Johnston_Well Abandonment_20220817

rr1r1jJa--MAhP.2MM COD y
ibis fonn cell be used for aingle or•rntrlUpla weUt WIUMI U0 MLI.
1.\Yell Coo re or Inronontlunr
(fall C for (er II owner en 7a.Number of reds be
baadonedt
oaal(yabandonlooiriUDnhlJbaN°pr r): For mIllfplr lNreflon r: non-water rrgrply vdl+ ONLY uuh Me tarn
t con,rrvrne✓ebortdonmr
fir'—'' 7 -_ ; nG Jrou eon iubmll our form,
t•IC a Contrxe ar Cerdpexuan Number a A! s
N.W. Poole Well & Pump Co. AUG7b•NPprozfmaletolumko[walerrtmelningineeU(s): sl•p l G i r; 2022
Co:upnny Name FOR WATER BUFTLY WELLS pNLYt
h}Y^.�ti:n.�+:��l it i iN
2.MI Constrnetlon ' i':r,C?C 7a Type of dbinfeetaat oaedt
rr of,applfcob7r eel/ rrn ff.f(
Lr N: � v
p R.e.Co,otfj,Srorr,rrorrmrrr,rryrc�I rre)(/lno+rn YA
11'cil use(checkwell use): 7d.Amooat ofdlsin[retan(used: !�
11'atcr8upply}Yell:
DAgrleullurnl 7e.Sealtag materials aced(check■U that apply):
OGcoUrcnnal(1[caUng/Coolbr Su I OMunlolpeJ/Fubllo 0 Neat Cement Grout.
g PP Y) Aesidendal Water Su I tin e ❑Bend Cement grout 0 BenlonhE Chips or I'ellels
Clludustriallcommercinl -- PP Y( 81) d Dry Clay
❑ReyldarUel Water Supply(sirered) 0 Concrete Grout
Oini atlon 0 Drill Cultings
Non-Waller Supply Ncll; rWpeclally Grout ❑ Gravel
rOAAqntiifcr
iloring BcntoWto Slurryon Nell: uRecov U Mier(explain under 7g)
fcr Reclrnrge 7f.For each material electedaboyer provide aroouat bfmaterials used:fer 8tolage and Recovery' dwaler emodialionTest
❑GxperiutcnW Teclulology
O5lormwalaJ7rahtagE r
Mubaldcnuu Cvnbvl
❑Ccoll:ernal(Closet!Loop) UTrsurr 7g.Prarlde x briCef dticrip(lluunoof the abandonment procedure:
123coalerT281 Icahn' Conlin Rettim 001her 191nundec•7 �_F V/�!l/L�j1,a�/►1'�j
!.1)nlctreH(s)abandoned:
in.Well lot:alluu:
r5oilliy/0wner Name
(� FrdUtyID (Ify.pUetblr) 8•CertlflcafJoar
Phyrleel Address,CI1y,and Ztp ,�/
8 d `o[Cer$fibd We, onlnolor or Well Owner
Dal
Couuty Dy ftgrdng fhltj°m4 I here certify Olaf the ive/I wai(vere)abandoned bf
Patcel ldeMhleadod Na,(PIN) dccortidntie 141Ot'JJ,{`NCAG�01C,0100 or1C.0200 Well Colulnrdfon Slandmrft
3b,LnUtudh xad;ion¢(luite ln'rtegreesiruihatet/secoads or C°PY decimal degrees: ohdthairr o
(Ifn•ell lidd,'one IaVlorig li IuPlieieot} f IIIG rtc°rd heu been Provided to the reel!on•n¢r.
5. (pej2 `i 9.811E dlagrtlm:or tddlU6nrl well detaUs:
N L��� You miey usdaUeolc of Mile pogo to prvvido addiU°nal well site details or Nell
W abandonmeat'detalls: You may also attach addlUonal pages If necessary,
Arldeh�ti/
relli b 1 jjr'j i' ins ctfM} u a lq
If
non=irarir ngrpjy ed `obaliddHiriiiil,foil edtr►ub611r stir John,
^;n,Well IN: lox.For+ 11:W'tht Submit this form witidn 30 days of cornpictlon of Ivell
ebandodintmi io Uro foUiiwhrg:
�'br'I'otal well deptb: Dlvtrion'of lyaterRetources,Jururmalion Processlug Uull,
(f4) 1615111ill Sirvlce Center,Raleigh,NC 27693.1617
:.Borehole Manletcr:. F11J'L1)Ee- llbit`Syrlltr In;nddlllon to sending U:e form to the addrus In IUa
A- Y (In.) above,tdav`lu8ailt'olib eo
PY of Uds form wlUtirt 30 days of completion of well
abandonment ld.Ufo following:
'ri.1Valerlerd beloiy•gratlriil iirrfiier..
(IL) Diylslon of:-1VAlErResuarccar Underground Injecllou Conirol Progrnm,
1 Il Oer•ylte Ceater,%high,NC 27699-1636
�•Outer cueing lehgttsi(I[1hlUirh): j
iho.a?bd?,.rd,'
h1 addition to sending Ole,Conn to
. , aso subgtltonocopyof Uds form VvI 30 days of
Inner casing/tubing length(If•kndwn)r �' comp ivoh.abandoLebl' l the coup hcalUt do
la ( ry puttrenl of Die county
.+5crcclt`•.Idii�(H;,(Il`;1E4oivli)►�i •�� P
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' North•�ittillniUepulruaalb[Ph.lr�e�,...,..,..... ._

221N.T MCORD
for- (ctaal UZ ONLY:
)leis form cnn be user)for eingle or rnu ftbte wells
!.\V I{Contractor rdrvrwntian:
)('e I Carrlrsclor Nuns(or well ocvoer personally ebwdoula ii��>mhlJha 71.Number o[Wdls bet Ig Abandonedl
j P�uty� ,.`.F.a m vuhlpJr ft�rMl I non-valet at¢rply it'll! ONLY n rrh der name
trrener✓obandonmr
n;youu Can+ubrnn one form.
