Wake_Well Abandonment_ (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well ntractur Information: WELL ABANDONMENT DETAtt
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Wolf Contractor Name Or well owner pmaonany abandoning wall on his/hot property) well construction/depth,only I GW 130 is needed. Indicate TOTAL NUMBER of
r J_ wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
N.W. Poole Well and Pump Company FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
2.Well Construction Permit#:
C W-0""1-2021 lc.Type of disinfectant used:
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)if known 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Weft:' 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) �tesidential Water Supply(single) d Sand Cement Grout ❑Dry Clay
❑IndustriaUCommereial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.Fo each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �
❑Aquifer Storage and Recovery ❑Salinity Barriei
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7 vide a brief deee���cccription of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer „�
❑Geothermal eatin Cooling Return ❑Other(explain under 7 )
4.Date well(s)abandoned:
5a.Well location:
Jose Orlando Orell Funes
Facility/Owner Name Facility ID#(if applicable) S• rtification:
2513 Piney Plains Road, Cary NC 27518 J
Ph sical Address,City,and Zip Si of C ContNctor or Well Owner ate
V�lake ertiS Well
By signing this form,I hereby certify that the weli(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field one lat/loag is sufficient) 9.Site diagram or additional well details:
35.746575 N -78.752754 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 WE • .t )BEING ABANDONED SU$MITTAL 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 Welts: Submit this form within 30 days of completion of well
6a.Well ID#s ent to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depths (R) J U N 0 3 2022 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For julectjon Wells: In addition'to sending the form to the address in 10a
6c.Borehole diameter. (ln.) ,;+ ','i I`bbve also submit one copy of this form within 30 days of completion of well
Pt 3-CieAUMWto the following:
6d.Water level below ground surface: " (fG) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
R
6e.Outer casing length(if known): (R-) 10c.For Water Supply&Iniectiop 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
6L Inner easing/tubing length Of Imow4): —(it) abandoned.
6 .Screen length ��—g gth(if known): (ft.)
Form GW 30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016