Franklin_Well Abandonment_20220603

711is form can be used for stngle or meiWplb weW Mull UN any:
1.Well Conireetor Inforwettonr Z/p O� I
. r
Well Connector Nelne(or well owner penenal(y ahmdoala 7L Number c[*dh belcg abandodedt
s i itlba Wdherpropsrly) For tnolllplr iq/rellon ar xon•xaftr Ttpply rnlb ONLp xrrh the aanie
con1rrvcn0n/obandonmrn4 you can rnbmll bxt form,
NC Well Coolrxotor Certification Number 7b.Approximate►olnnie of water remolding Id neU(s): el•
N.W. Poole Well & PUMP Co, ig )
Corupany Name FOR WATER BUPPLX WELLS ONLY:
OC
2,NVeU Conitrnction.Permit H: :!_�___ ' 7�Type of dbinfechdt nredr
Lrar allOppllceblt wrll prrmlrt(t,t,Cmmty,Srolr,Porfgner,lrtJrcNoq tl L
Iflrmrrr .
3.Well use(check well use): 7d•Amount of disldfNtltdt used:
Weiler Supply}yell:
OAgrtculiural IL Sealing materials toed(check■U that apply):
❑
OOeoUlermal(Healing/Cooltn Supply) Muntoipel/public 11 Neel Cement Grout
8 pP y) esidedal Water SuPPIY(sin!la) ❑ ❑Hcntonite Chips or Pellets❑Industrial/Commerelal 7 Send Cement grout
O Dry Clay
ditesidaldal Waite Supply(shared) Concrete Grout
C7lrri atloll O brill Collings
Non-TYater Supply well. >Qipeclalty Grout El Gravel
Monitoring all.,ing d Benttmlle Slurry d Other(captain under 1g)
❑Rxov
❑Aquifer Recharge U For each material adeeled ob"el provide aroonnt of materiels used;
❑Aqulfcr Storage and Recovery' 1J8dbti d eler remedlutivn
It❑Aquifer Test
❑Experimental Tcohnul.gy
11S baldenca Cu trul
t ❑GeolJtermal(Closed Loop) 13Traoer 7g prorldelt brlt[deleriptlon a[the abandonment procedure:
❑t3cotitentlel iatln Cpullng Rettitn
dOlh°r lain under.-7
4.Date wcll(s)abandoned: � ``-:'"" `�, �`
5a.Well IocnHuu)m
ra rltty/Owner Nerne
Feel
UtyID#(lfsppUoebts) 3.Certi ont
F
Physled Address,City,and Zip
A6 el 471 81p1r Cnaid We tr�6fcr orF'eU brvatr.., bale
Couoly .Dy Jlgrring 1hlr.
Peteel I hrrY�y efrt(fy tW 111l wells)war(were)abandoned in
lderrd6eadod Na,(PiN) doiro
^b.Latitude�pd;IonQltu t�cleot)de in dejrbe>i/shinntetJiecandi or deetmal degree: rtAdnCc py �f�NClC,02C,0100 or2C.0200 Will Corulruclton 51andardJ
ngi
and[hat copy of(lilt rrcortf Jurr been provided to the well corner.
{irwelfl3etd,one'1eVlti ,
9.Bile dlgtltm or>adtNebhl Hell deGUl;
O g You tnky Usd;tJfi;,Ie
abando of file tag°to provide addilivna!well site details or well
' nmeat details: You n1lu albo attach additional pages If necessary,
/lsl,T1p
rtrJ4til4r }�'id liflr�` " xt rd`'i3bgpdd'' iij ceiirufnrllrenOrrronlrunrrrq,ply liTliU_ CTIOIVB
hM i3'
Ion,
'ia,Well Ibdt r t •Submit this frmn Wilton 30 days of compledoll of well
endonmen!to Ihie following:
t,v,Tote)hell depth; (�) JlJN O 3 702`� blvil(od afli'aterRelources,information Procersing Unit,
161y Mill Service Center,Raleigh,NC27699.1617
-Borehole d(ameteel. ,",� yv j al IDb li'
In ~O� troilr r In:eddition Io sending the form to Ulo address In IDs
o��eei ev`�utiiillt'ohb copy of this form within 30 days of completion of well
• •s��t'd'onnienl id tits following:
=n.WaIerlevelb06irgrgt(n�iurface;. .:
(ft) 171vlelbao[lVAltrAtsources,Underground Infection Control program,
16 II�,p l�ervlce Center,Raleigh,NC 27699-1636
°o,Outer casing leh,gtMt+(i[kudivh)t
_j the adtlttiibli( '" Aso rnibrrtlt one � Ili addition to sending the form to
{:Inner casing/fubinQ tedtills(I[hndiyn)r completlun o[ivoll_abeitdonrnenl'Io Urn rAuny of lids form within 30 days of
.._._ .(fi.) when ,?dot tY health department of the county
`4;Screen ldn�ttt,(If kdn�vp)t ..e-
<httn OW10
Nor1hL"aivllnel)ep�atufEnrfrbameatYadNnunilte�oi>roetwlitrhioeofWsdrut,�,....