Wake_Well Abandonment_ (10)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well C 793ctor Information: �7 WELL ABANDONMENT DETAILS
�/ ,9 7a.For Geoprobe/DPT or Closed-'Loop Geothermal Wells having the same
Well Con actor ame(or yfell owner personally abandoning well on his/her property) well construction/depth,only 1 G -30 is needed. Indicate TOTAL NUMBER of
-'^ wells abandoned:
N Wel Contractor Certification Number 7b.Approximate volume of water;remaining in well(s): (gal.)
N.W. Poole Well and Pump Company i
FOR WATER SUPPLY WELLS'ONLY:
Company Name HTH
G W-074987-2022 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) %iesidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation_ ❑ Specialty Grout 'travel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials uvd
❑Aquifer Recharge ❑Groundwater Remediation { r�/Is �/
❑Aquifer Storage and Recovery ❑Salinity Barrier S�G _g �6►tV
❑Aquifer Test ❑StormwaterDrainage '
❑Experimental Technology ❑Subsidence Control
7g7Pvlde a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7
4.Date well(s)abandoned: : � ,�i •T
AL
Well location:D160
Davis Drive Cary LLC .�^�!%�- i5eA
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
10152 Lake Grove Blvd, Cary NC 27519 � ��
P ohs Address,City,and Zip
ake f rti Signature ofied Well Contractor or Well Owner Date
hV�l
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
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.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.823286 N -78.845132 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.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#: � /"� G I' andonment to the following:
4 I P 1' JI Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) JUN 0 3 2022 1617 Mail Service Center,Raleigh,NC 27699-1617
d „� 10b.For Iniection Wells: In addition to sending the form to the address in 10a
�' ' �''i '� above also submit one co of this form within 30 days of completion of well
6c.Borehole diameter: (in.) :�re�,..,.,.cv...., ,,.r ��1=n} :r,> PY Y P
I'fad,hCESIS::i;+Lb�donment 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): A) 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
c�
6f.Inner casing tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016