Lenoir_Well Abandonment_20241001

. r•r.IL`,x.Jl., 1U AINJJ jINMil lYr RECORD
• For rntcrunl Uac ONLI';
I,Well COrutr,etor Iufornialinn: � /��/ �T�,�y/ WELL ABANDONMENT DETAILS
,< `/��^��e '/ ielpi'a//! _ 7;1.For Gcoprnbc/UFT or Closed-[.Oar,Gen \wells hnD theut
1Vc11 ConlrnelerNnn,e(or well o,vner ursonoll nbnudouu, ll on l,ialbor o,crr• well construction/depth,only I G/I_3O is needed.IllcrtnaI Indicate l'O'1'AI-vtg NU�4saDGeR of
•wells nbmJoncJ:3/(T2J - /
._ gad)
NC Wdl CoutrnclorCort;fcntioo Number 71L r\pprnximale volume of wafer.
In Ivell(5): ..__,_""
N.W. Poole Well & Pump Co. FOR\VATER SUPPLY WELLS ONLY:
Company Plante f-ITH
7c.Type of disinfccInnt used;_
2.1Vell Construction Permit II: 1/2 lb.
l.i.a all,spp/icnhle well cn,ulrnelia,perntll.c(i.e. WC,Cnrm(V.Srnta, I'arinnco,ere.)ijknmru
7d.Amount of disinfectant used:
3.Well use(cheek well use): •
w:,t,c,•Supply Well: 7c.Sealing materials used(cheek all that apply):
Ongricultursl DiVtunicipnl/Public 0 Neat Cement Grout : '► 13c11(01111c Chips or Pellets
Ctccoutcrin I(Ilcnting/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout ,• 1.-.
• L.d Dry Cloy
❑Industrial/Commercial DResidential Water Supply(shared) 0 Concrete Grout OCTT / 2024 0 Drill Cuttings
Olrrigaliolt
Not-Water Supply Well: 0Specials)'Grout ��',:&.i:,•; ,.., 0 Gravel
ram:-.
7vioniloriltg 0 13cntonitc Slurry % Other(explain under 7g)
°Recovery .c (r?S -0
Injection Well:
7f.For end:materiel selected above,provide amount of materials used;
OAquil'cr Recharge ❑Groundtyetcr Rcmcdialiou '6. /R�
❑Aquifer Storage and Recovery DSolinity 13nrricr d'�'J�D ��� H� � /�""'
OAquifer Test OSlonnwater Drainage
Olixperimental Technology OSubsidence Control
❑Geolhcrntnl(Closed Loot 7g. 'rovide n brief description of the aban<lonmenl procedure:
I) C171'accr
, °Geothermal(Fleming/Cooling Return) Dotter(explain under 7g) Ur' 0r ,ref✓tr:6- /,�j� ' P_' /,
4. D;Uc wells);ab;uuluncd: �/J J /j',eI.1/p `�„ �/firg pf�2`m!V_
5a,Well location: L
6
Facility/O„•ncr Nema
fncilil)rID/I(if applicable)p ca blc) 8.Certification:
aliml:....4 /�,
iii
� ' o 6 - / �
ram .Physical Address,Cuy,and/IpAitJ / S,cnnty of-Certified W „ .ntrnclor or Well Ovtcr Me
CountyQ)'sighing (Iris fount. 1 hereby coif) Ewa the trell(s) was (were) alnudorwcl in Parcel Idenliftealion No.(PIN) accordnneo,rift/S.1 r\tC:IC 02C.0100 or 2C.0200 Well Construction Standards
Sh.L;r tit UdC and longitude in degrees/minutes/seconds or dccinrnl degrees:
cud that a cop of thiS recOrrllills been provided to the well curlier.
Witch'field,nee Iaulona is sufficient)
36* 7-85 X2 9.Site diagram nr eddilinnnl well derail,::
ClU J N — -I 1 ,SsC c-i�i�p2 \\i You may use the beck of this pint. to provide additional well she details of Well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING A13ANDONL'-D
ttachnee//consrn,clionrecurrl(s)Ifavailable. Poi-multiple injection or•nnn-u•ntcrsupplvwells $UI3\II'ff,\L1\'SI'RUCI'fONS
(IA'!.)'with the.came cnnrrrr+cr/ore'abonrinwuen(,you can submit one Atm.
