Johnston_Well Abandonment_20220603

sonr r LLld•�,�1�11'Ul�MElYT RF COED }�y
'Ns form can be used for single or mtilUplb walla FI �(el»aI UN ONLY.
wen co veep`0 7a.Namber otirella( wellownerJp�enoast(yabandoalnl Mil bu Ida,property) For multiple injection nr Aadon dtIF on-water fpPJY W111+ ONLY „rr1, the ao�,e
�� �• eannrverlar✓obartdonmrrut yev can rubmlt one form,
NC Well Conuectar CertlDatloo Number 7b.Approslmate volume of water remaining In vreU(s): nl
N.W' Poole Well & Pump Co. (g )
Company Name FOR WATER SUPPLY WELLS 011JU '
2.Weil Conttruction.Permlt N: p, 7c.Type ordbinfeetant heed,
Lr+r oil applicable,vell per-mlra(1...Cotw arare,t'mianee,lRreerlort ere-)Ub,—ate-) --
213
3.Well use(check well use): 7d•Amount of dldnkeh<nt aced:
1Yater Supply}Yell:
UAg'riculluml 7e.Sealing materials toed(check aU that apply);
CIMunialpal/publio t]Neat Cement Oroul.0ludus cnnal(mmetea g/Coeling Supply) K-Identlal Water Supply ❑Sand Cement Grout 0 Bentonite Chips or Pellets
❑IudusWal/Comnrcrclal PP Y ❑ Dry Clay
❑Rcsldrntlal Water Supply(eherod) ❑Capsule Grout d[rH ellou 0 Drill Cuttings
Non-1\�ater Supply�Ycll: ><9pecialty Grout ❑ Gravel
Ohipnlloring ❑Bentordto Slurry 0 pther(explaln under 7g)
I A'P"on ail: I7Recov
❑Aqulfor Recharge 7f.For each mtte�rlt/l�selected alrovy provide amount bf materiels used:
❑Arluire00
r Storage and Recovery' albil d Barwater mierrier
��e'`�1� `,�Q
❑Aquifer Test V/" —ty��
❑Slomtwaler DtahlageC �.d���/G
❑I3xpbninlcntal Technology ❑Subtidenc0 Control
Dacoblcrrnal(Cl
Loop) �Treoer Ire Frorlde t brief dtdvfptloo of the tbtndonIn I procedure:
00cotilctnlal &silo Coolin Return ❑Other I gin unda:7
(I,DRIc\rc11(s)abandoned:, ✓ ��� /'�nT� PdJ� / /Le
x5n.WC-11locatlon:
Feciuly/Ow �r Name Fsdtity IDw(Irsppuceble)
g,cartlnr,uen i byeleel e11.City,and Zlp
llaaihai'otCertitled Collhatorbr a Owner Delete
Comfy By tlg*,,g tW.fvrnr,I hni�y r"fify drat the wells)war(were)abandoned fit
Patcel Ideotllicadod No.(PIN) accolrlmres tibi(h 1Ja`NC,l 01C.0100 or IC.0200 Will Colutntdlon Standards
(ir el Acid,:
ci alb�nd:lonQlivtlp In deg�eei/rhlnalet/iecoads or decimal degrees: anal that a�P3'°f 1111r rrc 4r 0,2.r been provided to the well owner,
pf wait fluid,uad 111A g t�tuFBciebt) ,
rj 's-2Z 3 N _ �(� '� . 170
� 9,811e tlltgriial.orA'of nil well delallr:
o�O b / You mry utdae ti0c�t of 11iJe pogo to provide additional well site details or well
' abandonmlxli'diwis: You triay also aliach additional pages Unccessary.
MlT.,}0t+i lti r. B
bnt `adtiitfob 3lidein;ianiI k Mr,rirbfirdr pnef karrr'nq,pJy
-in,1Ye11 amt 108.Pvr` II:W' 1 •Submit ads form wiUlin 30 days of completion of well
!�!_ f8�` abandufteiil Io Ul'o'rUU6wing:
6b,Total iveli dep(b: R " ` D Dlvlslofi oflyaferRuources,informt(foa Processing Uull
(�) JUN O 3 202? 161�Mall Stryice Center,Rilelgb,NC 27.699.1617
`IDb,Borehole diameter:. �leC— In'addillon to sending Unc form In U1e addrw's In Iva
(in.) ,," Tii> above,61so`lil�iiilt:oiia copy;of tills form wltilln 30 days of completion of well
y��l,�,,l,,�,;enl ld.(ho followingt
=r+.water level below groUrirl iurface:, M1 ,0
Ie PRO
I1,
(n) Division 011Ylitir9ttnr rces;Underground Injection Control Fro
i63tw}Ii(iill l�arr'lce Center,Relelgb,NC 27699-1636 Brnm,
;•r.Quier cR1lal lthgtit(If lli arrh):
lho ad In addition to sending Olt rum,Io
M-�i�it}Yb�also submit one copy of Uila form wiUiln 30 days oC
Inner cealdg/tubing length(If knitwn)r whamcumpl tloti of Ed.nb and oninent to the county health department of Ule county
\vtla•c abnhdoned.
,4
_r_<5creanldn�Zti:',(1C:Iuiiiiyb)I�: "�"" p `
eras OW-30
' NOrih�siiillni b'ep"i,rtmeot bf�rlrbaareol Yad Nstunl Remi,ri,e:::rii..r.,_,._.,..�- ..

