Wilson_Well Abandonment_20230825

fl'1 uL.i:. 3 A } O 'IYTRDCORD r
'ilea form can bo reed m
for elm le or• uItij 1'e well" F�"� mI Um ONLY:.
I.Well -on actor tnrurnnlion:
.WELL ABAriplINMENT DF,TAtT 9. • '
u •
Well enlracler flame(or well owner penvnally.bmdoning Ai11en hlrJherptoperty) 7a.Number of ells being abandoned:
For multi le ! talon or icfl crater rupply tre!!: ONES' u•tdr tie some
3o y� i f on�nverronrnbondanmreu you coast rubm it oar jornr.
\tl� l
NC Well oulrwetor Certlaeauon ttumt,er 7b.Approximate volume ofvrater remaining!n vrell(e): L L�(gal.)
N.W. Poole Well & Pump Co, 2023
AUG.2 FOR WATER SUPPLY Si'ELIS ONLY; •
Company N retc r t�7 U��
' rp `i-t►P/�. 7c Type of disinfectant ored /J
i _ �f7
2.Well Construction Permit li: AE�� �L ,�/
List all applicable well permdra(i.e.County,Miff,r oriame,leltrcttoa,etc)If blown of J
7d.Ameont disinfectant used; �/�?
3.Well use(Check well use):
.[water Supply'Well:
7e Sealing materials used(chick all that apply):
:i❑Awleollurnl ❑Mortal al/Publlc 0 Neat Cement Grout. ❑ Dcrdonite Chips or Pellets
❑Geothermal(I•feating/Cooling Supply) *ResIdmttial Water Supply I (single) 0 Sand Cement Grout
i❑Indusuinl/Conuncrclal ( � ) ❑Dry Clay
❑RatdmlUal Water Supply(shared) 0 Conacic Grout
0Drill Culungs
.❑Ins nllon
•
Non-Water Supply Well: 9peclally Grout ❑ Crave'
L7lvipniloring ❑Demlm
❑
illo Slurry Other(explain under 7g)
lnJecllon Ycll: ❑Itwov
11 I❑Aquifer Rcchaigo 7f,For each material selected abarq provide amount bf materials used:
17Ayulfer Storage and Recovery' ❑Sa Ilnhdy gamier intlon e,
I DAquifcr'1'csl ❑SlormvaterDrainage '
DExpbrintenlal Technology ❑Subsidence Control
C1Gealhennnl(Closed Loop) ❑17nacr 7 ,Provide a brief description'of the abandonment procedure:
I.OGcothennal death). Cooling Return) ❑Other(oxplain undcr7a)
L
r� •
Dale will(s)abandoned:_ ? '" '
p .
,,
3a.Well location: °
Pacillty)on•ner Nnme
• Fee:Illy ID (Ifspph'oable) • 8•Certlfic
1'hyelcal Addrese,•Clly,and Zip ��9f'[� -+s
7S �� �
^_�/4 �r A 8lanrlum of CatiJled We entrust r or Well On nee Dale
`'i01y �•••.,�9 'By signing A�•for I here d•ergUy that the well(s)Iva.\(wore)abandoned in
PavelldeldifcedortTin.(PIN) accordu>ir;,With liANCAC01C.0100or1C.0100 Well Construction Standards
b.Latitude andlongltude In degreesmlaulei/"econd'or decimal degrees: and that a copy edttr re cordhas,.been prodded to the well otrner.
NC well ileld,'ond Iati bap li iiii&clebi)
s ' n L�. 9.Site diagram ar addtifoual Trill delalls:
�Y I N , 9 O l You mgy is tlfo baeac of this pa'go•to provido additional well site details or well
W abandoruneiddbialla. 1'ou may also attach additional pages if necessary,
•
riridel'll$11 �t;.
rrlla bN 1'f,lli'lli)rt�liii c6111hi tll aislii'd.T ig,vk i.:1.i f Drir -iratir•ngrply
11'eIIIDN: 10",Ivor •Subririt this form within 30 days of completion of well
abandodtnehllblhofollowing: i
ia. h .
b+'1'olal Well depth: •• • Dlvlsloll ot.WaterReaiourem,Information Proceeslug Uult,
(fl.) 1617 Mall Service Center,Raleigh,NC 27699.1617
:•Borehole diameter:. 10b For illegal b�° ' r •Imaddltlors to sending Mc Point to Mc address In 10a
(In,) •,about,idao'�(Il..ifliCiihb dopy of tills'form tvlUtin 30 days of completion of well
fs'''... . abandutuilent id.U10 following:
'c'•llinlerleti'el bcloii•grotlrili eilrfaee:• .: (IL) Division ofiWiteritesourcesl Underground Injection Control Program,
•
1636 Mittgen1ce Center,Raleigh,NC 27699-1636
e•Outer casing lengthi((f ltutlivn); ��
• (ft.) — • l0c
10 .ad : In addition to sending the form to
canner cnslrietubing length(Il lcatiwn): �....e eomplell orc�b b�aonm not ltto thone e worry Ipy f Ilh departme this form nttn 30 days of
of the county
---- (fG) where abandoned.
Sctecltl..IdtiiiG(il;l giiiiijl;+. I
• ( )
••.qi!I OW-3U
• ' Notitl•tl Mill"bepiutlaentuffnrlrnnmontY04au...,_ .: .. .... .