Durham_Well Abandonment_20240423

WELL ABANDONMENT RECORD For Imerual Use ONLY:
i
I;11'c Ontracfor Information: WELL ABANDONMENT DE'CAILS
. 7a.For GcoprobclllPT or Closedt-Loop Geothermal Wells having the same
Wd onlraclor Nam or wall owner personally abm,donius well an Iris/her properly) well construction/depth,only 1 GO-
7 is needed. Indicate TOTAL NUMBER of
w ells abancloncd: I
.... !
�— 7b.Approxinulle vol une of%valet rcnwining in wcll(s):� (gab)
NC Wall Conlr,cloy Ccrlifiealion Number
N.W. Poole Well & PUMP CO. FOR WATER SUPPLY WELLS ONLY:
Colllpally Nal1(C HTH
��/� 7c.'I'ypcafdisinfectantused:
2.11`ell Constt•uction Permit#: t/�o f�!9'v4�/�01
Liu all applicable hall cnn.cMnclio+p,trmilr(i.e.UIC.Cormp;S1v1e,MINIance,etc.)ijkaalrnijkuol ll 1/2 1b.
7d.Amount of disinfectant used:
3.Well use(checic\vell Ilse):
Wmcr Supply wall: 7c.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neal Cement Grout *&-13cnlonile Chips or Pellets
0Gcothermal(I•leating/Cooling Supply) . esidcnlial Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Conupercial ,❑`Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation i I S eciall Grout
Non-11'atcr Supply Well: ) ❑ Gravel
❑Monitoring ❑Recovery ❑ 13cnlonitc Slurry ❑ Other(explain under 7g)
lujection 11`cll: 7f.For coch material selected above,provide.:unount of rllater•ials used;
❑Aquifer Recharge ❑Groundwater Rcmcdialion
❑Aquifer Sloragc and Recovery ❑Salinity B.ttarzr'icr^ '��
❑Aquifer l est ❑Storm\valrr'OYa;'aase
OCxperintenlal•Technology ❑Subsidence CoK�oR 2, %� 1'GZ� 7. r
OGcolhcrmal(Closed Loop) ❑Tracer t- t'ovide:r brief descripn tio oflthe abandonment procedure:
❑Geothermal(I•[caling/Cooli jig Reun'n) 00ther(cslllgirt•4r1tYler<7�)',;... ; ^!� �'
{.Bate well(s)abandoned: -
�'
$a,11'CIl IUCaf10t1: � /149
facility/OtvncrNamc f��C FacilityI F(ifamAiwble) 8.Certiflcalilill: _04A ib✓ �
Physical A ass,City,ant!"Lip Pj ® Sigl alurc of Ccl • cd 1 cl Contractor or Wcll Owncr Date
Couuq. ! Dr sighing this(al•hr. l hereLv serif,Mal the wel(A) was (irere) aboncloned in
Parcel Identification No.(PIN) accordance u•ilh 14 AICAC 02C.0I00 or 2C.0200)Nell Construction Sichrr(c+rc(s
51).Latitude and longitude ill degreeshninules/seconds or decimal degrees: and that a col))-a(lhis record hcisGeen provided io the a-ell owner.
Orwell field,one lal/long is suf6cicnl)
re, O� Q !,, 9.Site diaf!r:un or atltlili0nal well details:
"' V 3� w 96 ?j��� 1V You may use the back of this page to provide additional well site dclnils or 1yell
abandonment details. YOUmay also allaclt additional pages if necessary.
CONSTRUCTION DETAILS OF 4VELL(S)BEING ABANDONED
Inac/rlrell conctrrlcnwlrecord(s)lfavata6le. l'orvnulripla it jeclio+arnan-water srrppftnrellc 5Ui311.11TTAL INSTRUCTIONS
UA'f.1'with the sane corrstracliarilahohdorhhe++1,you col suhnrlt one form.
10a. For All Wells: Submit this lornt within 30 clays of completion of well
,61.Well ID/I: abandonment to the following:
Division of 11`atcr Resources,Information Processing Unit,
6b.Total well depill: (ft.) 1017 N9ail Service Center,I1,11cigh,NC 27699-1617
lob. For lujection Wells: In addition to sending the form to the address in IOa
Gc.Borehole diameter: (ill•) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: q/j (ft.) Division orwater Resources,Underground Injection Control Program,
1636 A•lail Service Cell
Cecr,Ralcigh,NC 27699-1636
Gc.Outer casing Icngth(if Ictlown): (ft.) loc.For Walcl'Sunnly&Iniection wells: In addition to sending the form to the
addrcss(es)above,also submit one ebpy of this form within 30 days of completion
«.., of well abandonment to the counity!health dcparuncnt of the county where
GL Inner casing/tubing Icngth(if Icno\vn): (ft.) abandoned.
Gg.Screen Icnblb(iflulowll): (ft.)
r
1.01-111 G W-30 Norlh Carolina Deparunem of L•nvironnlonlal Quality-Division of Water Resources Revised 2-22-2016