo address In f0a
rr„MI Tf ebovq dlao duBiiih?olio copy of oils form wlUlbh 30 days of complcUon of well
` QI° Tit?w!�?(1��S�t fit M nl iii.di-lnllowing:
"ti.11'aler level beltirv•grol(nd iibrfacer..: '
(R.) Dlvldbn oflYf(IEriza80nrces
16
Outer calltlg'Ie iU Jrervfce Center,Rrlefgh,NC 27699-1636
r. hgtbi(If itildivn)t �.
(17) IOc,
Uhl 4d� : In addition to sending Ole romp to
ibcfvti,'*alio submit one copy, of Uds form wiUiln 30 days of
Inner casing/tubing length(Ifkndwn)r eompletidtl of troll ebandottinenl to Ute county health department or Ote county
Alert Abandoned.
it_,screen'.i�u (H;(Ifauioiviijl,i:
'enrol OW30 ' Nottlt�itiillni De p'YrttheMblEnThbnmeatYndNthtnlAetni:r,+.::,rii:.1.:_,.•_....'. _

cv � la(UN ONLY:
This form-can be used for single a r•rnetltlplb well[
f.\Yell - ntreclor Inrorvoellont p01
6 p '
vVell Conoeclor None r wet owner penonal(y sbandonla 7a,Number of roll,began Abandoaedl
atriU Da Ws/het property) For multiple injection ur Hon-rroler rrVply vrlle ONLY arslt dm aamr
—L eonrrweHer✓abondonmrn{you ran rvbin!!Ont fOtm,
NC Well Conlreclor CertlncaUonNumber 7b.Approximate
N.W. Poole Well & Pump C ►olnme!o[n:ter remalalag In neU(s):
o.
Conrpnny Nasnc FOR WATER 8Ur rLY'WELIS ONLY=
2.Well Construtdon.Ptrmlt N: 7�Type of dblatechot nseds
Llrl all applrcable,,.rl/ rrrnlrs D; 'I
p R•t•caws stair,Irarlene N rnaK rrq)
3.Well use(cbackn•ell use): 7d.Amoont of dlslnfectant used:_
\valet strppty}veu:
(DAgriculllunl 7e.seating materials coed(chiek.0 theta ply)
OGcoUlermal(HeaUng/Coalln Su l OMunlolpel/publlo El Neel Cement Grout .
g PP Y) Vesidendal Water Supply sin e ❑Send Cement Grout PVQCnlonite Chips or PCIIcLr
❑ludusu{lll/Comnrcrcllil PP Y( � ) O Dry Clay
❑ResldrnUd Wales SuPPIY(shared) l7 Concrete Grout
0[tti anon O NO CulUngs
Non-}Valet Supply}yell: 13-Specialty Grout Oravcl
OMonlloring ❑l3eelonito Slurry 0Other(explain under 7g)
In ecttoll Well: C3RlxoY
OAqulfcr Recharge U For each mafertaa seIec �bmy provide amount bf mahrlels used:
❑Aclulfer9lorago end Rccove ❑OCO�dwelerRernafletlat I
rY ❑Shcnity Bader
l7Aquifcr Test Dra nag
OExpbrimental Technology ❑Slormwata e
❑SUbeldenco Control
OGeoWertna!(Clostz!Loop) OTraocr 7 rarlde a brlt(desCdPIlUn of the abandonment procedure:
OQcoUtcmtAl ctitln Coolln RCltun
OOthor Idle under-7
el,DRIc lvell(s)Abandoned:
3n.}Yell location:
Fee Uly%OrvnerNeme' J`���qqpp
�{ FaolUty It7 (it Ilcable) 8,CertltleaUonr HIo'iK..
Physical Addre�,Chy,enJ Zlp � G " `�;�q� ,
j gtg,!ho°of CertlDt Con(rao(or or Well Ovraer "
Acounly
_ Dy s)grdng thee.Patoel lderdlOeadod No. IN rDrn► fhe eert'(fy Mal Ilse ivell(s)lVad(were)abandoned Ill
P meu11J1J,�'NC,fC,U100 or 1C.01001Ye/l Corufnldion Slandarda
3b.Lell oaetUluldd6n.aaa ld dl":lonQttitte fn de$reti/rtticutet/seeands or deelmal degree: and that a rnpy aJlhLr reeort(
(Ir n lrnr been provided In then ell on nee,
I liil9o(eat) ,
35.�3-� ��3 !!�� 1'�Ilme dlaentm;or addtflbhtl well details:
��'� 'V��� r h wd;i(1e.�iac�s of 1lile pogo to provido additional well site details or well
ebendonment'detells: You may also attach additional pages Unecessal},
"• in brittrl Q6.gNdetiiiiin%i•d'k�ri,b,rrlroi OF MOH'tratrrnyply
in,}Yell IbN: 10a,Fnr r •8ubinit Uds firm MOdn 3U days of conlplWon of well
abandoliinlrril Io Uto foU3wing:
`bs'Fatal tvell depth: (CL) /� � B � blvlslon of}Yater''Resuurcu,Information Processing Uull,
6 �/ Ibt7M�ilBlnlce Center,Raleigh,NC17,G99.1G17
11
llorehole dlemetcrl. lob, r
(In,) `'UN 3 20z� Above,.dju—MR16": Y;! di form wdull to nding301 days of oom Icdrus In IUa
abendortrrtenl ld:lhti following. P ion of well
-n.11'aler Icvel belory gentled surface:..
