Wake_Well Abandonment_20220603

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well ConSp9or Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well o ner personally abandoning well on his/her property) well construction/depth,only I GW10 is needed. Indicate TOTAL NUMBER of
_ wells abandoned:
NC WeII ontractor Certification Number 7b.Approximate volume of water remaining in well(s): �aL)
N.W. Poole Well and Pump Company FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
G W-076527-2022 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ;!*entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) T66 idential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑bri 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:
❑Aquifer Recharge ❑Groundwater Remediation I &
Rafizw
❑Aquifer Storage and Recovery ❑Salinity Barrier l '�
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7 rovide a brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �1
❑Geothermal(Heating/Cooling Return ❑Other(explain under 7 ) T � /��l ,/ �
4.Date well(s)abandoned:
/r
5a.Well location:
A Squared LLC
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1210 Kent Road, Raleigh NC 27606
Ph sical Address,City,and Zip ture o ertified Well Contra for or Well Owner Date
Wake
By signing this form,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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has beets provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.781168 N -78.694329 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 DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) J U N 0 3 2022 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
tnR- , r,r
6c.Borehole diameter: (in.) �}'�,.,s Y��i iar4 above;also submit one copy of this form within 30 days of completion of well
,I,3,b"Oonment 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&Injection 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):
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i' Revised 2-22-2016

Mild. ;AIYDO IYT R CO D
77us form can be used fbr single or mnWpib weW �0� 8I UN ONLY.
I.Well contr for IorermaHont
Nell Contractor Name( well owner penonal(y abandoaln 7s.Number of hells being,abandonedi
gtrillDelddberproparty) For muftlpls injection of non-parer rtFply tedle ONLY with the a.me
` eonanrenon/abarr,i�nmrnt, 'e
yvu on iubrnrt one form•
NC Well ConlreclarCenlpc,UonNumber 7b.ApprosJmatevolameofwaterremaininglnneU(a):
N.W. Poole Well & Pump Co.
Company Namc `-/ FOR WATER BUPFLY WE11I i ONLY:
2.lveU Constrnctlon,Permll of: 0001
7�Type of disinfectant p�cdt
List all applleoble wrll permtrr 0.e.CmarO'Sreie,Per f— at,)VA.
3.1Ye11 use(check well use):
7d.Amount of dLinfectant used:
Fcustr,
er Supply Well;
c 7e Sealing maler♦alsused(cheek ap that apply):OMunlolpel/publlo ❑Neat Cement Orout
ot)Ietma)(I(eat(ng/Cooling Supply) Alden �yata 8u 1 atn e O Band Cement t3routC Bentonite Chips or Pellets
al/Cornmerclal pP Y( gl) ❑Dry Cley
OResldential Wales Supply(shared) 0 Concrete UMUt
ellon O Drifl Cultlngs
Non-Staler Supply wclh )9Pectalty Grout O Qravel
t7Monitoring Cl l3t wonite Slurry 0 Other(explaln under 7g)
Injection ell: 1311ecov
[]Aquifer Recharge 7f.For each material selected abtrvq provide aroonnt of materl is used:
OAqulfer Storage and Recovery []��dwater g�aemodidion
[]Aquifer Test � S
❑Stormwatct Drainage
❑Experimental Technology []Subsidence control
00etiWermal(Closed Loop) []Tracer 7 Pro►ide a beef deaer OD of the abandonment procedure:
❑OcoOlermal eatln Co.olln Re
ltim ❑Other lelnundrr7
d.Date vrell(s)abandoned,
So.WEB location,
Facility/Owner Neme Fs6IH1y ID#(ifapppable) • g•
Pbyslcal Address,City,and Zip
V a/ ///Y/
� A S 6o�Nae of CettlHed or Il b"et Dele
County Pateal IdeuflAwdotl Nn, W f ll d 1 ' . f hin�y car iYY thwf the welf(s)war(were)abandoned In
(PIN) dCCOrdfbtds 141(li]SA IN'UC 01C.0100 or 1C.0100 Well Corufr-udfon Standards
ab.Laytude.pdaonQltude iq de$ree:Umiaoleusecands of decimaldegree, cind r hat a °f1krreconihay beenprvvlded la the'Pell(amen
ftfwell'field oueleVlimiIsIdAileat) ,
9.Bile disgnkm_or addloohli well detaUs,
N /� . W You miry utd;tlie b''tdlc of tlile page to provide additional well site details or well
ebandonmeat details'. You MAY,also attach additional pages itnecessary.
�14
l►q �+sily` 1� Or ✓vpfy
eb>i� •trl a6iflddNhteii�,jt7Y Niii subdtir enema-irarlr •
6s,Itch lby; lOs,za 'Submit this form within 30 days of compleOon of well
p-- sbandoninefit to the tolloaing:
Sbt Total well depth: ` (� �
blvDiori ofWater4uourcu,InfnrmsHun Processing Unit,
(D•) 1619 Mell 8ervlce Center,Raleigh,NC 17,G99.1617 JUN 0 3 202? _
Darphole diameter:. tin) `above aov Foes Ineddid O
on to sending Ole form to ,o add"in loa
..abe,deo'sillftillt olio copy of,lit Is font Wid,ln 30 days of completion of well
'a° ebandonrtient td the followin
W>n�iu�l F+OCES Ji�I g
`d• nitric'e)below grottn�iLrfacen. DIvllton of WtitirResonrcta,Underground Injection Control Program,
(rz)
l �service'Center,Raleigh,NC 27699-1636
e.Outer casing leng(hi(Ir ugh),
O]e ad 1n addition to sending the form to
!jl " also oulfmlt ono copy of this form wiHn 30 days of
is Inner eeaing/tubinQ length(it l]nitwn)s. "^ completion or Vreh.nbandorlinesst to the county heahh department of the county
where abandoned•
"f,Screen iang(H(it kdowtl)I
Fb m OW-30
14ortb f'aivllnit bepittmeut bf p�rlroauxol Mud Nasunl Refound w DITI11oh of Water Resource,