Durham_Well Abandonment_20230120

Tlils form can be used for einglp or•rrltiltiplb wells PIa(reJ U�ONLY.
t.)VIIIJ vnlrnclar InrormaHonr
mum
IRA
w 0 1 Contnelor Nam (or we[ awoK penvnal(y abmdatdn 7a.Number of ir6 Mai abandoned,
QirrU�abldhKprvpt For mulflplt tglrerlort I or non-xerrr rrgply trdlr tlNLY u•!dr die Jame
� /{ �� � :"'� i^� 1yd eertrrrvcrlvn/abondanmrrr{you sort rubmff ens jornr.
NC Weil Co tractor Cettlneallon Namber i 3 0 E D
N.M. Poole Well 8r pump Co, JAN 2 Q �(123 7b.ApprvximileyvinnlevfwAterremilntnginweU(s): sl.
(B )
Company Name [1)R WATER BUPPI;Y WEI,I,9 ONLY,,'.
Type of dlllnfeefanf medr 2.WeU Constrnelion.I?ermlt
Lrar all applicable wrllprrm lra R•e•Cowry Stair,rarf y
4r<er. +tr eNon,efe�I/lreoxn
3.Well use(eheckwell use): 7d•Amount ofd1iWectAillused.,
Water Supply WeU; 7L Sealing materials tued(thick AN that a 1
bAgrleuhtrral CIMunlolpal/publlo d Neat Cement Grout. pp Y):
Clacualerrnal Gleating/Cooling Supply Hcnlvnlle Chips.vrl'dlels
pp Y) esideudal Water Supply(single) ❑Sand Cement Grout l7 DryIM Clay
❑industrial/Commercial t7Adldrngd WaterBu 1 (slated).Clirfl allatt Supply( Cl Comets Urout 0 DflU Ctdtings
Non=Waler Supply Well: 11-Speolalty Grout O Gravcl
ClMoriltoring d OR ov l3entmdle Slurry U met(explain under 1g)
lnjecuunv wtr ec
l7AqulfcrRecharge 71 For each mateNal seleefed abwy PrtI amount bf malerlels used;
17Aqulfer Storage and Recove Cl(3roundtraler Remedlallon
175alftiify 13arr1a
UAquiferTest
I ,ar�r.i r; :.❑Slormwaterl)►altugo '
❑$xperlrt MW Technology 0Subsldcnce Control .
l 1JCeolllermal(Closed Loop) ;': ❑Tracer 7g-Prorldi a brieNtscri�pttioonyoff the abandonment prate dure1
�C3togtcrntal '__`J _"`L�e j f
I601!!III Ito611n Iiehitii'; 00ther lain.undtx7
a• r ,
�f.
d,Unlc tl•ell(s)abandoned; � ' '�
na,Well lotaUuut
FacrUlyll)trner Name .,i,r FeelUty tbtl(1(sppgeable) B.Certltieattom
Pbysle ddress,.CilY,end Zlp
DI vfC bdwiu oatrsalorbrSYe Omrer bale
Couviy r �
Pstvel ldeMineadmlNe. p{ DY rlgrring lh4.fvrta,I hireby cergy(lraf[lie W/1(3)War(WsreJ abo»danEd In
L;l (P ) dreortldrtdt tGf(N tJ,'1yC,iC 01C,0100 or1C,0100 Will Caufrudion Standards
ib,lLaUtud6�nd,loliQllud�to degreei/minatet/seeondt or decimal degreat arrd rhafa rop3'9011Lr revord has beenprtn1ded fv 1119 Well mrrier,
t±Ervell'field,dne leUlbng 1i iiiF&&tell,) .
e 9.Site� dlsgMm,ar addiNbtirl trell'detallr:mn iltd:deW 9*tl;e a' of Mile page to prnvido additional well site details or well
obendorneal` You may also aliach addillond pages If necessary.
WerL{'tiN' f;i )r')lrir " chat 'ttlrrrfobpiiddit'riiil,�"N'e6lrrirb�ilihDee�'xarrrrrgrpty .' ��
;;n,jypll myt lDa, 1t •5ubmit lids form within 311 days of eonlpledarl of well
1 I � abandvritneril to UloffillorvLtg:
flit Total well iteplb; Divblup'vf WttierReaourcel,lnfurmaliva processing Uull,
Mill tit rvice Center,Relefgb,NC 27.699.1617
N..
