Granville_Well Abandonment_20230127

71ti5 funs can be used fbr shtgle or mnitlpl'e weUr wwI UW any:
r.\Yell Con velar Inrorwallunt
XLA
uMr
Well• onlraeior Name or well owett enotsally abmdoaluQirjUDnhirll,trproprrty) For Nmul plsnf j?Vaellontlnorabn�allo, r�PIY +rrllr ONL) „rrh (he as
evnrrrvcrfon/abondonmr
n4 you tort submrr onr form.
NC el1C nl'"Or tttIlcxUueNumber 7b.ApproxlmateTuIumeofaalerremaininglnneU(s): al.
N.W. Poole Well Pump Co. (g )
Cotopnny Nsute FUIt WATER SUPPLY SPELLS ONLY:
2.WeU ConrtrucUon Permit N: 7c.TyTn of dlalnfrttanf tired,
Lr,r all nppllcoblr>•rll prrndu Couno,Srorr,r'arforrcr,ll/rctloq rlcJ(!lnvxn
3.11'01 list(ch eck n•eli use): 7d•Ameenl of dlaln4cltnt vied:
Watt,-Supply Well:
I7Agrlcullttrnl 7e-Sealing malerialt sued(check rill that apply):
t7Munfolpal/Publlo 11 Neal Cement Oro -
CIOcoU,cnnal(1 iealing/Coollrrg Supply) esldenUal Weler Supply(single) Send Ctmrenl Orou t` �'�`-0 -i 1�� "Ile Chips or 1 ellcts
Cludustrinl/Comnrcrcltd ❑Resldm9al WtlrrSupply Supply( Ph)Cley
Olni alloll ❑ Concrete Oroul 2 brill Cul&gs
Non-Water SupplySvcll: wSpecl►ItyOrout JAN 7 20
O t3tavel
fJMoniluring ❑Ilrnlmdle Slus-ilr tf iri;iOrl Vim' ��r�(eii(explaln under 7g)
1u)ct(lon Svell: ❑Rmov DV/0V30G
ClAqufrer Recharge 7L F r each fatal telttlyd abv..,nr,"4de amount bf w-1—
❑UrvundwalerRemedlelotl 9 ' tits used:
ClAdulfcr 5lorage end Recovery I75allnl( Barter
❑Aquifer'fest
❑StarrltwatcrT?rahugo � �f) ..9
1[3lszperirnc1lW Tcolutology .
USubsldcucc Control
C]00o'llennal(Clos&d Loop) C3Tracer 7g•Pro tide a brief dtacriplion of the abandonment procedure:
174calhcrn181 catln Cuolln RDIU ll []Other Idn undcr..7
Unlc Irell(s)abaudoued; "' '�v✓�'� `� �/^
a
6n.WcU laealiuu;
t scihlylO,rner Namo FsolUty IDS(Ifrppperblr)
8, Zdid
Pby'rlcel Addrerr,Clty,and Zlp
816nrnolm or 4/e11 htrner �P�.6 / � Dale"
Couuty QY rlgnin8 lhlt.jorm,I htrrD ctr(((y Mat the R l(s)war (were)abandoned In
Patcel ldendQcadon No.(PIN) accorlidnct itith 1J,�NC�lC 01C,0/00 or 1C.0100 Will Corufnldlon Standmds
tb.Ladtudt:and:IonQltuile Id degrcei/mlontts/seeondt or decimal dtgreer; and litaia ropy°jlhlJ rtcartfhcu bear provided to Ule r:'ell onnrr.
(+rnelfffeld,�onelsVlbltg1i,.i lfeleot) ,
?".D 55 3 211 9,Site diagram or a d)uaoai,rell dtt,ru,:
N =� (pp G--1-2 You may tltd,tUt . T of US page to prnvido addiliollal well silo details or nvell
f
SY abandonment det;illa: you may also attach additional pages Urlecessmy.
.'4rfedhY4i l ,c,
till vN #rid )r lh�' M' cbnf `rrl tir►lo'baf1;lerihirnl,atr eft avbmitb nr fotm-iratir nq,ply Ka"Muks
Wen IDN: 10t,Pvr` ii:W•lli: •5ubmil this form violin 3U days of colnplcUon Uf well
abandotiineril to 01,6 following:
b,Tufal ri•ell depth; r D1vLloti oflysferRuourcei,Inforinatfun Pructrrfug Unit,
(fL) 16i71?irtll Sen•Ice Center,Raleigh,NC 27699.1617
10b,$➢
Ilorcholc diameter; I(gr In addition to srnding Use form Iv Ulo addrus In I03
(In•) above,sleo`'�ul1ii11t oho copy of 1.1113 fom) whllbl 30 days of complcllon of well
abandontuent to tlfc following;
:ri.Water laud bclrin•gradnil iilrface.. . ' •
(ft.) blvlrlon ol:SYtilirlieiourcta,Underground Injection Control Program,
1 Mill gtrvlee Center,Raleigh,NC 27G99-1G3G
r.. Cuter cntlug leggtlt(IC 1tnUisn):
IO c,
lho ad EI .1�1d4 to
tf, aibo submit one copyboC Udaluformn to swiUdrg 30 days Ulc of
Inner easing/itibing length(If kndrvn)I " completloti of 1vc11�abandonlnnit to Ule county health department of Ule cmudy
�yt,) wilcm Abandoned,
_«Serccu I�n�lb(Ifiuiiiivh)i i. --�
orm aw•so
' NOri}i Carotins DeplttmeM bf Eotlrbumeni snd tl.i..l n.._:.. _• , .