1011. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID//: abandonment to time following:
/6? ) Division or Water Resources, Information Processing Unil,
6b.Total well depth: (It,) 1617 Mail Service Cenlcr,Itnlcigb,NC 27699-1617
10h. For Infection Welts: in addition to sending the form to the address in 10a
G . Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to die following:
�r
6d.Water level below ground surface: J (ft.) Division ofW;IICr RCs)Urces,Underground Injection Cnnh'ol Prngrn in,
1636 Mail Service Center,Raleigh,NC 27699-1636
Gc.Outer casing length(if known): C,W (ft.) .IOe.For Water Supply& In'colon\Veils: In nddition to sendingthe fort to the
address(es)above,also submit one copy of this form within 30 days oFcompletion
of well abandonment to the county health dcpurlmcnl of the county where
61. lunar casing/tubing length(if(mown): ^.---, (ft.) abandoned.
Gg.Scrccn length(if known); (II.)
' Donn GW-30 North Carolina Dcpmvueot of Environmental Quality-Division of Wiler Resources
Revised___2-22-n_OlG

YYLLL A.b.A.I.NDUINIVIENT RECORD
• Por Internal Use ONLY:
I.Well Coillr ctorrr Information: �'�/,' / � WELL,ABANDONMENT DETAILS
iei ��.Ie'���'�r ileifiV/7 7 a.For Geoprobc/DFT or Closed-Loop Geothermal Wells having the sae
Wall Conlraelor Um owner
wall o „erlursonelly attend li won on histl+ar property) well construction/depth,only I Gly-30 is needed. Indicate TOTAL NUMBERm of
e�G�S wolfs nbondoned: /
NC Well Co/ulradorCorlifioolion N b.r 7b.Approximate voUune of wnler remaining in wcll(s):,__, (gal.)
N.W. Poole Well & Pump Co. FOIL 1VATE12 SUPPLY WELLS ONLY:
Company Nang • HTH
7c.Type of disinfectant used:
2.Well Construction Permit II:
hi..all oty+IlrnLle wall ea+ubv+e11N+prrm/Lr/l.e. U1C.Cn,,n,;!Sln/Q,,�al•tN7CQ.Q/C,1 ftalalrgl 1/2 I b.
7d.Amount of disinfectant used: •
3.'1Vclr use(cheek well use):
1lhtlar Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural °Municipal/Public 0 Neat Cement Grout
OGcothcnnal(Heating/Cooling�Supply) -_., �(3CI110I111C Chips or PCIICIS
6 pI y) °Residential Water Supply(single) 0 Sand Cemeftl.Gront, ' • , h 'O DryClay
❑InduslriaVConuperoinl w-- +l.,, , .? _. `)i )'
°Residential Water Supply(shared) O Concrete Grout
°Irrigation n 1 ° mill Cuttings
Non Water Supply Well: �'Specialty Grouu i T v 2024 0 Gravel
11onitoring 0 pcntonitc Slur
°Recovery It,`_.,t;t.... '. —•., :_t I ZO Other(explain under 7g)
Injection Well: —
7f.For each mtnlcriahedCCtei.ablivc,provide nmouut of materials used:
°Aquifer Recharge OGroundwatar Rcmcdiation �j f f her°Aquifer Storage and Recovery °Solinity Barrier ter• � ` ���G f
°Aquifer Test OStormwater Drainage
°Experimental Technology °Subsidence Control
7y, 'rOviJc a brief description of the nbnn<lonmenf procedure:
OGcolhertnal(Closed Loop) ❑Tracer
°Geothermal(Healing/Cooling Return) OOthcr(explain under 7g) ' I tt, irE
4.Date wcll(s)abandoned: ad � ��`'r"��"�-s-G���L�G � /rji(
5a.Well location:
bil AP-3 44e, ,
Facility/Osvncr Name t:ncility IDII(ifapplicabic) 8.Certification:
f
_0'tysical Address,City,and Lip Nrtjgf Sgnt of Certified V ntrncltr ur Well Owner kite
By signing this form. I herein cent/,.that the :rell(s) was abandoned in
County faucet Identification No.(PIN)
accohlanco with 1:.i NCAC 02C.0/oo or 2C.0200 Well Construction Standards
511.LaIllIlde and longitude indegrees/minules/secondsor decimal degrees:
NrdTharacopy a(th/srecordhrrsbeenpruvir/ed!01/retie//owner,
(if well field.flue lal/oeg is srrfrreieni)
3 ���r"1 N r 9.Site din ram or nJditimutl well details:
7 ( '69 Z;3 lit You may use the back of this page to provide additional well site details or well
abandonment details. You may aiso attach additional pages if necessary.