"—
�l=ir( .�Y GC v�U�tlTbtrls)on oC}YxibrRtiOurcra,Underground Inlecdun Caniroi Progrna,,
Ou(cr eating leggtti(If 1tnUfi n)t
1r>� N— 9"IcleCentersRaleigh,NC17699-IG3G
�•
(tt) 10c,Fl1 ;
lho ad 1hlr Irt addition to sending Ole rum,to
s�1"" also trubailt ono copy oC Uils Corm wiUiln 30 days of
Inner casing/lvtbing leng(b(lf knitwn)r `'�'• eompletltiri of ivo11�ebendontt to Uvo Bounty health deparUnenl of Ole courtly
wltacebandonsd,
(R)
' 140tib�irvllntbbpiirlmorrtt,[>�TlrbnmeotYndNsllailReeni>rn.�::rii:.r.i_,._.+.. . ' ,.

r r�uL�: �GORD ,J��•� e�71ds for OIiI/Y.
�Jj • . •
m can be used for single orInulupite weUa WwtWI UW
!.\Ye ntrnelor ortualtont '
. . ,:3(
\Yell Con or Name( well owner penoad sbandv 7a.Number of welis balcg abandoned,
alP1tallbuWLtherpropsrty) For mul(Ipls Inleello)l or non-wafer ripply trelh 61 nhh the aom eentrrueflar✓abandonmerq you can submit one form,
NC Well Conurclor CerUfleallou Number 7b.Approsdmale volume of water remaining In weU(s): s ail
N.W. Poole Well & Pump Co. ---��_cg )
Company Name 77d-Amount
WATERPPLY WEf,I g OiYI,Ys
2.WeU ConslrucOon.Permlt N: ! e(anf nsed3 �
Lr3r an appncable a-erl permlls p.e.ca,mgt tale,i'a"amf,Dveetror�ate.J/}n— a�
3.Well use(cbcck well use): nfe lint used:
e
F0WdUjLriaJ/Co=nmctjnI
5uiply}Yelcul(uml 7e Sealing materJals aced(cheek aU that pply))
❑Munfolpal/Publlo ❑Neat Cement Grout
alUCoaling Supp►y) es►dendal Water 9u I sin e O Send Cement Grout Brnlonhe Chips or Pdlcls
PP Y( Ill ) O Dry Clay
❑Resfdendal Water Supply(shared) ❑Comely Grout
CiIrr1 avian 0 IhIU Cuttings
Non-Water Supply Well: ❑-Specially Grout IVIOMYCI
Oh(pnlloring ❑Bentordle Slurry 13 Other(explain under 7g)
In ccUon 1 ell: ❑Rccov
❑AqufferRecharge 00mundwaler Remalfallml 79- ar each mata�eieeted abort'provide amoouuunn(bf ma(triab used:
l3Aclulfcr Storage and Recovery ?--••�`
ry ❑Salbtlly Barris
l3Aquifcr'fesi OSlormwatrrp(>dllago �� a ��.�'� ,��y
ElExpbrimental Taulurology OSubsldtxtco Control
(OCeoWerrnal(Closed Lvop) ❑Tracer 7 Provide a brief description of the abandonment procedure: '?
O(3coUlcmlel cello Coolln• Action ❑Other lainunder7
'i,l)nlc n•dl(s)abandoned: •-� "" --�� `
3n.1Vc Incaliufu �� es � '
Facility%Owner N e Faollity IDII(IfgppUvsbie)
B.Cer ncaUool
Physical Address,city,and Zip
916n!hadvf C id eU Colitraotor or eU Ovrner DAN /
couury
Pate By signing lhil.jorny I hsri rerfIy(furl the well(j)l(s)Ivan(lucre)abandoned In
al 1dsml0eadvrl No.(PW) accordrnlds iaJ�;ter,!Nc fd 01C,o100 or IC.0100 Nell Conitnrdion 5tm:dards
5b.LeU(udb anda6niltu0d to degreedthlnolea/secondr or deefmal degreu: and►hd a wpy offhlr reronihar been prmdded to rile well owner,
(ifrvell'field,one leVltingli iaFBolei3t) .
35,-7 3'SLf�� 9.Site OvAm or Ada-IUotial weU detaUsr
N You milt'Wd:tb 16� ol'tlile page to provide additional well site details or well----— ' abandonmwi dt tells:'You may also ellaclt additional pages Unecessar),.
rellb UAtil ,f1N. on 6t
effl�;i;i3 i•d►�idfi rubmlr dns�otrn.
58,Well WHI IOa,For` it•}y'ita: Submit lids form wiUdn 30 days of completion of well
e P°'1.V ori!to Ul'o'Jb1J6wfn'g:
`,b,To(al tvell depth: l r" blvlslofi oOVAterRuources,Informatten Processing Uult,
(n) JUN 03 20Z2 1619 Mrril Service Center,Raleigh,NC27.699•I617
Borehole diameter,. ,Fop Lleehoa'N.t(.
In,eddldon to sending 0,c form to 0to addrrss In lUa
copy,of O,Is form w1t11U3 30 days of completion of Weil
onMent(tl.lho(allowing:
11'aler level belo'Wgrotlnrl iurfacer. .
(tL) I)Ivldbn Offtilbrltefourced,Underground InJecdon Control Program,
I u gemce Center,ILtlelgb,NC 27699-I63G
"•Ou(cr caelug leggtb(lf.ltitU(Sb)s
I
aMv���
: bl addition to sending Ole form to
•ill.'ab du submit one copy of 0ds form wf0dn 30 days of
!Hoer casing/tubing length(Ifknown)r ~" oomplethin of tvoll abandonment to 03e county health department of 0;c county
where abandoned,
i
;r•_;Screeu`..lerirllti`,(IFauiniYbjl.(: ""� �
i i)rus 4W30
NOnh�siiilf ut bb(iYr(rhent 6f FJlrlrbnmeal Ynd Nslw,d Aetni r,.:i rii l.t_