Harnett_Well Abandonment_20220603

r►Ul.i�tr:tf11�U Ul�.EY�n'I'RE CORD POa�PON
11u5 form can be used for sin u�OR
or•m»ldplt+wella
1.Well C nlrgclar 2nCormallont
`V-- . k
ell Contrsclor Norte(or well owner penvad�e6aadoalnI ftll bn blAer propsny) For74.ty mmu10p1eer vf Wells 10?l Q ab OP n�xafedrl g%uply treill ONLY s,•frh the a..,e
`� - eonrlrverfor✓�1�arloament,yaui can Su61rrff orfe forrli,
NC well Canlrselor CerdpcaUou Number 7b.Approl;tmate volume o[naler remaining In eeU(s):
N•W' Poole Well & PUMP Co.
Cmupeny Namc POR WATER SUPPLY WELLS ONLY:
2.WeU Conslrnction.Permlt H: 7r-Type of disinfectant need:
�11V-11-1
..
Uaf all 6pplfe66)e$rll permfre(l.e.Cormo1 61
Sfa•!e,Pa a , el
3.18'd1 use(check well use).,
7d.Amount of dlshdtclanit used:
1ValcrSupply}Nell:
OAgrlculturnl 7e Sealing mail med1theck an that apply):
OMunlolpalTubl(o O Neat Cement Grout.OQcoulennd(Iieating/Cool(ng Supply) identiai Water SuPpIy(single)
n e) ❑Send Cement O Bentonile Chips or Pellets
❑ndustrial/Comnrerclal rout
O Dry Clay
❑Residentid Water Supply(sllefed) ❑Concrete Grain Oini noon to Drill Cuttings
Non-Water Supply Well: Apenlalty Grout ❑ Gravel
Monitoring ❑Bentmdia In Slurry ecllon Well:
C3Rxov O Mer(explain under 7g)
❑Aquifer Recharge7L For each material selected above,pruyide amount bf materials ustd:
❑Aquifer Storage and Recovery OSallnl d Barrierwater lallvn OAquifcr Test
OExperinncnt OSlornIM(erDrainagc / /�L /►,m��
al Technology OSubsldenco Control L•�
O(3eollnennd(Closed Loop) OTracet 7g.Fronde it brief description of the abandonment procedure:
00coUlctnnal calla Coolln Return ❑O(her lain under.7
i,Dnlc lyell(s)abandoned:
5a WC11lotallun:
sSfl 14A
FacfUiy%DwnerNeme �/ FeclUtylD (ifappQleble) B.Certilica
f 'I
yslet Addreee,Clly,and Zip p� +
V sip,tura'u nUid Wei can '`r ell Owner Dale
Cotwly BY Pakel IdoutlQcadod No.(PW) d co 8 n8 f re ciI(hat flit 11,0(,r)war(were)abandoned In
36.4a(1(ud6 audaona(tu8e In degr eei/rhtcnfes/seconds or deelmal degrees: Ce 14y 1hLh'L'�!G'02C.been0 rv4dedor 2C. ic7t Well Cofulnrdion Standards
rind char a rnpy of lbLr neafnihaa been provided to fire n el!turner,
(lfwell'neiJ,'Dud191ltingli &cfeitt) ,
N _ -7 p 9.Site dlagrtm:vr addtuohli wcU detail:
o'er 7 03�j You oIny ued t 'e 6'`ac�C of lilts psgo to provide addilivnnil well site dcleils or well
' absndontneat s: You M1 also attach additional pages Itnecessary,
AfFaidNlip3y' ''t ..
�I'ellb'd/T yp r':i tih)i n'•ir` )rr' obit "rfl`'abblida.••::::�� �ft sir 6r.non-trarrr ngpfy o reM,;d k nth"wit efie fans.
!is,Well Ib#! l Submit tins form wititin 30 days of compieUon ur well
41,Io Uno tvUriwing:
Total well deplhr (fG) JUN o 3 2022 Dlvbloa'OhNe'rReaourcu,Informatlon Processing Unit,
1611 Mill!twice Center,Rele(gh,NC 27699.1617
y fiorphole dlamcich. Sr` s+� � � J r In,Addition to sanding 010 fofln to Ole addrrss In IN
` .. Fmil ltbiio copy of tills form wlUtln 30 days of complellon of well
'"' l ienttu.lhotollawing;
"l•Water level bel6ry grodri�iiuriacer. .
((1) DIylslbn.Of,.lYit6rHesniur�u,Underground Injection Control Program,
c•Outer casing le4gtlJ(If IidU'To)s 1 U✓iervtce Center,Ralelgb,NC 27699-1636
((O lilt,
the ad ;°. In addition to sending Ole Corm to
eomplotlon of Wolfnb do n,lb
'lia o�w,�h�11 ciCparimenl or tios form roC3Ule cowtly
Inner casing/tubing length(Itkndwu)r
�_(fL) wlruc ebafrdmled.
,;N,5crectt+.len�lh';41Ckdoiyb))'t- I -
hrw OW-30
' 1Sort6�erollnab'epYrlmeul of Enrbonaxollnd Natural Reraisi,.:::,ii:.l.,_,._...�.
i

rr�ul.i�:t �1�1JUl�fun RECORD p (��,,,,,
llds form can be user!for single or m»IOplb weUa f�WtMI us ONLY.