I3orcbvle diameter; 1Db,FoP ele�lf__ n `jyRt�r 4additivrt to acrlding file form to life addrrss In IDa
(In,) eband tdm'�Ua. 6 o poll'ropy of this form wiUlfn 30 days of eomplellon of well
57
abandvmtienl lit:the following:
='n.water level betoiy grouYi�iurfaeer..; Dlvlaivn.ol;11'titErliesunrces,Underground Lr)ecllpn Control prn r I�) gram,16 II�aII SeMte Center,RA10911,NC I7699-1636
r..Duller eating lettgt t(I[itutltvh)
the ad In addition to sending the form to
complctloti of doninentmlo Ure counl one ntty I WU1 depart or us farm ment of Oledc6urly
Inner caslrig/tubing length(Ifytuvw!n)t `'�
t"i'ma OW-30
I, '' Not1;i�tttillnibep'ittrheMblEallrbnnxolYndNrltaslReiaia�e:sr;i;.t.r.�_r,,... ..

YYUL1�:.1:9B;AIYD•OIY�IYT�CO�D: . ��U� . . • .
Tltis form-enn bo used for single or•tnul P�
tipl'ewell Uny
I•)Yen C rector orormel{opt, !!
Well Contractor N (or we I ow er penonally sb/mV/IAo #' 7L Number of Wdlj belog abandonedl I
!� ] t r kba(�1 pros or multiple fyrctlon or non-rroler r 1 tnlb
J I J .... eonrrrucgan/abandon;n RuPY ONL)' twat, dm jams
r� !� "�Pv can nbmlr one form,
NC Well ContractorCertdlleauanNtrmba JAN 2 ® 2023 7b.Apprortlmale Tula
meol�rtlertemtlnlaglnsrell(s):
N.W: Poole Well & Pump Co.
Un 1FOR WA ER BUPPL'l'WELLS ONLXt
Corupany Name
2.}Yell Canstruction.Permlt H: 7�Type'If dLinfeetant'need,
Liar all applicable will primp,(r.r•Cmmq;Sla'!i,Por{grrer,frt/teRon
l oxn 7d.Amount of dlalnfect,<nt used;
3,Well use(ebeckwell use): .
Wetcr Supply}yell; 7e.Stallog mtterlals toed(cheek all that apply),
t7Agrlcullttral 17M aUPublle ❑Neat Cement Clrout. pP y),
UG"011rennal(I-ieatinglCooling Supply) esideutiat Witter Supply(single) ❑Sand Cementurout enlonile Chips.or Pellets
❑industrial/Commercial PP Y( �) t7 Dry Clay
t]Residentlel Water Supply(shared) 13 Conatle Elrout
Nuu atlott I7 brip/C,ultlttgs
Non-Water Supply well: =11R
C'Specfalty,Orout eel
l7Moniloringl7 Renlonite Slurry 0 Other(explain under 7g)
InJectiort Well:l7AquifcrIleclrarge7.For eaeh'nit seleeted abov provide amount bf malerltls used:
❑Aqulfcr Storage and Rccovcrygalerr e1 odlatlm d1❑Aquifer Teat rbralnago❑13xpbrintental Taehnulogy ControlOQeothermal(Closed Loup) 7g Pr de a bile[ eacri tion of the t
P btndooment proved re:
catln Conlin Relainunder7
-fo
rL Dale well(s)abandoned; I — `z2-,
ha 1Yalllocnlinn:
Pecilliyl0m tir ame Fatillity ID#([fappScabh) S.Cerflnut!
I J I .' �-7.F,/
Phy�lcel Addr ss, Ily,end Zfp
ontn��o'lm Orwell 0t�sr Dale
Couory Patcel IdsadQeadadNo, pl BY 111nln8 Ihfi form,I hFr&Y eert(fy Oaf Ilse we11(3)war(were)abandoned In
!p ) dciorrldrtdtttllh'11A•IYC,ll;01C,0100or1C.0100IIillColulrudiollSlnndar•ds
dhd 5b.L,agfudb.�dd;lonQlftiBe.Id degreei/minater/ieeandt or decimal degrees: t ampyojlhLrrertmihaa beelrprWrIed to the well miner,
(lEwell'ileld,�onelsUltirigiiijiFgolsirl)
35� a r1Q �� r 9.Slit tilagt or a�dlUbbrl Hell dctallar
e You Ill
ty-Us 6: beck of t)ile pogo to prnvido additional well site details or well
' abandonment detalla; 1'w may also attach addJtlonal pages If necessary•
veil.{61V' �f� jr`�Ir� m' c6rfF "ellth[iabafi`�dirtriifil,ii3ketinrirbMfre���aNrTtgrply � •
•Sa.}Ye1t IDN: 10a,Frm' itX•ller Submit Ibis fum, within 30 days of completion of lvcll
Q/f abandoninetii Io the following:
Gbs'Total tyell depth; !.