CONSTRUCTION DETAILS Olt WELL(S)BEING ABANDONED
mach well rnusrrnaionrecond(s)Ifovallable. Por multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
ONLY arid,the same cautr,ctloltahm,do,m,ent,you con submit ruse fans.
fin.Well UV: 10a. For All 1Vclls: Submit this form within 30 clays of completion of well
abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 94° (ft.) 1617 Mail Service Center,Raleigh,NC 27699-10J7
(,c.Borehole diameter:
IOb. For inlcctimt \fells: In addition to sending the forth to the address in 10a
(in.) 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: / (ft.) Division of Water Resources,Underground Injection Control Program.
//J� 1636 Mail Service Center,Rnleigh,NC 27629-1636
Ge.Outer casing length(If known): C�•�E/ (ft.) .10c.For Water Sum)!v&In cellos:Wells: In addition to sending the form to the
nddress(es)above,also submit one copy of this form within 30 days of completion
of well"ft.'""" abandoned�andatmwtt to the county health department of die county where
61.Inner easing/tubing length(if known):
•
6g.Screen length(if known): •••••emo_
M.)
. e
Ponu G W-30 North Carolina Department of Environmmual Quality-Division of Water Resources I)_..:__.r,„,a,..

rr Jcxj. ., 1•a.1.5A1JJJ1N!Y1Eff'1' RECORD
For Internal Usc ONLY:
•
I,Well Conf,cur information:
WELL AUANDONI•IENT DETAILS
,S -- 7%t'�/ le 7a. Fur Genprnbe/Dt'T or Closed-Loot)Geothermal Wells having the same
lUotl Conirnelor)\Innis(or well owner t>ersonally ni.,nn<lonin5 well on lus/l.er properly) wetI construction/depth,only 1 G'�-30 is needed, Indicate TOTAL.NUM
of
3/r,,/� /� walls abandoned:
T��I�5..1 7b.Approximate volume of water remaining in well(s): it
(gat)
NC Well Conlrnelor Corlifcotiou UuuiLer
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY:
Company Naml {i H
7c.Type ofdisinfcetnnt used:__
2.Well Construction Permit it: s
1.:..,all ry,plienbla wall enaciruciinn permits(i.a. (PC..Cnunht Sine. 1/arinuee,ore,)ifknmtat /2 I u•
7(h Amount of disinfectant used:
3.Well use(check well use):
\vatersnppty Well: 7c.Sealing materials used(check all that apply):
❑Agricultural OMunicipel/Public 0 Neat Cement Grout X3enionitc Chips Of Pcllcts
OGcotherntal(Heating/Cooling Supply) ❑Rcsidcnlial Water Supply(single) 0 Sand Cement Grout ..1 i.. ' `'f
❑InduslrinUConnncrclal 0 Dry Clay •
OResidenliat Water Supply(shared) 0 Concrete Grout it:
T J 1 2024 0 Drill Cuttings
Olrrigation
Non-Water Supply Well: aSpeciallyGrout -_ O Gravel
7ionilurittg 0 Demi:mite Slurry LM� ..•.:S; .., O Other(explain under ORccovcry 3 ( I 7g)
In senior Well:
7f.For each material•scicctcd above,provide amount of mrltcrinls used:
OAquifer Recharge OGroundweter RcmcdiaiionOiC0 y� /�O Aquifer Storage and Recovery OSolinily Barrier of /r4-/t �a:. ic./4
0Aquifer Test OStorntwnter Drainage
°Experimental'technology OSubsictenceControl
71;• 'l'nvtdC a brief description of abandonment procedure:
0Geothermal(Closed Loop) OTracer
OGcoliterntul(I•Icating/Cooling Return) OOlhcr(explain tinder 78) I "1 r_.. ,lrlf/rr:€ j• ' •1 )
�/'lrG.T N
d. Uttic wcll(s)abandoned:
5a,Well location: ,6 - 4rei ` " 2 r! [.�
,:v .A.713 ii_e.- .
