Wake_Well Abandonment_ (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information:
/r,,_,,,ryry WELL ABANDONMENT DETAILS
(( t/t'��� 7a.For GeoprobejDPT or Closed hoop Geothermal Wells having the same
Well Contractor Nam (or well owner personally abandoning well on his/her property) well construction/depth,only IZW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:_
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): �25
N.W. Poole Well and Pump Company
FOR WATER SUPPLY WELLSONLY:
Company Name HTH
2.Well Construction Permit#:
G W-071605-2021 7c.Type of disinfectant used:
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):
❑A icultural
� ❑MunicipaUPublic ❑Neat Cement Grout ;4$entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Nesidential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ` `'/ ravel
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 ❑GroundwaterRemediation ,/l .p V4
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 .
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
�
❑Geothermal(Closed Loop) ❑Tracer 7 Wvide a brief description of the abandonment procedure:
❑Geothermal Heating/Cooling Return ❑Other(explain under 7g)
4.Date well(s)abandoned: /p 06! i A F,/�
E �
Well location: n�
EM Phase 2 Land LLC
Facility/Owner Name Facility ID#(if applicable) 8.Certification: �'`t
2038 Wake Forest Road, Raleigh NC 27608
nIo
Ph sical Address,City,and Zip Signature of Ce fied Well Contractor or Well Owner Date
Ph
By signing this form,1 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
provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.809873 N -78.625365 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)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: following:
d"0 Division of Water Resources,Information Processing Unit,
6b.Total well depth: V (ft.) J U N 0 3 202") 1617 Mail Service Center,Raleigh,NC 27699-1617
C q ,--IINJ 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (0 (in.) p� ",,r 0 r � P'{aSoV�,'I,jalso submit one copy of this form within 30 days of completion of well
�`jr".ryrt7�n�11LP�ICI � r�� abandonment to the following:
6d.Water level below ground surface: Cd (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
617.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016