Dtv(W..ofWaferResources,Information Processing Unit,
1617 Mrill&M'CC Center,Relelgh,NC 27,699.1617
Ilorpbofe diameter:. .y �leCSoL "=;r In•addhlon to sending One Conn to 010 addrrss lir (Oa
(In.) ..above,.dlso'suyfiilt'otio dopy of titls.form wi0r{n 30 days of completion of well
abandoruiient lo.16 ibilowing:
gin•tiVaterlevel belo`trgroUSrl;ii(rftbe:..: 2c�
((1) Dlvlslan.oflYxlbrRetuurces,Underground LrjecUon Control Program,
rj 1 Wit l�ervice Center,Ralelgb,NC 17699-1636 r;<Outer eaeln(l leggttti(I[!litD`�h)s J
the'all t In addition to sending the form to
h(ee:•i idvb,'RIO submit one copy of this form within 30 days of
Inner casidg/ttibin9 length Otkndwn)r. —� completion or"11 abandonment to Uta countyh
—. (fL) Kitem abandoned, ealth department of vie county
'6ri Scr6etr1ite
E`hrru aW�30 .
t�Ott}l�attil�n�bepitfrueat blSoslrbnnmenl Ynd Narugtl Aoioiaoei w DlYlalnH nr W.i..b..-..-___

0 � I lltis fonn'can be Us"]for eingle or•tnriltlp UR ONLY:lb weer .
�•\vet unlraclar In[ar-matlnnt '. '
e onlraclor 1J t (or well owner en `� °' 7a.Number of
irells being rlbandanedl
I p oaa!(y.b r
r )' For multiple ln/eellon or non-}rater rrgrply trill+ ONLY trldt
cenximerrunlabandon the name
ntrn{yotr ea„Jvbxrtl one form,
NC well ConUxalor CetttncaUon Numbec JAN 2 O 2023 7b.Approzlmafo volume o[xater remainlag In nell(s): ,,> � al,•
N.W. Poole Well &_ PUM C� �•.Y -..
ConrpnnyNanto p Tr�ri �t^[3n r r... 3 ,�11R (g )
m ": FOR WATER 5MLx WELLS 0,, ,,
2.)Yell _/__ Z �� 7e Type ordlsrnreetant Used:
LIP allapplrroblrncUl nil ftnitrH:
P (1. Cmmq Starr,rrprfmrer,Iryrcnort,r/c)P toxn .
I 3.)Yell 117e(eheck n•cll rise): M-Amount of dWafectant used;
I 1YafcrSupply}Yell:
OAgrlculturnl le.SealLu j material,used(check all that
a +P I )
:DMunlolpah?ublla
[]Nal Cement'Gutbguppy) 0Ben ionfteChipsorPcllctsOhrdustria lCommerclal prntiallaterguPPIy(single) ❑Sand Cement Oroul
O Dry Clay
t71ni anon DResIticn tel Wafer Supply(ahurd) ❑Cona-ete Grout
Non-}Yelcr Supply ly IL 0 Drill Cuttings
pecfaltyGrout ❑ Otavcl Clhtpnitoring ❑I3entonha9lttrty
Injection Well: ❑Iitxov O OUner(explabrundcr7g)
❑AqufferRechargo 7f.For rxch malarial atlected aborei provide amount brm�(erlals used:
❑AqulCer Sturage and Recovery USaI[nf d b {ler aernalfallon
DAquifcr T st
❑1 xperintcrtW Technology t7Slor denm Control
d5ubaldarco Control
I OGehlennal(Closed LUa 7 PruTfd
P) ❑Trueer tr e a btie(deacripllo❑of the abandonmeal procedure:
� OacoUtcmial ietttln' Ca,olln" Rcttin)
[70thor IaU)lurdor7 �1,1r�' el
1 ,�
,t,llnlc)rell(s)abandoned: �` ^' r ;dy,�
!i
:in.}Yeti loeatluu;
I Facilhy)Dwner Neme `
� `� ..� j�- �FsclUtyIDpV(IfrppUerbls) 8, erilf(crrUanr
'! Phyricnl " droaa,.Clly;and ZIP
otC it Well Canhsclor orWeti Otrner --
' C°uoly •ny slgrrtng lhtr.