i
r r�uli�a �171J UPI�YIEIYT CURD
This roan can be used for single or.,nnIaplb weUe �Of�9(CfiffiI UK ONLY:
i
L NV ell Conlra l r IuCorwallonr 1
SVell Contrsclor Nalne(or well owner pereoaally sbmde 7L Number of We1U We g ilbandonedl
(� /� nlpiitillDahlr/heeptepsrly) For multiple Infection Ior non-gofer erOply lreldr ONLI n•Irh rhr eraser
v„j`✓�J-� eenirrverlor✓aborrdonmrn you cart subnrll one farm•
NC well Connaclor CerdlteaUon Number 76.Appro:dmale rolome o[eater remalalag neU(s):
N.W.' Poole Well & Pump Co. la (g )
Company Name FOR WATER SUPPLY WELLS any,
2.Well ConstructionPermit N: 7c.Type of disinfectant Distill
Vit all appllcab)e well prrrnfle(I.e.Cotmq,Starr,rrarlmree,rrr/rcHor�rr¢J(/brain
3.11'eli use(cbcckwell use): 7d•Amount of dlslafectalat used:
FIDAgrioufturnl
upply'Ve"' 7L Sea►ins maleNal:wed(check all that,rpply):
OMuniolpelfpubllc 11 Neat Cement Grout
nnal(I{eating/Cooling Supply) �Realdultiel Water 9u 1 rin a ❑Send Cement Grout O 13cnlonlle Cirips or Pcllcis
al/cOrnnletcIrd Supply(single) O Dry Clay
EIResldentlal Water Supply(sherul) 13 Concrete Oroul 0[rr1 anon O Drill Cuttings
Non-'Viler Supply Well: Specialty Grout ❑Gravel
OMonituring ❑Kivu ❑Bentonilo Sllury O Other(expialn under 7g)
Infection ell:
OAquffer Recharge If.For each atertal selected sI pror(de amonot bf materials used:
n' ❑Sdbil(y
OAgUlfer Storage and Recovery �O Aunty ater Remodlallan
Barrier �IU�RGi✓iv���,g�
❑Aquifer Test ❑5tormwaterDmimill
OExpbrinlental Technology OSubaldenee Control
OGeoWerrnal(Closal Loop) �Traecr 7g.Prmideeaa brief description of the abandonment procedare.,
Odcotircrnlel Ri,atin Coolln Rctum ❑Other lain unda.•7 y -,--� /�—A� ,�f� /��, �'=I
d.NatC 15'tII(S)abandOnCd: r {^c �� ZA10I J
3a.Nell lotallull. '/ �•_ B_ �
FealJtylOwnerNeme PeolUtyIDw(Ifsppacsble) 8•Certl
Phyrlcal Address,Clly, In ,Ip A!
/v �� ttMerr✓
-�1;yirjLLL-�� 8ldas. 'of CerttEbd W Conlnolm or Well Uxver �
ale
Couuly B1 llgrdn8lidt.fvrn4 I hrnDy eIII Ural the well(.)war(were)abandoned In
Palest Ids docadod No.(PIN) dccardrn elt lfllh'l.S.!`ky d 02C,0100 or 2C.0200 Well Cotutruction 5tandarda
ib.Lagludb.nd;tonaltride In de0er/1Wh11I U:econda or decimal degrees: and lhaf a
roPY ofUdr r>'cvrtilrar been provided to the well owner.
(IEwelflist),�ooelRl/Itirigliiiii:8elenl) .
9r site dlagrxm or reli detour:
N _ ��3� You mlry urd;tf3e� ac�c of lilts Page to provide addiUenel well site details or well—�' abandonment dt::ialls. You may also altach additional pages if necessary,
'drf6EM11q '
+relli()}V 111 )i'flr'r iri' ci1/i' 'tllNrl�a�n{lild° ":'fit f�l Ii bii,6erroM=iratrr'nprpfy
hhritrt,ytiJk eoh subklt ede form•
in,Well Wry: IOa,hL •Submit lids form Within 30 days of complellon of lvcll
abandafteril 16 ill'o'foililairI
` Total well depth: P F' r--1 Vr7 D
Dlvlalo6 oflVaferRerourca,information proces,lag Uull,
(f�) 1611 MAII Service Center,Ralelgh,NC 27.G99.1617
JUN 0 3 2Q2...9 . , �.
Uorpbole din mcicri. IOb,FoP LnlecNo__ it`N�t�teI jn,eddidon Iv sending the form to Ole addr>s In IOa
,Above,60"" tlii 11 Ofic copy;of tills form witirhr 30 days of completion of well
i06, �9�{awww went lo.IN following':
`ry•Water)cvel below grotlrid iurfabe:.
(R) DIvlslbn olilYiittrRdertie:40 rces,Underground Injection conlrul progrnm,
163fi ill
"..Outer cueing lehgtlr(If itrlUivd); ice Center,Raleigh,NC 27699-1636,
the ad etl addltfon to sending ale form to
! (� " Me
rb, ilea trubmlt one copy of ails form wiailn 30 days of
Inner cesldgltubing length(If itnuwa)r completion of woh nbandetlinenl to rho county health department of Ule cowrly
--_._��(ff) wha•c abandoned.
n_r 5crecn;len�tb',(If,kdbi�tijl•+: `�'
':`lug OW30
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