, .
•
facility/Oancr Nnwc Facility lD//(if applicable) 8.Certifier'lion:
L
Physical\I Address,City,anfd/ , ��g�—� / .�,iL. /fro
`/r ^r�l� c.��JJ7 Sptgnat y of ConifioJ i\+ .mrnctor ur We'll Owner )arc
County
`(� L i',signing tllis-forht. I hereby ctn.* that the trell(s) ins stare) ahandonoc/in I'atccl Identification No,(PIN) necorJanaa u•;t),).i A'C.1C 02C.0/00 or
2C.0200 Well Consu•ucHon Slru+dards
5b.1,2111ncle;lad longitude inde tees/minutesnntfthataco/{) nfrlllsrecant!lrn.rLeeuprosideclrothetrel!roust.
8 /seconds or decinutl degrees:
Orwell field.one Int/lona is sufficient)
35. Z 9.Site dinaram or ntldition!,I well details:
ti-1 N 'l /.l sl..' ", You may use the buck of this pugs to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS) BEING ABANDONED
:funs/,trel/cnuruvcrinnrccord(s)ifarallable. For multiple.injection o rnnu-Ira(ersupplpuvells SUI)611'f"f,1L INSTRUCTIONS
(IAY.I'with the some c(utsrruction'ahmrdnrtmcrt4 you con submit tumbril',
10n, Fur All Wells: Submit Ihis form wilhin 30 days of completion of well
(is.Well IN: abandonment to the following:
Division of Water Resources, Information Processing Unit,
6b.'I'otal well depth: "'' (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
r lOh. For tulectinn Wells: In addition to sending the form to the address in I On
6c. Borehole diameter: ©•�— (in.) above, also submit one copy of lh's form within 30 drys of completion of well
abandonment to the following:
6d.Water level below ground surface: /5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC27629-163d
6e.Outer casing length(if!mown): (ft.) ,10c.For Water Suppil'& Inlet:lin 1 Wells: In addition to sending the form to the
ntldress(es)above•also submit one copy of this form within 30(lays of completion
of well abandonment to the county health deportment of the county where
(if.Later casing/tubing length(if Icnon•n): ti.1 (ft.) abandoned.
6g.Screen IcngIli(if tin own): (('l.)
Fer ,GW-30 North Coroliun Dcponmeut of Cnvironmenu,l
Quality•Dlvic ion of Water Resources Itevixcd?-32-201G

rrJW.L.,.11., AliA1NLO.NMENT RECORD
Bar Ihuhonunl Uac ONLY:
I^'\'cll( nnhar or-Information:
Nr1;LLA13ANDONIILNTDL'fA)L$
•✓S� /,—. 7-ZhiblZifif 7;1.For Gcoprobt:/DPT or Closed-Long Geothermal Went having the sam
Well Co tractor Name(or well o�wharpersonally aband • 6 well on hie/hcr property) well construction/depth,only I G�-30 to needed. Indicate TOTAL NUM8I e R of
3 j /6 wells abandoned:
NC Wall Contractor Certification Number 711.Approximate volume of Walt:r remaining In welt(s): (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit It: 1......../...'
1 I2 I b.Lies all IT/likable well consbudian playoffs(La. WC.Camay,Sinn,. Variance,ale.)iJknrnrn
7t1.Amount of disinfectant used: •
3.Well use(cheek well usc):
\1'ul.er Supply Well: 7c.Sealing materials used(cheek sill that apply):
❑Agricultural ❑Municipal/Public 0 Ncnt Cement Groill.
OGcothcnnnl(I Icaling/Coolin•Supply) (single) tBcntrntilc Chips or Pellets
6 ply) °Residential Water Supplysin lc 0 Sand Cement Grout �'•'.4••• ,i 3-_a+bry Cloy •
❑Industrinl/Conun8f61al ❑Residential Water Supply(shared) O Concrete Grout
❑IrrigationOCT 2024 0 Drill Collings
Non-Wn ter Supply well: f;Specially Groui 0 Gravel
gvlonitoring ❑Recovery L`dsaa,. ,21�,� + Lb-tiller(explain under 7g)
Injection Well:
7f.For end)material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation l �j� �f y� p
OAquil'cr Storage and Recovery ❑Salinity Barrier L�a�T s"!'/IrA ��� /gi-Is
OAquifcr Test OStormwatcr Drainage
Olixperintental Technology ❑Subsidence Control
OCeothennnl(Closed Loot 7g.Provide a brief description or the abandonment procedure:
I) O'1'raccr
OGeotltcnttal(Henting/Cooling Return) °Other(explain under 7g) Fit r BIA1/W,'*J T /al---1f// i`/V
l y
4.Date wells)abandoned: '... ......
-
5. \1'cll location: Al•
7V 1 i°
V dA ?,3
•aciliq/Owner ante �Y •
Q/ Facility IDii(if npplieible) B3atJ %
P rysicaAdityans� 5 guunmurc ofCcnifier or Well Owner pate
Comity / /® ___ /j signing this form. I hereby coilfi+limit the well(s) urns(were) abandoned in
Paleel Identification No.(PIN) accordance with MI AtC4C 02C.0100 or 2C.0200 Well Construction Standards
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that acop/n/this record has been provided lo the well
(limit field,one 1st/long is sufficient)
35•/L�ra� 7� N �C 9.Site diagram or additional well details:
Q `� -1 �1in „t You may use the back of this pngc to provide additional well site details or tt•ell
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING A13AND0Nla)
:lunch welt caasuuctia+reeorvi(s)l/available. For multiple injection onion-water supply wells SU111111'f1'r11,1\SIRIICTIC)NS
UNl.1'with the same catitrrtctioufrdtnnl<rttiment,you con submit one faros.
IOn. For All Wells: Submit this form within 30 clays of completion of well
la.\\'ell I1)tl: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
tOb. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: .
5
6d.Water level below ground surface: / (ft.) Division of Water Resources.Underground Injection Control Program,
1636 Mail Scrvicc Center,Raleigh,NC Z7699-I636
ea Outer casing length(if known): / q (ft.) •IDe.For Water Simply&In lee tint)Wells: In addition to sending the form to the
addrcss(cs)above,also submit one copy of this roan Within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): ....ft. (ft.) abandoned.
•
6g.Screen length(if known): �•
(ft.)
•
Vann C W 30 North Carolina Department of Environmental Quality-Division of Water Resources
Revival".».your,

r r L3L/1_l 1•W.fs1.1VUUN1r .E 1T RECORD
For Internal Use ONLY:
I.Well Contractor information: I
". WELL ABANDONMENT DETAILS
KRIS. ,/ e`l ki Jam-! 7a.For Gcoprobc/DI'T or Ctoscd-Loop Geothermal Wells having the same
Wdfor Nomewell owner personally al+ro+d ' g wall on 6ia/6cr property)
well construction/depth,only I G W-30 js needed. Indicate TOTAL NUMBER of
`t/wj' ,�Ir('T^( wolfs abandoned: I /
NC Wall ContreelorCoral-motion Number 71t.rlpproximale volume of water remaining in weil(s): .../� (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY:
Company blame HTH
7e.'1'ype of disinfectant used:
1.Well Construclinll Permit fl:
/Jm nR npp/icnh/e wall cmulrnclinn perm/br(i.a.WC:Camay.S11710.1ra1011ce.dlC)(f l71att71 1/2 I b.