Patedtldeu}lptadmtNa• IN JoM6 f here eerl(ly Ow)lie )ve11P))vat(weref abandoned In
'+ !P ) dccordtbldt)4f►Ij fSd''Nf�lLi 01C,0100 or1C.0200 Well Cowthi ton Standards
-;b.1.aUtudb.and,fong(ttiil�1u tlegrcei/anlnntei/recartdi or deelmal dcgreel: andt/tea
(Irwell'tleld,one Inl/lbrtg li In'd) �'In'of stele recatTf has beetlProvided io ilia spell miner.
KI
��` 9,She dlrtgruu;or tlddltlbhal TTell detaUs;
N 1 You may u.-d 6"�Ji dp(�ja paga to provido additional well silo dciails Ur tvell
C ----N nbandontnmt'dctal(a, j'otr)nay elso attach additional pages If necessary,
n'ella Uf4 ''<'
;�iri))1'�h' ' ;n` cblt) 'SrlrJit)abcfhl'dlitriF7il�i<�f, '1H on 6r.non-tratrrnq�,ly ����I1�1I0N5
i r) chrrnrbriiltcrirjotrrr, •
I ;e,}}roll]bN: 10a,For, it•M Submil 903 form abartdodtnotil to w-fbH&w(ng: wiUtin 30 days of contplellon Uf well
t°br'fo fit l bell d ell(h; ��
(f�) Dlv611 oflYrllerResources,Infnrma(tonProcesslugUulf,16i`!Milli Service Center,Ralelgb,NC 27699.1617
'c.Borehole diamctce;. `� lob, 'Ad jrq �• �"
(ln,) ,abort,idso'filBiiilt py f U�is fornr wfU itfull to Utg3pr deystof compl to die etion oIn I II
-r+•IvaItrlevel belory roUnil abandonriientfo.l}iofullowing:
g ., ittrface:..: ►�" R 1)tvlslbn of�
( ) �YitbrRetrfnrces,Underground Injection Control Progrnm,1 14k;111lervicr Center,Rrlelgh,NC 27699-1636
j �•Guler eneing lengilt?(1f ItitUtTi,);
In addition to sending ale four to
hirer ensingittibing"lenglh(!f.knbwn)t hbdYb, aldo aubnilt ono ropy oC Uila form witlilrt 30 days of
cornpleilori df lvoll:ebaitdottineltt to the cowry healUt department of Une county
� nilcrc abandoned,
+'_r 5creeutl2ti�(}j;,(�C.kdvw4 i; '
i taint QW-30
` N9rih•CuidllniDtp'iuitnaatbtPsrtrr,��,.,.r._.,,,_.. ._

i
71us fontrcen bo used for eingle ur msilllple weUe Uui ONLY.
t•We untractor FnrorTnntt ns
I
" 7a.Number of hells bell, abaadonedt
I Well Contractor N (or we l atvoer penoaslly a6add14°
4. Far mulllpit Irlpellon .or rran-trafrr rupply trrlly ON0 u•fsl: (he came
t -t eomsruenor✓abvrufonmrat you ears+ubmfr i onejorrn.1IC Well Contrnetar Cestlneetion Numb, J A N 2 0 2023 �.y.,
7b.Approximate-volume orwater remaining in neil(s): /
N.W. Poole Wefl & Pump C (g"i)
1�{�rR;w�:!�t 7rc r.�w-4 Uril
j Company Name r PGR WATER SUPPLY WL 1 LS CNL Y:
eJ 1 Iv
2.WeU Conslructlon.Permlt tl: 7e.Type of disinfeefanf used: -
Dirallapplicablyu•rl(prrmlrf r Co Z
rrcr,Iryrcrfon rrcJ(f6sotrn . /g f�3
3.11,n1l use(check well tile): 7d.Amount of dlslnhctant used;
1 11'afe:•5upply 11'ell:
DAg'rieullurnl 7e.Sealing materlald used(check AU that apply):
❑MIMICIpaUpublio ❑Neat Cement Grout.
dludustrial/ rnme nglCvolbtg Supply) 4csldeuUal Watersu I eln o ❑Sand Cement atuut Mlonfle Citips or Pellets.
