Durham_Well Abandonment_20220817 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW,30 is needed. Indicate TOTAL NUMBER of
4165 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water in well(s): 25 (PL)
NW Poole Well and Pump Co FOR WATER SUPPLY WELLS ONLY:
Company Name Granulated HTH
N/A 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits 4e UIC,County,State,Variance,eta)ifkrwwn 1 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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaUCommercie ,a.a'^a' +`"� a idential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑hri ation t� 4 N Specialty Grout ❑Gravel
Non-Water Supply Well: 2�2� ❑ Bentonite Slung ❑Other(explain under 7g)
❑Monitoring AU�a []Recovery
Injection Well: am.;;, 4,;. t` 7C An7 U r For each material selected above,provide amount of materials used:
[]Aquifer Rechargpt¢:s5fl 1t3�= ❑GroundwaterRemediation 3 yards of env. fill
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g,Provide a brief description of the ab�an mi dorent procedure:
Poured material in from the surface.
❑Geothermal(Heatin Cooling Return) ❑Other(explain under 7g)
07/11/22
4.Date well(s)abandoned:
5a.Well location:
Scannell Properties
Facility/Owner Name Facility ID#(if applicable) &Certification:
2324 Ferrell Rd. Durham NC 27704 604%4 07/12/22
Physical Address,City,and Zip Signature of red Well Contractor or Well Owner Date
Durham 0842-77-84-9015
By signing this form,1 hereby certify that the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 lattlong is sufficient) 9.Site diagram or additional well details:
36* 0V 26.02" N 78* 50r 20.02° 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-watersupply wells
ONLY with the same constructionlabandonmen4 you can submit one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: # I abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 26 00 1617 Mail Service Center,Raleigh,NC 27699-1617
24 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 010 above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: N/A (ft,) Division of Water Resources,'Undenground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g,) 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): 00 I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

lids for"'can be used for single or•mbluplb weer � 1000NLY:
1.Nile oatractar inrermmlee,
3
- - - ,•K ors'
NI'� onuactor Nun or well owner en 7L Number of*oi belne Abindooedl S
p o:u1(yabmdonluq!tillIMhlAtrNgrny). For momspit I^�rcllon ,o
�+ non-xoler trgJply arrll+ ONLi ,rnh the some
� con,rrvcnor✓obondonmrnr,ya,r can rubmll our form.
NC wet CobtmelutCerdnea Numbs
N.W. Poole Welll & Pump Co. 7b.Appraslmale Tolame fester remaining In
Y
CmupUly Nau,o P0R WATER 5UPPLY WEI,I,g UNLXI
Z•11'eu Con etrncuogl'ermlt H: 7r-Type of d[slafeetant used:_ �
LlJr all npplfcoblr N•rllprrnrlra 6,(,Cash;S/oir,Parf4ncr,fr✓rcHoR rle b, s [r
V axn
3.11'eil use(check n•ell use): 7d.Amooal of dLlafrevnl used:
haler supply luau:
OAgriculturnl 7L Swung materlalt used(cheek au that a I OMunlvipaVPubllo ❑Neat Cement Grout. pP y)•
OQcoU:cnnal Meating/Cooling Supply) " gdldcnu&l Water Supply(,ins]e ❑Sand Cement(trout �tonl(e Chips or Cellos
❑ludustrial/Coninterclal / — PPY( gl ) C
Dry Clay
OW ation >11
g I +`a!Water Supply(alttuod) ❑Concrete Orvut 0 brill Culdn s
s�
Non-lYaler 5u ri , ' g
pi y We 1:�� ti - ❑-Specfalty Orout
0Monitoring ❑13rntardto9luny O Oravcl
Injection Well: ' r °V C7 00ler(explain under 7g)
❑Aquffer Recharge v y 71.For weh maleNat selec ed aboTprz� y prmide amount bf materials use
❑Aquffcr 8lotage nand rccCbv�' ';� er Rcmallullotn
n v "Q;3�'Bdlnlly Harter �
OAquifcr Test
117Cxpctinncntnl TechnologyOSub 45lotmualcrDralnagc
❑Ceolltennal(Closal hoop) OT ce�denco ConUol
7r, roTide a brle[deacripiton of the,abandonment procednre:
lOdcoOlcnnal Icahn Co.olln Acttitn
40lher lath under.•7
'.Ualc n ell(s)Abandoned: '
3n.11'cll locallnu;
r
t✓ Nadi iy pwner Nsme..