I:C Well Codtractor Cenlne+llon Number
2n��7b.Approximate rolume of remaining In rreU(a): al.
N.W. Poole Well & PUMP Co. �.1Jr ± - l'' (g )
Contpnny Name FO+R WATER SUrrLY WELLS ONLY;
'R7Li-�Y �S:.JiI r'. ✓•1 e'0• IJrii�
2•)Nell Conslrncdon :3�:t i e 7e.Type or di lnfec4nt nscd:
Lraro!l applrCl lr will etmili mtt ft:
P (i.r.Cmn.;e r!a•e,"T 4%ryecgam ere)t/}nokn
3.)Yell use(shack well tile): 7d.Amoonl of dLlnfrclant nscd:
))'nice Sulrply}Yell:
❑Ag'ricullurnl 7L Sealing material$Uietl(check all that apply):
OGcoUtcnnal afeaU g PP ng/Coolin Supply ❑Munlolpel/1'ubllo ❑Neat Cement Grout
Y) eRes(dendal Water supply(tingle) ❑Sand Cement grout ❑Dry Clay
Cltips or pellets
❑ludustrial/Comnterclnl -- PP Y( 81) d Dry Clay
OReillde ntlal Water Supply(shared) ❑Concrete(]rout
0[ni anon 0 ]?rill Cuttings
Nun-Witter Supply]Yell: Apeelalty Grout ❑ Oravd
Injection Well:OMon ❑Rexiov
iloring O Dentonllo Slurry d allrer(explain wrdcr 7g)
OAqulfer Recharge 71 For each material selected jib"provide amount bill ma(trials used:
❑Aqulfcr Slotage and Recovery Wall
(d gtttMer vemallnllort
Y S �
❑Aquifer lest /
❑5lormwalcrDralr►aga
❑Cxierilnental Technology
❑GcoUtennal(Closed hoop) aT cer sldencp Conrlol .
7g. orlde a brief descrip'Ilon of the abandonment procedure:
Ol7coUtcrntal "icatin' Coro Return '
❑Other lain under]
'I.1)alc trell(s)abandoned:
�. tQ
3n.1YeU locaHuu; �� e��r ®
Cecillly/0wner Neme
F lie lgtylD (Ifapppeeble) S.Ce o0
�t
t rycical Addy" e,•Clty; d Zlp a-..+a..4rAA 81os
D7� orcelD orWellOmrcr
Couuty Dy atgrdng thllfjmm,I hen�y certify Drat the tpell(aJ teat iiii abandoned In
Patcel Identl6ced:rd No. M
(P ) accordmtce l0jjh'jjA(Nll 01C,0100 or1C.0700 Well Corutnrdion Standards
�t!.LaUludb�tnd;(onglluUe In"rlegreei/inlnutet/seconds or decimal degrees: and that a ° hlr rtc°�h°r been pr°vtded to the well arrner.
(Irt\ell'Reld,'one IsVlSrg ii}uF9elei;t) C°!n' f t
5s (p 2 9.Site dligntm;ar addlUbbul well details:
N 1�. `f q'Ll.� You miry (sd i b'Ji;ofllila pogo to pro
vido additional well site details or well
e.
' ebandonmwl'delallI' You tdey also attach additional pages if necessaly.
Arfeeltliii ,. . ,• "t ,•
+relit())V tri 'irrlNrClabaijitoljj�ililvll^ [ r'"6r non-Sralir'ngply S
r)`��ebn rubM1r ens form,
pie,)Yell IbB: Submit ods furor willtin 30 days of completion of well
abandod'"lil lei llto'tolldwing:
f b Total n•ell depth: DivIllon"ohYaterResources,Information Froceulug Unll,
(fL) 1617 Mill Stroke Center,Raleigh,NC 27699-1617
10b."-•[lorchole diantatee:. �l gr 1h,addidon to sending Ole fonn to Ulo address fit I0a
On•) above,iJsti lUNii{It.`0 it copy of Uds form )viUlbt 30 days of completion of well
abandonment Ia..Ul following:i
:6.lVahrlei'elbelii'trgro►1•riij"iirtfacet.".'
((l) Dirir(on ofaYtitbrlt1:gt!Fccs,Underground bjection Control Progrnun,
Outer eaeing lengilr=(I[kuU�rh);
163�Will drvtcc Center,Raleigh,NC 27699-1636
.`^.-
(U) 10r. '
nti
tho adtirrtii( In addition to sending Ure Co to
'nbttvr;, alto t!ubtnit ant
copy of Uils form widiln 30 days of
Inner casirig/ldbing length(If•knbwn)r eompletlOn o[)Yoh ebando*6t�to the county healdi department of Ule county
(ft.) wirrxc abairdone d.
Scrcctt;Ifutti;,(�f;kgoivhjb'(;`.:.. ;
VQ I
' 1�ortbGtrullnabepitlmeMb[Ps.Irn�..,..r._a.r_.. ._