Harnett_Well Abandonment_20230120

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3.wtil Con radar Inrortneliont
-� �—�-- —�;�:,;- ,r, 7g Number otirelb being gbAndonedr}Fell anbadar Nsine(or well owner pen,raally ebendodng mil tm lildhapropetty) For mutrlple rtlfeerran 'ar non-xaner ,apply xrll� n•idr rho aoa,c
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%ey^'_^p r . D ronrrrvcnar✓abondonmrM yrov can lonfil one form,
NC w ICU u t or ettlpceUon Number 7b.Apprazlmnte rolume of�rater remaining In nEtl(s): (gal•),
N.W Poole Well & PUm Co. JINN 2 ® 2023
P FonwAT>�x evPrlxwl�r,E,s oNI,Y:
Company Name
If1iGfFYi3`! :l !�f"`G."v'.S;r:r`r�tlrkf F
p !' �, 'xrar,' e+ 7r-Type of dhlnfeetznt veedi_
2.}}eU Conttrnction.2'ermit N: �'` i-,
II' Gtrt oil oppllcoble wrll prrmtes 0.e•Cmmty,Srarr,vaHgrme,f1reflon,Era)lr o,rn
7d.Amount of dhtnfrctant used; s 41
3.}}'ell use(check Well use): ----fir--.
}Yager Supply}gall; 7e.Sealing materJals Cued(check all that apply);
t7Agticullurol 0MunlolpaUPubllo 13 Neat Cement Grout. .
❑QcoUicrtnal ❑23crtlonhc Chlps.or Pellets
Wealing/Cooling Supply) / esideatrel Water Supply(eingle) 11Sand Cement()rout bry Clay
❑ludustrial/Cornmerclol ❑ C'SidentlatWalerBupply(eharod) XC�atieOmut
CJlrri ellon O Drill CulUngs
;Van-wetter Supply Wcll: C'Sprulalty Grout 11 Gravcl
❑Monitoring 11 Uenlonlle Slurry tC Other(explaln under 1g)
CJRCCOY
InJec(ion vyelu go 7f.For each maieriaf selected abgry prurlde Amount bf malerlals used:
JLC1Aquifcrfteclter gGroundwelerRcmedlallmt A--UAqulfer Blotage mid Recovery' ❑Slblig�a ✓
C1AquiferTest ❑SlomtwaltxEhailtoga S `9 �,�^ l
pl;xperirncntal Technology ❑Subsidcnve Control
OCleotltennal(Closed Lvop) ❑Traver 7g P do a bde[deaer�plton of the abandonment procedure:
Cldeothcrntel catln' Coolln Ii!turn I7Clhor lahl.undcr7 add ' p/
{I
1,bale}rall(s)abandoned) r' ,� T-
1 a,WOO lueatinu;
Fsc'Uly%D,vncrNema Feclllt,ID..04(IftipPI1061v) B.Certltieaitont �
Pliyeieal Addroea,.Clty,and zip y J�
i (!,' 't,� 81pi�luro of Cst it Weq Coalmator br well bwner ale 1`
G
Couuty Pateel ldovtlBcadlnlNa, W(p ) Uy f 18�8 Ihll.fvrny'1 hp2�y eerf((y Ufa(llle W11(s)19aJ(were)abandoned In
dccvrdMd11 llNJ.i,{`NC,,lC 01C,0100 'or 1C.01001Yell CvrutnMton Standmdf
vlr,I,alllud6.and;IiiriQlftiB�Iri degroei/rtilattles/rteeanda or decimal degreert dhd thal a copy ethtarecvrtihx been prmIded to[lie wall aimer,
(lfncll field,one lel/Ibrig li iuF&eleirt) ,
9,Site dlxznut.or add<lilbrial Ren'detalls;
You tn' wd the
e h'. !, ,.,. aok of Ilia pogo to prvyido additional well silo details or well
' abttndontnwt diilnlle: you mtty else altach addlNenal pages linecessary,
:4rid dh'Y1>II UCTI(]NtI v etla biV }t o )1'N ;,t' r ri?r7 rrlwtl''baNda''; f. � i8 on 61!nvti•irarfr'n 1 '
a htn�6l,ydkcstfie„5ii1rtltirJotm, icy
�Sn,1Yel1 Ibtl: IVa,Pltr` ilM I -submit this fmti within; M days of completion of;Yell
abandu tterit Id Ul1i-ibD&V ing-.
b,'i alai tre]I Uep(h; blvlsloti'oMxferReauurcea,Warmstiva Prvicessing Uul1,
j to), 16I7 Mill&Mce Center,Raleigh,NC 27699.1617
I
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G 23orchole dlarncler;. IOb'�V eciloit°.SYc►at 4addldort iv aending Utv torn;to lino address In IDa
(In,) nbvve,rJeo'liltld{It oHo Colry of t)ds.fornt w1alut 30 days of cempleiion of well
, ebsndvruttenllii'lHei`oilvwing:
IYaler level bclriiy grotl>ui}'turiaee,..:
(n,) DlYielhn,uf;}'yptfrltelvurct:ai Underground InJecllnn Con(rul program,
I W gerrlce Center,Raleigh,NC 27699-163G
=�e,outercaeing,lehglit?(tE.htlU�p)t •
(U•) IOC. ,
tha ad '" -uli>igtl°u)Ye tit In addlllon to sendutg line form to
EA`` 1 den tubtnll ono copy of Oils furtn 'rids,; 30 days of
vompictltiti of tvoil:abaiidurtinent to Ole county healdt department of 0ic county
inner easinghtibing lengtb.(I!lmthyn)l
(E�) Kittxro abaitdont:,f.
i s BereenIply.-
Nina OW-30
' Notllt�ittslims;bcpititaeon6ELarltbttmeallndNtluttlReiai>roei:itiir6l�w�r,u•,.-n------