Fail u IDr(IfyrpU"ble) 8 Cerilficallon:
pb Ice cidresa,City,and Zlp o
a 6mturd etc Well Conine
lor or ell O:rncr Date
County BY 110n8l 1 brn�y eerfly Olaf Illt tpell(sJ tear Ol'tre)abandoned lrl
Parcel 1dcm10tadod No.(FW) dccorddrrtrt t6lt/i IJA'Nf.1 0]C,0100 or 1C,0100 lYtll ulnrdion Standards
or d
b.LatJtudb,and;lou�itutle in rJegreedriolcntea/atcondr edmltl degree: and that d
(trwell'tleld,one IsVltirig li iuFBolei�t� CD1r1'of lhia Cor
rtrortf har beenprot•lded to the well owner.
... 9,Site!19rrnm or tddltloAal trell MAU,:
N You mtiy -_'"baa of Mile'pago to provide addibnol well site details ur Nell
' ebandonmeirt dcjnjla: You may also attach additional pages Itnccessmy,Ada'eh�1Y
J,•atlr ah� ,,;; •
m on arltirildb'a drin;;Fi,�itk ,r rubeilrour xarrrngrply
;F,Well 1bH: IOR.For: tl•Sy'its
bsndoddlen r Submit!vis Rrmr within 30 days of completion of Iveli
at id ulalolldwing:.
"b' Total n,ell de Will Dlvlslo8 oflyalerIlesourcer,lnformaiten processlug Unit,
(fl) 1617 Mill Service Center,Raleigh,NC 27,699.1617
Borehole dian:clerl. lob,
t In n+ddltlon to sending Ole form to Ole addrrss In 10a
Abandonment Id:lll
(In,) .•above,tdao'ltlHiilt:�iilie copy of 011s foml wiOlhl 30 days of completion of Ivell
6 following:
^•water level beluty grouija surface:. r
(IL) Divteloa of:WktkrRelourcIee,Underground Injection Control Program,`"• Outer easing leggitli(j[6uITti), .•....-�
1 ��erTice Center,Raleigh,NC 27699-1636
• ((l,) lOr, tlnbh&tut Ir.N�..
111o.aa— addition to sending the fore:to
`:' inner casing/tubing lengttl(If kndsvn)► ..e slap auUmJt ono eo
completldti of lvoll`abandonineril to O:c co ty hca tit dc� mOdn 30 days or
:ae abandoned. pulmenl of Ole counly
_ Sereen`.Iiti�fH,(�[,►igoivti)t '®'
'`�rrm(31V•3D
' NorUl•f?aitillnibepirlrheMe[Ps.lnrrrr,..-r._s.,... ._
i

rrLL�.40 . MNT
71ds form can be used for stnile or•mnWplis weUs
1.Well C 'tractor Information,
Well Contractor Name( r well awoer par—ld(y abmdoall3l; lenh►�eTp,�erip) n Naambp'rof rcbo elAg ab�nD dNornl reply tre Ur ONLp wirl, the genre
.� cunrrrvcnor✓ebondonmrn{yo,;can rubmil one jonri.
11C all Canlrnclor CeKlpcalloo Number 7b.Approalmate tolame orwater remalnln In ntU s :
N.W. Poole Well 8t O,Pum C g ()
p FOR WACER BUFFLXIYEf,Ly ONLY:
Coruparly Natnc
Z,11'eU Conatmctdou.Pormit H: 7c.Type of dielefeetant bled:
Dit oil appirceblr n•r11 rnnlrr rj r
p (l.r.Corot Sro'rr,vart m e,IryrcBon,rrc)Vbrsxn .