1.\Yell Can tfetar Inrorvoaltont
s•k �
Nell Contnctor None(or well ovvaer penoord(j abmdv 7a.Number oti►ells being'ilbandonedl
a14iR►ULaWslhtrprall dy For multiple fgtrenlon a{ "on-wafer r /y naffs
e.+ eensimcnar✓obandatunm,you can submit one yor�mp ONLI >,trh the semi
NC veil Contractor erd(icatlon Number 7b.Approslmate volume o[water remaining to eeU(s): al.
N.W. Poole Well 8l Pump Co. �Q )
Ctimpeny Name FOR wArrR BUPPLX-WELLS ONLY./
2.WeU Construction Permit N: 7L Type of dblafaeiaaf tiled, f7
Liar all oppneoafe H.eff per,nrtr(I.e.Cotmfj;5(ojr trarlonee.Irl/ecNoq ere .Kn
1n ---------���---///7d.Amount of dlslnfectant used:
3.}yell use(check n eII use):
\}'afar 5uppiy Well:
OAgrleuliural 7L Sealing materials lued'Icheck nU that apply):
DMuniolPaliTubllo O Neat Cement Grout.OQcoutcnnal(I3ealing/Cooiing Supply) pldential Water Supply(single) 0 Sand Cement Grout 0 DryBen Clay
Chips or Pellets
Olndusuinl/Commerclnl PP y( g1) 0 Dry Clay
OIididential Water Supply(ehtued) 0 Concrete Grout[]Ini silo❑ [J Drill Cuttings
Non-'Water Supply'yell: XUPeolsJty Grout 0 Gravel
OMoultoring ❑Bentonite Slurry 0 Other(explain undo 7g)
Injection Well: ORtcov
OAqulfer Recharge 71 For ach malerrii�al selected■Lave,prvvlde amount of m.lerlais used:
OAqutfcr Storage and Recovery �G unity a rr Remed(alltm e� V/I A&V t]Sdbi!(y Barrie S
l7Aquifcr Tcst ❑S(ormwaterDraffiga
OExpbrimental Technology 0Subsidenco Control
❑Gchlennal(Closet Loop) OTreeer 7g.P den brief descrlpfloo of the sbsndonment procedure:
O(3caUtcrnlal cello Conlin• Rettan ❑Other lainunder7
4.Dole}t•ell(s)abandoned:
.1YcU In�eatlon;
peotUly/pwner Neirie �=�•�4J
FsciltlyIDII(IfsppUeable) 8.Certincat1013
Pbyelcel Addrese,.Cily+and lip
� 81aa�tvl"d of Cerltlled�t Coalrsalor or WeU Oxaer Q�
� ale
oumy PetcelideoalSradodNo, Qf(p ) BY slgrdng Jhls.fvrny I h14 certify flirt fife well(s)war(were)abandoned ht
ticcordrntdt>blfh 1S,!'NCrlGe 0IC.0100 or 1C.0100 Well Corutructlon 5mndar•dJ
Ur Lit O lud6 R'leL6nQ(tuUe In degreeli/rtdouleUieconds or decimal degrees: anrlrhata copy ojiltlr rtcmthaa born provtded to the well an�ner.
(tn•ell'fielJ,•iioe sVlbrigli FuFBoleirl)
N - �P 9"Site 40gram,or additional vreU'MAlls,
O.9 03 7O W You moiy usd the. ac�c ur tlile page to provide additional well site details or~veil
rt6dAlii.
abandonment ditAk You may also attach eddllionel pages If necessary.
s
+refit dIY 1� )t' }' ebrtJ "trlfliC)oiiel►�dlihiihl�aM rirMilItebe�, °' pQ""
ra.Well IbNs si r 'Submit Ous form wiUlin 30 days of cons leaon of veil
�tUN o 3 202tbandonmenl16U1'611twing. p II
fb,Total❑•ell depth: 111vbioli of WrtlerRuources,InformsUon processing Unit,
(M) !� 16171Ni11 Service Center,Raleigh,NC27.699.1617
ptq
Borehole diameter:. ���iigil0> t In,eddhlon to sending Unc form to Uto address hl IOa
(io•) above,tlao''liltlii{lt?utib copy'of Ods form v4ulln 30 days of cornplelton of well
abandonment id,thti following:
r }}'seer level belo►v grottiirl iurficer, Underground etgtound Injection Con(ro1 program,
(�)
1 14i;U Service Center,Raleigh,NC 27699-1636
OUICr Caling letlgth(If lttldt9h)t " �'
(U•) 10e, ,
the ad bt addition to sending Ole form to
•l�9 �altio;submit one copy of Otis form wiUdn 30 days of
Inner casing/tubing length(Il''knuwn)r comillet On of Avbll nbandlnlmerlt to the county health department of Ole cotutty
Wilaec Abandoned.
i_r•_.5crer:n',.ien�(ti,(if,kdoi�bjhl �" - �
O u OW-30
Nottll�'smllna bepettment bf EnThbaareat Ynd Nslural Reinien.: