Durham_Well Abandonment_20220603

Ire. ld:AV OU YMIYT GODD
This Innn can be used for single or mrilUplb weW �� I u n
I.\Ye Contrnclor Inrormallbnt - v •.�t �
Well Contractor N e(or well owner en 7L Natnber of hells belag aban'dooedt
�1�e , '� p va►t(ye6lndvolag��{lpaWvb rprupltty) For multiple Injection or non•xolrr a !
1 aantr vanon/aLondonmr WIPY unlit Oh'Lk trfdt die aamr rt�you ran avbmtl one form,
NC Wcll ConuxclbrCer(Incauon Numbs 7b.Approxlmale►otome
N.W. Poole Well & Pump Co. o[na ler cemelning In (l
Coroparry Nautc FOR WATER BUTTLY WE
LLB ONLY:
2,1y"U Conslrurdon_Permlt H: 7t Type ordlllnfeetant tiled,_
I_lrl all appllrablr tvtll ptrmlla 0.r•Comrfy;S/e t,*rfmw.livectlon,r/cf(llnotrn
3.Well use(check reel,use): 7d•Amount efdlslafeclaatused:
I Water Supply 1Yell!
OAgrleuitural 7e Ba'ug materials used(check aU that apply):
❑Mun(olpelftblic 0 Neat Cement grout. pp y):
ji OCcoU,ermal(Hcaling/Cooling 3upPlY) aldendtd Water Su I sin a Send Canrnl C3tout C Bentanlle Chips or I ellcts
❑ludusuial/Commercial PPY( lit) Cl Dry Clay
❑Resldentisl Water Supply(shared) t3 Concrete grout
Olr,i allolt O Drift Collings
Non-11'ater Supply�4'cll: ❑'Specialty grout ❑ NO
aravel
CjEctioll W Benlonlle Slurry O Other(explaln under 7g)
I lnjeclion,Yell: DRIxoY
)'❑Aqulfcr Recharge Mrun7f.For each mateNal selected ab"ei provide amount bf materials used:
!OAqufrcr Storage and Recovery 0Selllnl dBarder cation
t OAquifcr Test
` ❑5lormwattrDtalnag � n
L7Experimc,tlal Technology �.° -- � /�.41
�_�sl�datco Ctmlml
OCeoulermal(Ciesed loop) 7
.
g Yraride a brief deacr►ptton o the abandonment procedural
C713coUtcrntel cattn C061in Return ❑Other lain Under-7 j
AAO
a.Dale,eeil(s)abandoned: "` � �/✓� ����
,s,lVeU location: J �`
�Fsallty/Dwncr Neme
FAdUtylDj(Ifgtpprrbls) S.Cep
ph Ica Addroes,Cltyi and Zip
8iaastw$o[Cltd11 }you Can solar or Wes bxvlr
Dale
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y Parcel IdentiontlarlNo.(PIN) d col ng I � I htn�y cerf(fy Ural Ilit ivell(s)war(were)abandoned in
5b,LaUtudb ndaongllu0e In dcgreei/minatea/setadds or dedmal degree,: ct>bfrh/S.�'NCIt 01C.0100 or1C.0200 Well Cwuhucrfon SmndardJ
and drat d copy of rhtr►acar,flrar beset pr(rvlded,a the treJ!turner.
+t well'f eld,sae laVlting li iii�eletit) ,
9,Site dlagtl►m or addlflonal xeU detaill:
- N � You may u+dtll'e�iic�C of tlile page to provide additional well site details or will ebandonmeat di jajls; Yw may also Isliach additional pages if necessary,
,4rtoch'ilii
edI ofY 1�1;< r'ffi. eb/fr ' ' f' i nii 6C nori irallr rrq,ply +uue►uL(�
� d6.biktetlnrriil,itikrari rvbmlr ede form, ,
"a'1Yt111DNt 1lin Lr¢I�:�(*r •Subunit this form wiOtin 30 days of completion of reel,
abandodtittii to the folltlwing:
=bt Total i,•e►t depth;—Ao—(rL) DlvDlob of VVater7ieJourcea,Informs(Ian d'rocerslug Unit,
�IVIY ®3 202� 161`1 MAII Strv►ce Center,Ralelgh,1VC77.G99d6I7
c.Borehole diarnctcrt V
n.3Yldr In:eddlllon to sending Ills form to Ore address In IDa
Also JU&M,lt oho copy of this ' I'M Vdalln 30 days of completion of well
��'•�valerlevel bciovgroUlirf iutfacet. .: ..�
I aK i"�IC i'j�! ,nI id l}fe following;
to
(ft) I)hislon of;lYkOrResoortesr Underground Injection Control Program,
16 ilfiill agerrice Center,Raleigh,NC 27699-163G
outer eneing lehgth:(If 11aO4vb)t
Ile ad elAp aub�t one ht addition to sending Ole rum,to
Anner casing/tubing ienglb(If d(ntrtyn r i PY o[Oila form wiOiln 30 days or
conlPletion
whxe abandoned ll af We bendontnrnl to rho county hcallh department or Ole county
Screelt'.Itti�th(ifligoivlt)l' "»
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