Wake_Well Abandonment_20220603 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.We ontractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or ell owner personally abandoning well on his/her property) well construction/depth,only 1 GWy30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): A Z(gal')
N.W. Poole Well and Pump Company
FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
G W-078585-2022 7c.Type of disinfectant used:
2.Well Construction Permit#:List all applicable well construction permits(i e.UIC,County,State,Variance,etc.)if iawwn
7d.Amount of disinfectant used: 1/2 lb.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural ❑Municipal/Public ❑Neat Cement Grout wentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑bTi ation ❑ Specialty Grout Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
i
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage LTE
❑Experimental Technology ❑Subsidence Control
7 rovide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
OGeothermal (Heating/Cooling Return ❑Other(explain under 7 Y✓
Ft
4.Date well(s)abandoned: AV-4—OVAQ,
5a.Well location: ( �.
Helix Ventures LLC Well #2 ✓ s
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4112 Friendship Road, Apex NC 27539 4A A J,% N1 JA tTJ
r� �,�,
Ph sicaI Address,City,and Zip Signature of Certrfie 0"eh Contractor o ell Owner Date
Wa,c ke
By signing this farin,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
35.674332 N -78.904904 W 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 DETAE S OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructiontabandonment,you can submit one form.
�'^�(� p or All Wells: Submit this form within 30 days of completion of well
6a.Well ED#: P�R®'r,�1 X � of Went to the following:
sion of Water Resources Information ProcessingUnit
6b.Total well depth: L (ft.) JUN 0 3 202 Divi
6 1617 Mail Service Center,Raleigh,NC 27699.1617
I VV 2 ;TMb.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) {Priw;AWlpIy} O A�tQlpPyj3lubmit one copy of this form within 30 days of completion of well
a`�an �onment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form 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.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

rr�uu�:,t�,fll�l1J'U�I,�Y�IYT�rCORD jp(p'� ry
7lils roan can be used for striate ormriltlpib wells � '°�"��I UN my:
I.Well Cunlr clor lororwetiont
� r
(fell contraclor Name(or well owner entmally etrendv 7L Number of i►dla being abandoned(
.� °1PB1►iUtrnWaherpfoparty) For multiple t rcllon' or N nvn•xater etrpply ,rrllr ONLY uldn Ilm �on,r
• renrrrvenen/abondonmrnt,ypo eon rv6mfl onr farm•
NC ail Conttxcl or CenlncaUoo Number Tb.Approalmale volume of water remalni I ng n neU(a); al,
N.W. Poole Well & PUMP Co. (i )
Conrpanl'Namo FOR WATER BUPFLY WELLS ONLYs
s
Z,1VeU Co nalrnctlon.Permlt H ridr 7c Type of disinfectant necdr—_ � '
Llal ell opplleob)r„•rll prrmlrr(r.e,Cormq;S/orr,Yonimrcr, rt/rerloK r/qf((anoxn ✓)
3.}yell use(check n eli nee): 7d.Amonnl of dlatafeelant used,
Fw
tcr Supply 1YeU:
grloulltunl 7L Sealing malerjala naed(check aU that apply):
co0,cnnal(IlceU ng/Coolln Supply)
u I ;unlolpalpubllo 11 Neat Cement Oroul
B Pp Y) dldtxttlei WelaBu I aln e O Send Cement grout13cnlonfle Chips or Pellcis
dusuial/ComnIercInl PP Y( 81) ❑Dry Clay
(]ResidentialWater Supply(allertd) 13 Concrete grout
t7irrl "lion eJ Drill Cuttings
Nan-Walter Supply Weil: 118peclalty Orout �Oravel
01VIoultorin C7Recav
g 4 Benlonite Slurry O01 In)ed all Well: C7 er(eaplaln undo Tg)
❑Aquifer Reellarge 71'.For rash malerlal"elected"Lary prvvlde amount bf materials used:
dAtlulfcr 5torego and Recovery
❑OroundwalerRemedlelltnt
ry Mal Gil(yHarritr � �/' ,
t751ormtitialcrUraJnego —,��F--.Lt J ��'�.�. I`v �f7Experstncntal TcolmologyOSub •�
❑l3col11cnnal(Clostzl Loop) OT cs�datoo Control
7g Prorldt a brief deaeripllon o[the abandonment procedure:
L❑OcoUlctnlal ctitln' Win Reltitn ❑Olhor lain under:?
