Wake_Well Abandonment_20230120

JIM
11'.t'iUL:t1]}i�l�UD jib �Nrle� ''CO�iU �y Yry IAN 2 0 2023
11r1tfhnnrnnlamt.It6reinglAeyrnr,INplbaselle ,WUg tine
' Ilf4tr'i3if7'-n.'t�•`l ;�M� y.� .
t.��•, ��� ram `"�"'".3Ur.�
e I l un)rector tnr°emrtlunr v +6,Lo
�,�, � .. . ,SYE[rilAll6p(uil1�ffiii�TAILy , .
tt'ellCat+Utetor1rlmi(et%,III ,pen°realtytbend°nlitNWhMb%tfltru Fer[iamberofirell,bola,eband
e eatdt��_
• r h) +ItB,tr L•�rettcn of rer..,refer nr.l ndb"� ref+rrvreez+e2arda�-re:tt cveerlrb!. gar ONLY xlrh the rn-�r
ttC Well Contrteln Ce�nulloa JIUMb" j rflelryerm.
76.App""rall galaateof-,reelerrimelolallinrrtli(t)t
N,1N,Paolo\Noll&Pump Co. (gala
CompenyNuttc FORSYATbR 8(JPPLY W$I I y d YI,Yt
1,Well Consttvttto s Ire Type of dhlnfeeten!nradr
U,reilaprlfrohfrMrllprlm2 IL
lrQcrlCmc
0.
•SfeYr,I'mreRer,ryerrton,tietJ kraxn / Q
J.11'tll"It(@htck well ute)r 7d.Atonal ordhinfeeVntosedl� /fir• �1-►
Water supply lytilt
❑Agticulturnl 7e.Stltlas mlt,rlill coed(thcek IU thal apply):
❑TtlunlalPeUPubllo C)neat Cement()rout.
Ot7coUtcrtnnl(lleoUng/Cooiing Supply) �tglJatdil Weia9upply(tingle) �Denlonha Chips or Pellets
❑tudwlHallComnittNoi 13 SAndCementamut 0 Dry Clay
MITI ,poll ❑Redldatdil Wider Supply(tlttuad) ❑ConesdeUroul
❑NU Culungs
N013-1lhter Supply}yell: ❑'Speclilly Orout �(Ornvel
Oidonllofing ❑Dmiotdla5ltusy, ptlrcr(rspialnundcr781
in)cttlon Yell; ❑Reeov ❑
❑Aqulrer Itecltnrgc 7f.For ue6 mlleHal I�e�ft�ef�ed�slsor y prorlde Imoufrl bf me(rrta�ts used:
aAemalldltm �'9 .n-1��•.,r G— !�p�
l]hqulfct5lorage mid Recovety ❑Omundwal❑SellnllyDuHa
❑Aquifer Ttst
I❑C•xp'erislltnwTculmolo ❑5lUMMIltrDrelnege
FY ❑SubsldafroContml
[3(lC Ucm (Cose Lap) t ❑Tmca 7F Prorlde t bHef dtserpllop of(he sbsndopmenl,,,,,dare:❑1e,litmial Clln-Coolln Rel, Miller idnunden7 a.Date ntll(s)abandoned-,
;,:c
FaciUlylonnerNAme' ptlylD (ICeppUn— yl�) A.Ce,Utlet
Q 'el
pb)dcel nddreu,City,end zip
f/r 81�etmdo[Ccstlpt C `, orWeUbaav
C0 D1 pY slQrdnB e e ►W+Jvrny 1 htrrD err*prof the Nell(tear(were)abandoned!rr
patclldod0adodHo,(P1N) aeb,rdmtnWlhf,b,('ACfL'OIC.0100,r1C.0100IYtllC,rufnrdlon5laudardi
Sb.Latitudeagd;iootiltudelndtgreeilialhel,t/seeoadtordeelmddegreo: °ofhafaopy°flhilRwrdh.be,n
llrnet[f)eld;oai)eNting li tfiFaolect) prodded fo fhs trell orrner.
3e ])42 57 9.Bile dlsgntmorXddlUoh1ltrelldtUUs:
You mfy iub;die bielt`of Uib peso to pror(do eddiUcnd well silo details,r well
ebandoltmeal'delella;You may dso attach additlond pages Ifrtecessary,
lrlefk(uiI ° v .