7d.Amount of dislnfectent used:3.N'cll use(check well use):
Water Supply}yell: 7L Sealing mateNals rued(check all that a r
[7Agrieulttunl ❑munloipsYpubllo ❑Neat Cement arout. PPI Y)
Ucleoalerrnal(Heath CoorrlOnhe Chips or Pellets
� lie 8 supply)Pp Y) �aldenaal Witter Supply(single) ❑ ❑ DC
gaud Cement Grout p
❑Iud-Wal/Cornmetclal ❑Rwldeadel Water Su Dry Clay
❑Ini atlon
PPly(shared) Concrelc Grout 0 brill Cuttings
Non-Witter Su s r.. ❑Specialty arout ❑ arevcl
❑Monitoring Z y y ❑l3won110 alturyCCOYMY ❑ Other(explain under 7g)
InJedlon Well:
❑Aquifer Recharge qi j r Z r 2027 71.For each mafeHaa selected aborq prvrlde amount ormaterlals used:
❑Aquifer Storage and Rccovc',^-. ❑Groundwater Aemodlatlan
❑Aquifer Testln r n, v :tgMigiiifyBetrier
J. al6 ❑SlormwatorDralnago
❑I;x0rlmcnta1Tc01mology ❑SubsidrncroControl
lacer 7g,Prorlde a brief des eripHoa of We abandonment procedure:
, ❑Geothermal(Closed Loop) ❑T
k❑GeoUlctnial cello Co,olln Reltim pOlher lain
4,Date sreil(s)abandoned; �r•� ),��
5a.Well loealluttl
I sciaiylo�ner Neme P16IU IDIi If Uoeblr) S.C erat ir�aonl
.t,.( aPP
s
Phye sl Address,City,and Zlp
SIP r,lri of Cert(� ell Contra ltor or Well Owner Dale
Conaty !ly slgrdng 1htr.fvrtn,I hsrje�y certify(drat(lie well(s)war(were)abandoned in
Petcel ldem111catIftNa.(PIN) accord�r(ca ifItN BAIPCAC 01C.0100 or 1C.0200 Will Corulnrdion 5tanda1-d3
51t,Latitude and:IonQltude In degreer/minotet/secands or declmaldegrees: and rhafQ CW°f fit f cord heu beers pro,;Ided to the well Owner,
(irwel(t3eld,ooeieVlbrtg 1i IuF801eo1)
9,Slit dlagnlm.or addltlbnll Trell detalls:
N "You may wd;tlie bai. of(Bile page to provide additional well site details or well
i;.
' abrtndonmeat de'ialls; You may also attach additional pages if necessary.
BVINGARANDn
Ar16eM11i ,i
�r•P1lf tylV.�+��;�;}` irr' cbrrf `rddiil�'6nNdd. : ' �► ' i odi br nee-irarrr'r�ply
i+tiirhl,jiiti epic rirbtrflt Brie jehn,
,7nWell Wfl! lox,For: tI:W'tle: 'Submit this form wiUun 30 days of compietion of`veil
_ abendoriin Mil lb IhO foU6w(r1g;
rr �
'br Total well depth: Dlvblob OAVAferResourcei,lnformatd0n Processing Unit,
(f4) 1617111riil 6ei-rice Center,Rxieigh,NC 27699.1617
Borehole diamcterr, . 1 In addition la Sending are form io Uro addrrss In IDa
(In,) above, so"tiubtr{It:olio copy o'C offs form wlallil 30 days of completion or well
abandonmoni ld th6 following:
'n.Water level bcloty groUnrl iurface;. c®�
(n) Division oflYAlbrAtso'urcra,Underground In)ecaun Conlrol Program,
16 }1tifl Set •lce Center,Relelgb,INC 27699-1636
°•OUW cailog Iehgth(If 1lnatvh)1 '�"
,
The ad In addition to sending the form to
p`'ibavb;afil"Ubmlt one copy of Uds form wiUdn 30 days of
r.'Inner casing/tubing length(itknbrvn)1 �" c0mpletl5l ottvoll.nbandolunent 10 the county heAlUi deputment of ale cowlty._.__(ft) when abandoned.
� Screen ldti�lh(Itkutitvh)► '� I
(fQ
rarctl OW-30
' Nort6C(cello!bepilimea(b[paTby»menlaadNnunlReioivoei::tii:l.rr,ti.,r.ir..._ti__

rrUL�:.�,�I1�0IY�YIEIYT�GO�D '
I
71ds fott F�f MI U1 ONLY.n can be used for ehtgle or mtiitiplb wells
r.�V Ali C ire clot I,n ro rvoaflbnt �- �`�
- Y I
well Contrsctor Name( r well owner penonal(y sbmdoolne�riilDa tildher 7A.Number of halo being abAndonedn
ProPs►tY)' For multiple i>lleedon or non water rtgrply �1111110NLY with the aomr
_ eemrrvenor✓abandonmrn{yotr'can rvbmrf one form,
1JC\ ail Conlraeior Cerd6wUon Number 7b.Approslmale volume of water remaining In N.W: Poole Well & PUMP Co. (g 1
Company Narnc FOR WA'1-ER SUPPLY WELLS pNLY:
Z.\1'eU Construction Permit N: 7-Type of disinrettxnf used,
Liar oil applicable wr11 permits fl.e.Cmmty SIair,t�arlanee,/r�reMor�rrcJ(Ib,otrn .