OludustriaJ/Contnterolnl o�+ supply( gl) Cl Dry Clay
j ❑AaldrnUn!Water Supply(sl uodJ ❑Calatte Grout I!l .Ohti allon Cl DriU CulUngs
Non-Water Supply jycll! Specleity Grout Gravel
{ Clbtonlluring l7 Benlonllo slurry Injectloll Well: C1 OUter(explain under 7g)
I ❑IReeov
C1AqufferRecltarge 7f.For rxth mcfeNal selected abl PM de arvounf bf malerlals used:
❑GroundwalerAcmodletlsm ``�
IDAqulfer Sturago and Recovey ❑Sallrlliy Battled
DAquifer Test
❑SlorrltwaterDra(nagoji � ifl��p. �,, �'
OCxpbrintcnlal Teoltnology ❑Subalilm"Control J
CIGeoOlennal(Closed Loop) [7Tntcer 7g.Protfde a brief dedcrlpllnn of the abandonm¢nt procedure:
t 00coUletmel lr1ril Cntilin, Rcltirn ❑ether lalnundlx� _ L�`T �'
%�YeIJ Iota Quill =d �p'�r459
01
1 acillly/Dauer Nama � Faclllty ID (Ihlrpgeeblq
B.cerilncauonr
-
I Pby I Address,Clly,and Zip "
s(tat of C Ed Will Coabsolnr or Well 0ti♦net
Dale
C uuly ny Pdtcdlldontlflcadml Na. rigrdrlg fh1j.)k :/I htre�y eerf(fy Olaf!h¢ well(a)1V21()Pere)abandoned!n W
!P ) dt corddndt 14)cN'13d''NC f�i Ol C•0100 or 1C,0200 Well Colulnldlon Standards
:gib.LAUtudbAnd;IrinQlltiUp In dtgreeifrnlnntet/deeandd or deelmal degree) nhdOraf a
(Ifr•ell'fleld,�iioo le!/Ibng li iiiF&elsrirt) C°Pl'llhlr reevrtf hat be¢n prodded fo the well amn¢r.
1�1 9,Slle lllaet»m.or addltlbual wtu'detalis:
N You miiy itid` o 6-11' of Vila page to provide addlUmal well site details j ebandonmeat dtltills; 1�w lnay also attacil addlllonal pages If necess or well
ivy.
NwAn jji l®'r irf` eb", `rdtlttlaba{kldtihii)il,y3ir c6rt"rybMJf Dn'e fahn �afrr'ngrply
3r.1Yb11IbN; IOa'h : 'Submit lids fvrnl V40dn 311 days of c0lllplell011 of)Yell
ebdndotiinetil Io U,o foU6Will g:
t'b,'fotal well depth: DI'I'leeroflYaterlle.sources/InfurmallunFrecesaiug Unll,
(fl) 1617 Mill Service Center,Raleigh,NC27.699-1617
1
5e•Borehole dlatnblerr. r• lob'ar t In addlllvn to aalding qlo form to Via addfrss In IUa
------(10.) above,Alsv`duFluift oiib Copy of Ut(s fern) endiriftfti 30 days of camplcl rr of)Ycit
Abandonment I.0.016 following:
'd•1Valer level below groUnif'iilrface:..r •
VL) I)Ivldbn of;WtilirRespurcesl Underground In)ecaun Control Frogrnut,
1b Hervice Center,Ralelgb,NC Z7G99 1G3G
::�e•Outercading'Ietlgt�'(I(llrlti(rh)t
(fL) lk
the addtr�h( i letUa-- n Weil': Ill addition to sending Ute feat to
hb
completloti of ivoll.abaildoninent to Ole,county heal Ul department tof3Ute county
l:Inner casinglitibing•length(Itkndwn)P lu
i wilmc abandoned,
<<_,ScrbciP;Is+ri�iH:',(1hlEitiwii lr `�"
Nl aw•sn
N�rih Giitillni 6t d
' P�Oot orFliTlrs,nn,...,�-J♦1_.. •- (.