R E C 01'V E D
JAN 2 0 2023
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Apprailmste volume of rrAltr rinixintD,in
NAIV. 1110DIO Well & Pump Cm (CAL)
FUR Cnm;•+nt'ileum
2.WHI 7e.Trim attillInfactani Died?
m .
J.Well 113t(clitch well nit)l 74.Ao .l of dIlInfeclfin,Died;
Wmitt,Supply With
7LS1AiIn&Mj(frjjjj
LIAgrIculitirAl 11Jed(eheekalf that p1j),
dltiunlolpallPilhllo 0 Neat Cement Urvul
00covicI11141.(IIER(IIIA/Coullf)i;Supply) cildmild WRIff Supply(dole) ❑0 SAnd Cement r1mut
01ndusufallcomilletcIrtl >� ;5Q)ry Clay
Dite3ldnU&l Water Supply(!hued) a CAt tia UrQUL E Drill C uIlIngs0111 All it
Non-WRter Supply Wtill 3 Spciaty Grout Ulavel
Mfolillutins
13 nctilonfle Slurry 1;H colon Well: URCcov 13 Mer(explAin under 7g)
0Aiiii(rcr ReclinrSe 71.Foranch material silreled aln",provide 11MOODI bf Ina ICrIAIJ uxed,
OAquffbt Slorugo and RCCOVery 13SPILnIlynanler
OAquiter Test
U Ot-lptlhilmlw Technology I:'iPb1h11c:IW Tcchnolugy 13SubsIdmce Cuntrul
IOCron'tFind(Closed LODI)) ❑ 71,Proflde A brief du'
OG 13Thccr _CziPflO13 Of flit AblUdo
co icinial Itilln" OD11n Relum [3001117 18111 WWII A - 4Z
.4
�_ , 4V YA)722 - L
'i.DAN lvell(3);jbRudguid:
is.)VEll locafluu.
ly WIM,wn-r AID3
Facility
G 7A
Phy'llcil Ad&ejj,,CIjyj end ZIp
WiOgUodlla, Py lWag cen'try Mal flit Wflf(j)war rivire)abandoited In
Occonlang 02C-0100 Or IC-0200 Will Conistrucilon;Standardi
5b.LRUIUdt dnd thda' a
(IrT,,irflAid,'bcAnjd'lG'1lllidB'U'degfee"falcIll(Ids Itaxtil or decimal deg rtroni been Provided la fill ire//turner.5
N You mr/.W"
abndontum 6' P,, 1F.�of'We P880 10 Provide additional well site Malls or well
t ditills:You may ZISU allach addlIlond pages[friccessary,
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WON;A? c*" it
d dfihl h -1v ftllmll��
11 ell,MY i
1;r;,Well Ilyth
Olin 30 days of completlon Or wtil
abanduftepi Id UjjfojI6wjh8:`br
'rot;jl well allilhi QOYAlfirliesolirces,Informallon Proctillng UU11,
1611 Mali senice Center,Itald9b,IYC27693-1617
lob,E
burchole dlaintler, 2
(in.) Ph U UMV
—aboy;AJ161,0A.I -M,'In additi on IV ScII&I;Ule form I V file adilms n Itij
.bhb OuPy Or 0113 fbmi l2b,30 days or completion i
of well
abandunnieni id die following:
haler It itl btI.D iT*RrOiIA-j11rrAi,,.
lirliciourcu Underground injectjoa Control Program,NIA g,rTlca&11ter,RAIE1911,NC 2709-16jG
lot,
Outer culug Itilgli,(it UUTh):__L6 Ull In addition 10 sending Ule ton,,to
lho N to:-liz�S-Ulb,_Hllt
Inner calluElItIbInp leingth(If-known)l COMPIA16A;f%YQl,RbRndotfMcjjt to MCI copy or EWS form 1%itli.111 30 days of
—(fL) wlicte,abandoned, 01c county healtll department of Ule courtly
V.3cl tew iiijiill

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RECEIVED
RL-
JAN 2 0 2023
In ;fit unii
I-WM
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pc�'a Woll Co.
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