Nash_Well Abandonment_20220817

This form can be used for single or•mriltIpllewept �� 111 U�iOI1LY.
t•well nlreclor Inronontlon: •
�i en ontnelo Nw,e' o eIt owner en 7L Number of ireJls bei g!ebsndonedl
V om1(y ebmdonlnQ hell Ion WAer proprrty), For
✓ mvinple rcllon of
non-water r�pconnrvero✓obodm ly xrpt ONLk
}rou eon tv6mff one form, n'rrh da aanie
1tC 1Vell Contmelor CerttOcadou Number �. r s
�` -. �R•� 7b.Approximrate-volume o[nater remaining In xell(a): AI•
N.W. Poole Weli & Pump i tl )
Conrpnny Name CO• FOR WATER SUPPLX WE LLS UNLY:
2.Well Construction.Permit H: i" ' " t Ur:13 7e Type ordisinfeetent oced:
Uaf all oppifcabfr H•rlt prrmlfs r, ^_.__
n• Cormq:sra'ir,►rcrlmre..lNrcaoM1 rrcJ bto,rrs Q
3."'ell use(check n ell❑ae): 7d.Amovnl of dLlnfaVot used; �!
11'elin Sulrply 1Ye11:
C1Agrieullurnl %Stsling msleH:ds used(check■U thst s r I
DmunlolpdgPubllo 0 Neal Cement Grout. ply),
OGcolhc mill(t-I /CoolhigSupply) XesldenUel Water Su 1 sin e ❑Send Cement Grout 13 l3cntonlle Clrips or pellets
lowdustrilid/Commerelft] - Supply(single) 0 thy City
olrsi orlon ❑ResidardsiWetcr Supply(shased) l7 Concrete Grout
I7 Drill Collings
Non-Sl'ster Supply lycll: 'Irwpacially Grout O Gtavcl
ohtonilorin8 C113entanho slurry ,
InJcctlon Well: []]teeny0 CUltr(explain under 7g)
DAqutrcrRechargo 7L For etch msleNsl selecled sbi pruHde srnount of ma terials used:
(JAqulrer Storage end Recoveryl7Groundwaler RemedlellOn
❑Salbil(y)3aMer I�Ib+�{!f ��
OAquifcr Test
I Mxperimenlal Technology
DSlorm water Dralruge
❑Subaldcnco Control
OGcodltnnal(Closed hoop) []Tracer .Prorlde a btie[descripltao of the abandonment procedure:
OOcoUlcmtel (satin Coolln Return ❑Other Ialn undcr.•7
09
'.Unle witIl(s)abandoned: S
on. U IotaUuu: ��(�,d✓7y� �f L.c - N"'—��€-r
Fec:liy O,, Neme'
Peollltymi"Or��pUoeble 8 CerUticsUoul
Physical Addreea CII
yr and Zip
ed Wdll ontnotor or Weli Omer�^ ale
County by lfgrdng lhlt. W.
1 hr4 ceri(fy Olaf the tvell(s)tear(were)abandoned/n
pascalldetdl6tallodNo•(ppl) cind ddnctglfh%1,�'jtck01C.0100or1C.0100)YtACorulnldionSlondm�da
b.IraUtude�ud;lonyli la In'rlegreei/svlet/iecondi or deelmal dtgrea; °nd hat a °
tlrn ell'flthl,onGe]IeVliing lqi IiiFiielei�t} In' f fhfr recvrt>•has been provlded to the Nell owner,
��• 1 7 9,Bile dlagrstm oraddltiocrtl rell'detsllr:
IV 7• 1(101D You mkY!l, ff'`,ba6)r of elite page to provldo additional well site details or Nell
�r abandonment details;You may also atteclt addlUvnal pages ltncassary.
if J)r''f1r?` iis' cbNt cr)` obel►ddsirneil, k wbmlr enrastr nyrply IONS
a,)Yc11 IbH: aba,anddinOhl u ft It•�y'llis Submit Uus fuml within 30 days of completion of}veil
to rho follawing;
'°h 'fotal heli deltlh; blvitlor't oflYsterltesourcer,Igfvrnrallva Prvcculug Urrll,
(fL) 1617 Mall Sirticc Center,Raleigh,NC27699-1617
ir..Ilorehole din nlcicrr. lob,Fot�Ie
(t°) above,dlso`sUdiiilt py Dill� fornt wlUt�htg30s days of completion
hl Iva
abandonment ltl.lho tollowing.l pl lion of well
'n•1V1Iler level btId ii iilrfsoer.
((L) Dlvision.uf:WklirAcsou�cts Underground Injection Control Frogrnm,
1 Outer cailug lehgth(If ktlU}vh)r �4ri1flgerrlce Center,Itslelgh,NC 27699-1636
101�e• ! . ,
the ad ' ' 1tt addition to sending ale rem,to
�.,. �`nbt}vi;,-•deo tlubuilt ono co
Inner casing/tublug)ength(If lenusyn)r compicilon or 1vo11:abestdotdnenl la the courPy t r Od PePerm -fill 30 days or
where abandoned. department of ale rowdy,
_ 5creett`.Idti�tfi,(Il`aiytiied)1'+:' `""' �
Omrl ONY•30
' Nort}t(tivllnibtpiulraeolorFhrlrn�..,..,._t.i_.. ._

711s fnnmcen be used for single or mrilUplb weUe dIUIN�UN ONLY,
!.\1'rl nlrnclor Inrortneilool
oil t 1 cl N e(o/well owner en 7s,Number o[Weils being abtndanedr
p neat(yfbandaaingilillbuhldbttprvpftty) For multlplr f ertlan dr
w N di
t t snllr ONLY
eanrrrvenoe/abott*nmr ' W�Py v11h the jams n{yet',eon+vbmtf one jortri.