4,Date trell(s)abandoned:
5n.�YCU lucanuill
r1VPf�rnH,,,.i. tvl'h �.
Fecd1}�/prvner Name
Fecllllylb j(UaTUoable) 8.CertlBcaUoal
Pbyelcel Addreaa,Clly,end Zip
IBna of C td W o�(riotm or- IU Owner bale
4cuo ry By"tarring lhtt. alTT(,I h!rr eer0y that 111e Ivell(J)tear(were)abandoned In
Patcel Idemllicadodno,(PIN) viceor .dt jj;jM+ U-jyuC;01C.U100 or 1C.0100)Ytll CoruMrdion Slaridards
(Ih.eirhei ,:6-dh—+ on111"'In degreer/rtdpnhdaecondt or decimal deg r nrndth°ta cvP)'ojlhGr rtcartihas been provided to die well turner.
(tfwell'fleld,'ontileVlbngliiiiFg�l�)
S 17 —7 9.site dlaQntm:or addlltbhtl neU detaUr.
W You mriy tt;d tHe.b`eclt of Vila pag°to pruvido addiUunal well site details or well
r.
ebandonmwt di lane: You may also enact(addltlonal pages If necessary,
drfeell�4p ,
flrq }t fjl )i' �'. M' chill' ,:11t ful ib Dii 6E lron•lrvllr'ngrply
UCI7bN5'rrl`'a6eliddlih "McaerrubmltorirJotm,
•.,n•Well will-------------
IOa,�: •5ubinil Uds foml widdn 30 days of conlplea011 of tvcll
ebandodntori!Io llto foUowlrlg:
Total tveli depth; (fG) ® � '11106 ohYaterResourcea,Information Pruceaalog U°il,
_ 161911li118tMce Center,Rele(gb,NC27,699.1617
Borehole diameter:. 5 jY JUN 0 3 2021 lob'
&LVJJkl In'
,addidon to sending the form to Ut°addrrss b IOa
(In,) ,above,ttalcut llfidi, iifio dopy of 0113 form wIU161 30 days of complellon of well
e�endortlhenl ltl.lha following:
Water level beltiry grollnil iurfa¢et. .: T
OM
PROCESMG Ua'Ylaltrn 0MV91trAtsoureur Underground Isr)ecdon C°ntrol Progrnm,
fU Outer caeing lehgtlt(If UdUird); Jlervlce Center,Raleigh,NC 27699-1636
^• ,
(U,) 10t;
the a� ilYllif�ou lYe ir: ht addition to sending 01c foul Io
Inner cashig/lublog length(IC•knuwa), co dB� py of lids furor wiadl, 30 days of
t}vb, dap atibinll ono ao
wll�abandon Will nbaildottin t Io Ulo county health department of Ule county
�(�,3crecn;Ilu�lh;(I[kiltiivti)I', -�"' (f t.) �
VIL)
term ONY-30
Nottll�aivllna b'epirlrheat bf 8n/ifbameal lad Natural Rennin;,.:i riLl., _.... -1

►►LL�:r �U�11V��Y1�'iCOD
Tltis Enna can be vatxl!br single or meilllplb wells Mal f("�O""M1
Y
r•We onlreetor Inrortuetion -
' JMAU
�Vel Contractor N (or well owner per,-LIly sbmdoain � 7L Number of hells being abandonedI
g ttillbn hl�
property). For crulnpls Iq/tellon or t n on•xo 1
eon,rrrrerion/abartdonmr I e°pPY lrtlle ONLY alrh the name
n;you can rubinrl one jonri.
NC We t Contrnettx Cerdfiativa Ntms6a 7b.Approximate volume o f water remaining In nep(s):
N.W.