3.Well use(check well use): 7d•Amount of disw"tant used: "®
Fr3
Supplygrlcuitural 7e Sealing materjals lued;(check all that apply):❑MuniolpaUPubllo 0 Neat Cement(trout. ❑ Bcnlanho Chips or Pellets
eoUtennal(Heeltng/Cooling Supply) fl('Elpldentl Water 9u I (single) C Sand cement❑ludusuia lCornmerclal Supply( 8l ) ❑1hY Clay
01rri anon - °°+ f aitlal Wrier Supply(ehtuod) Conaeid Qrout O No Cuttings
Non-3Yater Supply'tYc11i�" ?5 S ❑'tlpeolally(jr-out
n l7 Qtavel
L7Moniloring i ' Zl'�.Recov ❑BeMonlleBluny Ot�ther(explalrtunder78)
InJectton 1 ell:
❑Aquifer Recharge , ,_) pr--zq' Un 71.For each material selected abovq provide aroonnt of materiels used;
❑Aq fir rBtorage an Reco c ., l�roun waterRemodlallon
�, GiaO �SallnliyBarrla
Mquifer Test ❑SlOMM(cr Dralnsge
p6xper{tncnlal Technology ❑Subsidenm Conhi
00eolhermal(Closed Loop) ❑Tt cer 7g Provide A brief deacrlplion o[the abandonment procedure:
Mcuolcmtal ca(In in Return 00ther lain und car,7 r
J
4.bale irell(s)Abandoned:
r,
Se,Well localinn;
FaciUty%Owner Neme �� Feelll ll Ir Ilesbl 8,Cerilflcatloai
Pbye Al Address,City,and Zlp
A
r
glen of C ell Centiaolvr or We0 bo net Date
Cbuoiy Parcel idetdi0oadotlNo. IN !ly slgrdng tld1 fvrnt,I hrn�CIV OW 111e 1vell(s)wa►(were)abandoned to
Ip ) dCCorddlld!161f11 tfi{'N(aC 01C.0100 ar 1C.0700 ird!Conabucfton 5tmrdnrds
9b.el Wudt.andaon 1i. in de rees/mtpnlea/seconds or decimal degrees: and f/raf a cW of tltLr recvlrf hay been provided fo flit well turner,
{Irwelllleld,oneleVibrig Ii iiil:clef) ,
N �� 9.Site digrgm.or raddlNohAl well details:
�-t V "W You mty itad flit"b`s of tide page to provide eddhitmal well site details or well abandonmeat dtialla: You may also allaell additional pages If necessary
driddkYip
8 bn1 "td d'6e dlihiilil,}tik eoh rvMiill M� 5raltr rtgrply
5n,Wef1 my! IDa,For' o ,6, r .Submit this foam wi0iirl 30 days of completion of well
1 abandotitnont i fo(lifwwinng:
'b,'Cofal well tleplh: Divlslati OtWxterReaourcu,Infurmallon Processing Unit,
(fl) 1611 Mill Strvire Center,Raleigh,NC 27.699-I617
IDb.Fyrinlacllott°y ne
Borehole diarnttcrt. _. '�.r Iri:eddidun to sanding 01c Perm to tltc addrrss In IOa
On.) above,elso'dublillt ofio copy of Oils form vd0lbn 30 days of co
abandonment to rho following:' mplellon of well
'=d.1Valer level bcloty grotlnrl iurfacer. .: ®_� •
((L) Division OTIVilfrRetources,Underground Inf ecllpn Control Program,
16 11tiiT Nervtce Center,Raleigh,NC 27699-1636
Outer caeing lepglh(I[ItlUish)t '�'
the ad In addition to sending the form to
`ib aliry silbQdt one copy of this furor within 30 days of
Inner casing/tubing length(It—known), � completl6ti of W611'abandoninent to the county health department of the cow,ty
. -_(fl,) Where abandoned.
- Scrtanitn�th,(Ifkdvrrti)1 """'
1�6tta CW30
' 1•lorlllCutilln�rbepittmaMb[parlrennxollodNatunln���6r,,.:l:ni:.r_._.. ....

tills fonn'can be used for eingle or mrilUplb weUr FB I UN ONLY,
n
].\Ye unlraelor lefortnelion: !
r
tt'c onuaclar 1Jatn or well owner p.r,.(y ebendonlntiriUbn hl�br<proprrty) FarNumber rof elbb eln tb dNa sett r ur ONLY
w eonrnvenm✓uborrdornmr W�P/y uldt eta aann
l� n{you can rvbmll oneform.
NC Well Cootractor Certilleallon Number 7b.Approximate volume pofaraler remaining In neU(s):N.W. Poole Well & PUr�e,.a
mp Co. FOR WATER BUFPLY WE
Company Nama LL9 ONLY: '
2.)Yell Co nstrnctlon.Permlt M: 7L Type of dtrinfeetant used:
Lrrt old epplrcoblr will prrm(te(l,e,Cmmht Stair,Morten er,lrtt�cYt M rfeJ VjO M n .