14C 1Ve l ConUeclsx CettlOcaUao Number
7b.Approzlmtle rolamek f,Wtter remalning In WeU(a): al,
N.W. Poole Well 8� Pump Co. (I )
Colupnny Nsmc '7 2� FUR WAT$R 8U1'PLYiWEI.I S ONLYt
2.1VeU ConalrncUon,1?ertnit N: 1 URa 7c Type o[dbinrwint nscdr
Uet all apprteaGlr r%)
prrmtra fl.r.Cca 9V
• . �.o.1Cf,I/irfenan,fICJ 1/Irlalrn
3.}yell use(ebeck well use): 7d•Amount of dlslafeettnt used:
11'a1111 cr Supply li'eIh
CJAgrlcullurnl 7e Setling mtteritls rued(cheek■ll(Let apply);
IJGcudlennal(I-f,aling/Coolbl supply) OMunlolpal/publlo ❑Neat Cement Grout.
B pP y) kesldalUal Water supply do a ❑Send Cement proof 0 Bcntafille Chips or Ycilc[s
❑Wdustrial/Cohn clill PP Y( !� ) ❑»r}Clay
esldentlel Wader Supply(stirred) 11 Concrete Grout
OLti orlon O Drill Cuttings
Non=wxler Supply Well! •Speclalty Grout
OlWonlloring 13 ❑ Gravel
1n)ecllon well: Meetlyl3rntonlla slurry 0 Odler(-plaln Under 7g)
❑AquifcrRechargo 7t.For etch mtieNtl selected tborel prodile trnaunt bf mtlerlels used:
C)Aqulfcr8torago and Recove f7GroundwslerI�emedlallon
Recovery ❑Salted(yBuder
OAquifer•rest
❑SlarmwalcrDrahlagc
I t7CxperinlcnW Tcolmology
Ooeolhcrmnl(Clos6d Loop) []Trader Control
71.Prvrfde a brief deauiplinn of the tbsndonmcot procedure;
`[7(IcoU,cmtai icalin Coolln Rcltitn ❑Other lainundcr7 �` ,
l
51.Dale li'tll(3)abandoned:
3 IN,eUlocliQuul
6,illy%Orvner Ni 7_71 y IDw(Itrppgofbl
.., c �+.� t1.�rllfleltionl
Pllydcel Address,Clly,and ,1 V
_81`nstiai of Ce 0td fill Cont"alor or Well Owner
Dele
Court Dy Ngrdng Ihl1. �y
Pa�cel ldcatldaadod Na.(PW) dccorddrtct l4fflt l/t~,{C 01Ce y Ul at or tCc 0101 0)W aJ OPI rd)abandoned In
a 0b.Latitude�tnd:l6n�lluite Jp degreci/ridhnht/tetonds or detimti dtgreel; and that a Cvrutntdfon Standard)
(lrnell t1eld,and lel/Iting It tdf8ofetlt) CW afOttr Mordhar been proiided to the well alrner.
N ,.�qI_ 9,She tlltgrltm or addluol"I nett del,ills:
I lRQ You miry itrdabe b`acic of llilc page to provido additional well site.details or well
ebandonmwt dclajla: 1'w may also eliaclt additional pages Unecessa,y.
Arld�e�' ," � '•`p '
n aOi fllU
1+{ i'lir`i M clnir 'erlthC)c�'a'liddlttri..- 9 �b Br n°n•lraffr'ngryly .
t 3 cdh ri hrrllf Drirjofm,
Wth IbN; log,For` n:I .Submit this rvrn, willtin 3o days of completion of ivcll
abendodtnem(Io Iho folli)whlg?
"b,'folal ive11 ileptb; i blvblo8 ofWtter;Resourcu,Information processing U1111,
(f4) 1617]Neill Service Center,Raleigh,NC Z1699•I6I7
` Borehole diameter,. lob,fVplij[Uo r In;edd10911 to acridfng Ole Conn to ti,o adders In I0a
(I°) ebavdoAmentiB.Ujo ull �vpy of tills forrtl wilhln 30 days of completion of sell
Abandonment ld ifio following:
=d.Water level before grotlri�lilrfteet.
([L) Dlvislbn oMVXffrRetourcta,Underground Injection Control program,
1 �8 lle l rrce Center,UtIgh,NC 27699-1636
�•Outer caeing lehg;h(j[kilOSvh)t
• ((I,) Inc. ..l�Inlleotivti W tl.
lbo.ed ' ' °.ab ---- In addition to sending Ole form to
+� alI subtnit an
copy oC Uds form wiUdn 30 days of
Inner casing/lubing lengtl!(If llnbwn)r complell6n of ivoh.abendoninent;Io the county hcalUt de
��(tL) wllac ebandurned. department of Ole cowrty
Omlw ONY•30
' Nortb•Gdvlln�bep'ittnaaMb[Psrlrr,�,.,..,..,,,".. ._ j