7d.Amount of disinfcclant used:
3.'Wcll use(check well use):
1\ials;r Supply Well: 7c.Scaling materials used(Cheek:ill that apply'): •
t7Agricutturat °Municipal/Public 0
Went Cement Grout._.. , .�+`1. peittonilc Chips or Pellets
°Geothermal(Heating/Cooling Supply) ORcsidcnliol Water Supply(single) 0 Sand Cemeni Groton.T 1 SY
Oln<luslrinl/Connnercial U 2024 O Dry Clay
°Residential Water Supply(shared) O Concrete Grout Olrri ation 0 Drill Cuttings
Non-�l'n to Supply Well: f yr Specialty GtbuL:•'d.i're: ,.. , ijg,Grnvcl
�vt O 13attonitc Slurry 0lrfr;c#tom y o Other(explain under 7g)
oniloring °Recover)Wel
Injection 11cll• .��
OA<luifer large 7f.For end:material selected above,provide amount of materials used:
°Groundwater Remcdiation
OAgllitcr Storage and Recovery °Sa s /1
linity Barrier
OAQtlifcr Test OStormwatcr Drainage
°E..pel-hum lnl Icduiology °Subsidence Control
OOcothcral(Closed Loop) O'1'raCcr 7,.Provide n brief description or lbe rubanc10n mess I procedure:
°Geothermal(Healing/Cooling Return) OOthcr(explain under 7 ) ur 1V/v/rig-hail
4. •
Date well(s)abandoned:
4•
f ` '4" / ' '�R/iJ4 ip'Li i'- 4' ,r/!
Sa.11'elllacatioll:•
• 5d in IV iOP
facility/Owner Name •
��� j� ,�/ ���/,�+faeility ljD'l'F(ifapplicablc) 8.Certification:
4:2
rfi'z
Physical Address,City,and Zip e'• /�/,,
A♦� 6
l� / Signat a of Certified We ontrack+r or We weer
ale
Cotuuy (PIN)
By signing this,lorn,. 1 hereht'cent j,that the tre// frets n
Puce!hlenl((icalion No. (s) (were)abandoned ill
oceordemeo Ira/;,d,VCriC 02C.0100 or 2C.0200 Well Constriction Standards
511.Latitude and longitude in degrees/tninutee/seconds or decimal degrees: ""�dletret copy njtAisrecordharGeelr prurided!o the well owner.
(if well field.nee Wass is sullio:aai)
SS �� ��� 9.Silt diagram fir additional well details:
N " t,�?'3 11, 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 WELL S BEING A13ANDONF D
leachwellconvctionnecorrl(s)Ijovailable. l•or/uulupleinjection ornan-u•mersupplvwe/ls SUBMITTAL INSTRUCTIONS
s
ONI.I'with lire.rate crostractio lnbnnrinnnleln,yam:can suMu/one farm.
(ia.Well II)!{: 10a. For All Wells: Submit This form within 30 days of completion of well
abandonment to the following:
Division of Resources,Information Processing Unit,
fit1.'I'olal well depth: i g
(ft.) 1617 Mail Service Center,Ilaleigh,NC 27699-1617
6c.Borehole diameter: lOb. For intecliou Wells: In addition to sending die form to the address in IOa
(_a__in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: •
Gd.Water level below ground surface: /5—•••
(ft.) Division of Wa ter Resources,Underground Injection Control Program,
w 1636 Mail Service Center,Raleigh,NC 27697.1636
6c.Outer casing length(if known): /f`,( (ft.) (St.IOe.For Water Snnulr lnlecUan Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
^.1.11 of well abandonment to the county health dcpartuncnt of the county where
6L Inner casing/tubing length(if Itnoivu): (fl.) abandoned.
Gg.Screen lcngllt(if known): 0---''''
(R.)
r
o...:._,,,....nee
Faint G W-30 North Carolina Department of Environmental Quality-Division of Water Resources

R31' for Internal Use ONLY:
I,11'cll Contractor Information: / WELL AUANDO fl NT DE coos
• g•/5'
i'''&7�4• 14ORW 7a.For Genprobc/DPT or Closed-Loop Geothermal Wells having the same
welt Co Iraelor Name(or,vcll owner personally nt,nnd g well on his/her property) well construction/depth,only 1 G W/30 is needed. Indicate TOTAL NUMBER of
3/pa. ...4wells abandoned:
NC Well ContrnclorCerd,colion Number 7b.Approximate volume of water remaining In well(s): (gal.)