3.)Yell use(:beck well use): 7d•Amount of dlslnfecls,nt used:
)Velar Supply 1Ye11:
UJAgrieuliuml 7e.Sealing materials toed(check aU that a 1
❑MunlolpaJ/Publlo 11 Neat Cement grout, pP y):
Clgeodlennal(HeaUng/Coolbig Supply) �Idential Water Supply(single) ❑Sand Cement proof 3enlonlla Chips or I'cllcls
O Ind usuiai/Comm orclal t a S" ( �) ❑ Dry Clay
, g#R I�tlal Water Bupply(altered) ❑Concrete Grout❑Irri anon t. !s - O NO Cultings
Nan-IV aler Supply 7�1cl; ❑'BProlvty grout ❑ Gravel
❑Monlloriits ( (; r 2L�Z ❑Bentlmile Slurry
InJectfott)Yell:
ORecov ❑ Met(explain under 7g)
❑AqufferRechargo n 7L For each maieNai setae ed■bovy prov f ide amount b malaria s use
Ifdu+' "r,,1 JlglvundwaterRemodlelllm
❑Aquifer Storage and Itccovc "Icr
r.r ❑S
aibil(y Barrier
I❑Aquifer Test ❑StotmwalerDrahtage •
If7CxperfntcnW Tceltnulogy OSubsidenoo Control
❑Gcoulcnnal(Closed Loop) ❑Tracer 7g,Prorlde x brief descriplIUD of the abandonment procedure:
❑GcoUlcmtel ieatin Cobling Reltim ❑01hor lalnunder7
4.Dille wtll(s)abandoned:L_i2_��-.
3n.Well lotRQUIll _
�0".
a FeolU 1D�(IfappUerble) 8 CerUticaUont
Pli Ica ddrels,Clly,and Zlp
��q 8 to trail of C Wit U Caufnotor or ell Omrer bale
County FY Ngrdng Ih4. I htn�y e[rf(ly Uurf the 1ve11(s)tear(lucre)abandoned!n
Patmel ldeutldcadlroNo.(pW) dccotflr6tct lflt{t f S,{'NClG'01C,0100 or1C,0200 IYt11 Colulnrction Standards
ab.I aUludt.and:lonyll]iill In degree i/rtd nhd rhal n nntea/tecondr or decimal degretl: a
n ell'tield,ooe 1e1/)tirtg li iiiFlioiabt} fil'ojthLr t2cwtf
her .beers provided to l{re well owner,
S•J I f r 2 i 9.She diagritm.or stddtNonai xeU deluUs:
R� (1 t 5 1 You mky it�d;t�e"brig of stile Page to provido additional well site details or well
' abandonmeM"ditalls: You may also al*
ach addlHonal pages(f necessary.
�f ddc
natlrj{ i'i1i'r' in' bti} '1 er1` bii6Rneli•lrarirngiply � ffiiII�lIQNfi
o�a{I�diitnikl,jt)li cti}ir►vbrtllr Dnr form,
tin•Well dblf: IOa,For' n•EWr Submit tlus rum, wit) n 30 days of completion of nvcil
abandodinent Ili Uto ruo&M g:
''b 'foist ivell depth: Dlvblan oflYa(erResourcel,Infnrmatluel Processing Uuli,
]?frill Service Center,Raleigh,NC27G99-1G17
lob, EQL t^-.13or:hole dlanretert. �i�! in�addldun to sending Ole funn to Ole addius In IN
(In.) above,dao'lUbtrfilt`0 a dopy of Utis form veltilbl 30 days of completion of well
abandonment ld.the-followingt
'n.)Velar level belo'ty grouiurf surfacer• •
M) DIvlelnn ofilvillrAtIgtircte,Underground Infection Control Program,
Outer caHn 16u'�?�li llerslce Center,Raleigh,NC 27699-I636
�. g lehgt)](!f iltllf'IFh); �"'
the edLl]iLttiFlia-- jlt: In addition to sending the form to
the ZM
$b also Submit one copy of lids form wiOtln 30 days of
Inner cas14110ing'Iengtl](If Itndwn)t comple 16ti of lvbll`ahhdotttnent to Uto county hWUt department of Ole cowtly
wham abandoned,
_;.5crecic.l8ti IH`Il;
ldotth�iru1L,4 bepiitltneot bf Envirh—I._„0-.. ._ r