Wayne_Well Abandonment_20220817

rrL1�:�BA�yD'OIYT RECORD
11tis form cnn be used for single oT mnlUplb weU, Ful l UN ONLY,
1.Well un(T etor it rvnnnlion,
11'rll onlnclodunt ( well awoer pentxi H 7a Namber of irdb be16g abandodedt
al(y tbmdoaluo iriU ba hls/ber proprt For multiple fn)t[flon a?a+� �. L e;a n; f conrrrvcnar✓abondanmr nt non-water lip,
lywell: ONLY will, aril ,oroe
1IC Well Can y you an.rubx,lf onejorrn,
eonNumber
7b.Approx�mat
N.W. Pool etolnmeo[nalerRmeldingldReU(e): al Poole Well & PUm Co. . 2022
P Cotopnny Nettle p.0 ! FOR WATER SUFFLY WELLS ONLY,
t__. �iFn ..1.. �J1
2.WCu Construction.l'ermlt N: Ir1+�rrfad. afye•'�C)G Tr-Type of dlslareetant Used,
U.re oll appltcobtr will ptnnns rl.e.Counq;xwe,r'°rlanee,INectlon,tee)I/b+oxn
AQP
J,11'ell use(check fvcll use): 7d.Amadal of dlelnfeetinl used: y too
es
11'a(cr Sultltly 11'ell:
OAgrleullurni 7L Sealing ma(erjais deed(check AU that a I
❑Munlolpel/Publlo 0 Neal Cemrnl Orvut. pp y)t
dt7eoutriall rnnie ng/Coolh,g Supply) e3ldeutial Willer Su I (single) 11 Bend Cement Oroul Cl Bcnlonfle Chips or 11clids
❑ludwUfal/Contntcrclal -. pp y( gl) 0 Dry clay
DRaldenuel Wale Supply(steered) 13 Conac(c Ordut
Obti anon O Drill CulUngs
Non-Water Supply\Yell; Apealally Grout 0 Oral
Iho,tng d BrnlonhcSlurry 0 Outer(explainUnder7g)
vet
Injection}yell: f711ecov
Mquirer Recharge 71.For etch maferlal ,I,tied alw ei provide amount bf malerlels used:
❑Aquifer Slulage end Recovey ClU uund gleraen1Odlellal
❑Aquifer'resl
IoLxperinlctlW Tcolmology �51ortn11ahrDralnaga
oCcollncnnal(Clos�cl Loop) oT bcsledalco Control
7g.preside a brie[descr►p11dd of the abandonment procedure:
I❑OcoOlcnnel -Icatln Co.olln Rrhim '
❑Other lalll uttdu:•7 M �'+"� �/.�
�,,I)nlc u•ell(s)abandoned: "�� ��L.,;,� .
3n. 'eU loca(lull;
ra ly/p,vner Nsme
FeclutyID (Ifp,pDablr) 8.Certln�c !ou
`itliyslcel Addre,s,Chy,end Zlp a.
Iv�
`''c �lpit of CertlDtd W u lfic Well btrner Vale
CCU y Dy signing llrll.jarrry I htre�certify Uwl fht 1vtll(sJ liar(vereJ abandoned Ifl
l atcel ldemlp[sdodNo,(Ppl) dccorddir(ct t�)fh'j1.{NCjC 01C,0100'b.1 aUlude or1C.0100 Well Colufnrdlor151andards
and;louyUuUe In degrbee/ridndtet/aecoadt or deelmal degree,:
and shot d colJJ'oJtlrlr n wrtf her been provlded to the,sell all-tier,
Oeld,'onti lel/Ibtig is iuFlacleot) ,
af 9.Slit d(agrnm.or addlUbn I?rtN dcUUr,
N 3 ,• You m>iy u�d;t�e•�ac�C of IliJe pogo to PfnYido dddilirnd Well site dctnils ur well
�' abandonmwt'd�talh: You may also allach addillonal pages If necessaly,
ar16dJ1'It1!{ `• •
t en1 blV rip lqk,
bNF `rrlf►r[)'buflddHhl-in
k ' ' i eri 6e eon-xanr ngrpfy' 'e" d1�[�
° r i ebb ri bait,ens jorm,
' 1Ycli 1bN: 10a,Fir ALL-EQ. 'Submit Uds rum, wiUtin 30 Jays of complcllon of,veil
ebandudihmi to Ulo faUi�vie,g:
bi Total ivell depth:"""
Dlvleldd oflYaferResourcey Iufnrmalldn proceulug Uull,
(f�) 161911iiil Sirvice Center,Ralelgb,NC 27,699.1617
1Db,Lp' a.
'r.llorebole dlamcicr fort In
Above, .addlavil la sanding Utc form to Ole addfcss In IUa
Oa.) d1s d{)l'r;h1 copy or oils foml lviulbl 30 days of completion of%veil
abandonment itl.Uic following;
ri.}Paler level bel6s>grotlnil iilrfacer..
(ft) Division ofilvilirRetbnrcee,Underground InJecuon Control Progrnm,
e•Ouler 1 d }4L',U dervlce Center,Raleigh,NC 27699-1636
: eaeingieggl�(Ifltuuirh):
(�) 10e yJ11➢1L&'itilrnu nWen1:
'be
adt(ti�li(b('.'ab hl addition to sending Ole fonts to
inner casing/ldbing length(Ihlwuwn)r ' �e0 eub�t out copy of Uds farm wiUdn 30 days of
�*..r complMloti of 5vo11'abanddtdnent to the county ltwut deparbrncnt of Ole county
-+inao abandoned,
_,5c�een•.Idl�tb,(�f;knriivpjll;' "'�'
VL)
::;,nit OW-30
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