f uLw:ttll7UUl� 'RECORD LW":A1'3
f
71i1e fume Carl be used Ikrr aingle ar mdltiple zvellr u0'ONLY,
1.Well ua Yaclur lurormallont
/ - .•�
Well&ntradui None for well owott penooal(y r�d . 7a,Number of Well,being AbAndonedi
�sU�ahl►berptopttty) For multlpir !rtl¢llon or non•iraler rvppiy irrllr DNL1 ulrh the ramr
~ ronrr vcrrodobondonmrn{yvtl can submit oar form.
rlC Well Conu-aolar CetlIa"Uon Numb, 7b.Approximate yolome of water remalning In nell(s): el.
N.W. Poole Well & Pump Co. lg )
Coropnn}'TJame FORSYATBR aUFFLYIYELI,g pNL�';
2.Well Construction Permit ff: 7t Type of dlslafec(aot weds
U41 all oppllcoblr N•rll prrmlrs O.E.Cormq"Srorr,l'crfamr,lrlRcNon,era)((,y,m„
3.11'cil use(0cck well use); 7d•Amount of Unfeclant used;
Water Supply}yell;
OAgrlculliunl 7L Scaling malerlals Used(check all that apPly):
0(icoulcrinal0tcat1nglCoolin Supply) �1MuniolpeUl'ttbl(o ❑Neat Cement G _
�', --• -� �Brnlonhc Chips or Pellets
g PP Y) �esldentlal Willer Supply(tingle) )�sqand Cement urtu ' ' ---��,�❑tudustrial/Cornrnn err lnl ❑Resldeauti Willer supply 0 onaele grout .. o Lz+ l�ryit-,)Clay
PP Y(shared) �'• � s
Cl[ni anon CI DHU Cuttings
Non-Walcr Supply 1yeli! O SPeclalty Grout JA N 2 7 202,b utnvcl
dMon(luring ❑9entmdie Slutty ❑ Other(explain under 7g)
lnJccuun Well! ❑Recov It1�ir�3;F � , r:.:
7f.For aeh maternal uleef�°d'eti'q l.ln.l
C1Aqulfcr Recharge ❑Groundwater Xemodldtlon f de amoun(bf ma(crlels used;
ClAyulfcr Storage and Recovery ❑5allnti Barrie
DAquifcr'Cest Y
❑Slormwalcr Dralnag0WMA&
j
1Ji?xperbncillal Tcclmulogy
❑Subsldcnco Control
000 Ulcnnal(Closal 1 vop) ❑Tracer 7 roride a brief desviptloo of the abandonment procedure
I,OtJcathcrntal 3calln Coolln Rclunl ❑Oihor lain tmder.q /?
''•JM0 well(s)ALAndoned: r/ z ZAl�
11'clllocalivn; /�'�T�/' iAffl
IaciUlylDnner Neme
FsollltyIDii(((,tr,ppcsbls) 8.Cerilifauonn
pbyslc l Address,Chy;and Zip
f / 81sos o[CtttiDed WeU onlna C or WeU�mner
/ &A /t/, j5 De1e
�ouuny By tigrrfng fhU forin,1 herr�cerfVY Olaf flit 11e1IN wan(were)abandoned lit
Parcel IdeaillliadvdNa(pW) dccorddnct llh 1J,('NC,lG�lea
( L!rT 01C.0100 or1C.0100!Yell Corurnlcilon Standards
anlhrdeandaonQlludeIndegreei/ml6nhec Mods arulrhar'acvpy ofrlittrecuriihasbeers lrndf OeIJ,one IaVlo,ij;li}iiFltelei,t) � prartded to the well owner.
9,Silt dlagntm;or a dfllonAl aep delaUr:
N J d �� 13C�0 You mky t[tdafie bac of Mils pago to provido addilimnal tivcll site details or wdl
abandonment deialls: Xou trlay also attach addlllond pages if rlecessaly,
t
.4riech'1ll+l r
�uf aN .'; S
G�i rl)i rlli@ Oh Or rran-rralrr ngply' Cfttlrila6al{�drihirnl,ji3li cdrr rubriill one fora,.
'i�:Well IDtI: 101,Fer':&LF I -Submit Uds furor wi0un 30 days of completion of hell
abendm munl to Ulo following:
b '.Cv(Al Well depth; DlvDlon 00YAierIlerourcu,Information prvcculug Uull,
(ff) 1617'Al ill Serlicc Center,rialclgh,NC 27699.1617
r•Jorehole dlarnctcr: 10b' �IecU- o�'�Vel=;t It(eddlllvn Iv wilding the fvnn to Ulo addrus In IUa
(In,) above,tdso�UUii(ll'bho t:opy of tills form widlbl 30 days of completion of well
ebandolmlent ltl 016 following:
fti-Water levelbelun•grounilli,rface:.
(rt.) Dlvls(on of;'Ylilfrlietourcea,Underground Ljecdun 1 Control Progrnul,
7iS J�errlee Cenicr,ILuelgb,NC 27699-1636
�.Outer eAtln�lehgib Or ktluirb);
(p,) IOr,
tbo ad : bi addition to sending ilia Come to
. . alto aubmlt Inner casing ono WPy of Mils form willdn 30 days of
/fubing length(Itkndwn)n `��' eompletloti of IQl�abandoninrnt Nrilmo abandoned, to Une county health depat{rrtcnl of u,e cow,ly
-t,Screen idi�lh(IlitriuivrU)t :": ,•—^
nval 01Y 3tl
' NDtlbGaiollnnbeptrlmeMbtEorlrUament►adr1.,...,a_._:.