Poole Well & Pump Co. =
Co,upany Name FOR WATER SUPFLX A!ELLS ONLXs
2.\Yell Conetrnclion,l'ermit N: '� _ 7L Type of dhriafeetaaf steed, Ir
lst all applicable wt/l per•mlre(r.t.Cmm%Sldrt,Morf„er bt/teMor4 tie)(r,b,
7d•AIDooat of dlslnfecttnC
3.Well use(check well use): nsed:
1Veter Supply}Yell:
UAgriculiural 7L Setting malerjais toed(check all that apply):
❑Muniolpel/Publio O Nest Cement Grout.
00eolhermel(Healing/Cooling Supply) esidentlei Water Supply rin a l7 Neat Cement Grout �Benlonite Chips or Pellets
❑industrial/Commercial PP Y( BI) ❑Dry Clay
dResldrntlnl Wain Up*(eharod) 11 Concrete Grow Cllrri anon 11 Drip Cuttings
Non-Water Supply Well- I3 Speclaity Grout �Otavel
OMonitoring U Bentonite Slurry Injection ell: d ether(explain under Ig)
ORxov
Mqulfer Recharge d 7f.For ash maitNal sefeeted slrovyrov
provide amount bf rnaterlels used:
Mquifer Btu ecovery' [7SalUi1 ty H�tremedidlOn
rago and R VG. ,� 7_.
OAquifer Test
O1;xperimenlaiTcohnolo ❑Slormwalcrl)raU:ago
USubsidence Control
00eoUterma1(Closed Loop) ❑Tracer. 7g.Prrrr)de t brief description of the abandonment procedure:
OCicotilemlel satin Cooiln Re ' 4-4--_ �C]Olher Ida under 7
J '
l.Date tiell(s)abandoned! �►���� � �/f'1te �/� �
5a.1Yep Iotatlnn; AA
Feci /Owner Neme
Fecfpty,M#.(lfyrppcablr) S.Ce (fctlfow
rM&
Physical ddr a Cl d 91"
�4��
81tn.tuni otCerdBed Coatraolnr or wee Uwaer•
��- bale
County V3'slag 114 I h;rr y cer*tlwt►ht Well(J)war(were)abandoned In
PeteelideMlficellouno.(PIN) accon 7rds 10i1h.SAI CUd 02C,0100'or 2C.0100 Well Colulmcfion 5landards
5G.Lalltudb And:l641tude 1p de$rees/mlhoteslselante or decimal and thata
(lflvell'4el vP3'of rhLr ncortf has been pravtded to the well turner,
d one lel/lbr, l fuF9ofeot)
9.Site dislimm.or r!ddl8oiik1 hell details:
N g, �(OS You mtry Ad ttie,�'edlr of twit page to provido additional well site details or well
abandonrnprl drldfs:•You MU111190 altash addlNonal pages If necessary.
Arradh�l>i
a i Eli sr rtori•1r alFr t�pjy' A]B
Itf "Crl'`o(~hAaAlihliltlr Ok alit lllblMll Elie t,
a,1Ye11 IbN: 10a,For: tt W tt.r gubink�� this frnm witltin 30 days of compietion of veil
° .� ptofolldwln
b,Total,Yell depth; (n) �IUN 0 3 nry Ind oflyalerResourca,Inrormatfon Processlog Unll,
�02� 1611 M/II Service Center,%lefgh,NC 27699.1617
�Vor0ole,diameter,. Q
(in.) r .In:addidon to aendtng Via form In pre address hx 1Da
so'sifbiiilt*otia copy of-us,form witilln 30 days of completion or well
KM �1 f?f�i��^a�ll�'p`f'ollox'ing:
"s ti.Wafer level hclo�;graUnd tturfacet.
(ft) Dlvirtbn.ot;lYilbrltehiurces,Underground Injectlon Control Program,
;e.Outer casing lehgtlti(j( g�h)s 16 ��tce Center,Raleigh,NC 27699-1636
rho ad In addition to sending the form to
+.:Inner ceserig/Nbgng length(if-knbwn)1. Blsg �birtlt one cOVY of Qds form within 30 days of
r...� where abandoned,ll abaitdoninent Io the county health department of the com,ly
�+ScrEen Idn�lb(ICkdotvp)I •
(L)
OM OW-30
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