N.W. Poole Well & Pump Co. FOR 1VATEIt SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.1Ycll Construction Permit tt:
l.im all Err licnhla hall ennerne,lm,purnals ad. WC.Cma¢t, S,n e. Variance.ere.)iinnmrn j2 b.
7d.Amount of disinfectant used:
3-.Well use(check well use):
\'nitr apply Well: 7c.Scaling materials used(check all that apply):
oAgricultural °Municipal/Public 0 Neat Cement Grotg
oGcothcn»aI(hlcating/Coolin•Supply) Chips Of Pellets
b PI y) ORcsidcntiat Water Supply(single) O Sand Cement Grout �'v. ° • s
Olnchlslrial/Conuncrcinl � to Q�Clay •
t7Rcsidcntial Water Supply(shared) 0 Concrete Grout O(
°Irrigation I 0 1. 20240 Drill Cuttings
Nun-Water Supply Well: EL Specialty GrotJJ 0 Gravel
loniloriltg O 13entonite Slurry [mik.':; , .i.; 'O;,Q31tcr(explain under lg)
Injection Wel z.� : ,
°Aquifer Recharge 7c.Foreach material selected nhurc,provide amount of materials used:
❑Groundwater RcmcdialioIl (�
OAquilbr Storage and Recovery °Salinity Barrier ' ���� / � /�' g^-c—ImitS-S'
°Aquifer Test OStonnwater Drainage
°Experimental Technology OSubsitlenee Control
7P'.Provide a brief description of the nbendon,nent procedure:
OCeolhcnnnl(Closed Loop) OTfacer
OGcothennaf(Healing/ oolinl;Return) OOther(ccplain under 7s)•
ie
4.Dale well(s)abandoned: s, r a rA,� rIr f� rJ IJG
S
�
a Yell location: • / >D /.
V D. 3 LAG • '
Facility/O»ncr Name Facility IDII(if applicable) 8.Cel'tilic, i
•
WW1 i • /1E2/77 , . r
Physical Address,City,and Zap 7 •e ` i
f� �� N plA �fSig urcofCertified r I antra or or clOwner Dale (�
Comity parcel Idenliftcalion No.(PIN) By signing this MILl liereby certify Mai the %re!/(s) was(,ware) abandoned lit
oceo,r/aneo with/3.4,\'C.•IC 02C.0100 or 2C.0200 H'el/Conrlrmellon Standards
ds
51).Lalitutle and longilude in degrees/minutes:/seconds or decimal degrees: mid that a copy of this record has been provided to the well ender.
Of well field,one lataoep is surfeimn)
935. Zi.S T 1� N — -7'7 • J n ,yr,. Site diagram nr additional prise
detail,:
j� j< <1 r)C,j „r You may use the bacl:of(his pnoc to provide additional well Silc details or trcli
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED
:loath wen consrn,aionrccorrl(s)fovallnble. For multiple Injection or non-water supply wells SU(Zil1)TTAL1NSI'RfJCTfONti
ONLY with the saute cauinrctloWahandanl,eul,you can submit nuek n:,
6a.Well ID/I: 10a. For All 1Vtllg: Submit this term within 30 days of completion of well
abandonment to the following:
Division of WaterResources,Information Processing Unit,
6t.'l'otal well depth: 61d
/� (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
101). For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: p`••. (in.) 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: /e...-5".' (ft.) Division of Water Resources.Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2769 9-1 636
6c.Outer casing length(if known): CL___(R) .10c.For WaterSunnly&infection Wells: In addition to sending the fonn to the
address(cs)above.also submit one copy of this form within 30 days of completion
61.Inner easing/tubing length(if known): eft... or wete
llnoandow000t to the county health department of the county where
(ft.)
6g.Screen length(if known): (ft.)
e
Iron,GW-30 North Carolina Depnrtmem of Gtvironntmual Quality-Division of Water Resources
Revised 3-32-2016