x rtlf A(jf l p'tl i t n n ?erle J 6e'
idrr r eri dr naa•x°nr ngpV S
il�dmni6l,jvY tvbMff onlyotm•
1r.Wall IM 101,ALAL'U l(t-submit Oda hnm witldrl 30 days of eomplelion or"ell
nbindodmrnl Id 0io lArMog:
+b,'Co1el n'ell ileplhr Dlvlsloo lurormlllon Proeeuing Uolf,
hillil Service Cealer,Riletof}yllerIiq,urces, gb,NCYidactniq
lob, r
:�Dorebole dlanreter:. ((a,) „ ition to acst
above,ilro 1Uyj(LI"IPY f in Wts rbntt tisiUr(ng30r days of11)Ills address it,completion of nepll
Ibind,nnitnl Iu INo follotdng;
lY°ter lcvd Lduir gr,ud'd autfala. Division 11,111,let3ieloatcp,Underground lnJecOon Caalrnl Yrogra,r,
oulcr ceslog 1,hglh(11 Nuo yh): ull Servlca Center,Itslelgb,NC 17Gy9-1CJG
IQ
the Id k•;bI ab'y8'nli �Iflout lPy pC 0dalon form snidi 5 3Lh 0e dorm of
inner tas-,ngltublug Iingth(Ir'kaunn)r completion oC 1ve11'ebandoluntttl to Ih°county heal,,depulment of the camq,
((() xbtcr Ibmdoned,
".3crecu;)eut:lb:llt,lwyivd))i,-'.. —
(n)
ma n-+o
'1torlhptiullni0,pittrorcibfpmb^^.,..,..,.,... ,_
i

I
rr U�:��(yllOIY ENT WRD . .
this fortis can be used fbr etngle or httSlllpib s eUr �� I Uric ONLY,
t.1YeII�C nlreclor InrurmnlloutrZ
"
0• e
. . ::k
11'e11 Contractor 1qune or wsll owner penooally rbmdo 7rL Number of WOU being Ibuadunedi
h rBirrjbhPubrp�roprtty) For mahlpb lnJretlon ar Kan-xafrr rupply tnl/r ONLi n•uh (lie name
'� ` `+` �ntB�r�eaan/abandamnr rou e
►� Je'jy n4} nrr Jvbfiff alf[farm,
Nc ell octrsalar CertlOeaUon Number * �'``
�'Tk6ruximrtlerolume o[attler nmelning In nell(e):i ��� al.N•W: Poole Well & PUMPCo. 2 0 (g )
JA N 2023
F1F1U1R'1WTATB,­R8U1Kc"1 W)✓L).q ONLXt
Coropnn}'IJauledltln(eeiaututedt 2.1Ve11 Co°alroctlou,Pcrmlt ff: /(s� '�v�r
!IN aN applicable+rrll rrmtra —T
rl r (Le,Cv v.�.0,.,.arrarrer.lgrrallorti rreJ(/knoxn .
3,}yell use(check n•ell use): 7d•Amouut of dislnfecunt usedt
1Vatcr Supply}}'ell:
Cthgrlcullrunl 7L senting rntrler)1ds tued(check rill that appl});
❑MunlolpWhbllu ❑Neal Crmrnl Grout. .00cuutcnnal a 4caling/Coolbrg Supply) VesidmUel WalerSu I tln a ❑sand Cement 0 Benlonile Cldps or PclIcLT
❑Ilydustrtal/Comntercinl Supply( el ) ❑Dry Clay
❑IRedidtnHal Walla•supply(ehatul) 0 Coracle Grout
.C1Uri anon O Drill CtrlUngs
[Von-S1rAler Supply}Yell: rwpeclalty Grout ❑ Gravel
ClMoniloritrg C1 benitm)le Slurry Cy oY
C1lt Mier(eaplaln under 1g)
luiecllort 1VcIL cc
C1Aq«Iforliccltargo 7f.ForeachmtleNeltelre¢ed,lwryprm•Ideamountorma erlKlsused:
Mqulfcr 5tumge and Rccove tY ❑Groundwa rlier
)]Solidity BaMtr
OAquifcr'I-est ❑Slotntwatq•17ralnage .
17Gxperilncnlal Tcclutoln ���/A ��� ,
gy C1Subsldcnco Cunlrol
rJQeolllennal(Closal Loop) C1Ttecer 7g I'rorlde t brie[deavipllun of the ibllndonment procedure;
0Ocnlltcinrel H&MInwCU61111A Returlt 170U1or IaUt wldtx7
,r,Dale u•ell(s)nbautluned: Oil
5n.11'eU Incalluu: ��
. i�
1 actlJty/pwntr Nema 8,
® r { rAAf/,,// FseWtylD�(Ifsppscsblr) Certlflta
W6 4
P yrlcnl ddrola,•CI Y,Knit Zip
��•— � 81sn4vrtiof CertlDed WdU nhsolat tirlVeU t?rrner last
4(Y ' r (^
a(ideollOtaUod Na:
BY t10rig Ih►r fornr, !/Irr, I ertUy uwr lire ,v 10)War(were)abandoned In
Patc (PIN) dveor*llee�khy'f,�,{'1'CG t102C,0109 or 2C,0200 WfIl Corulrucflon Standards
b,1 alllud6 rrnd:IBriQUtiUe Id tiegreei/minuferlreeaudr or deelmllf degreer: uhdOwf a ropyojlhlJ recorclheu beer pruvlded to rile well°wider,
(Ifnell'neid,one InVltitigli 6iifflelenl} ,
e r R 911e dligrun.or a dlAobrtl nett delallrt
N �11 r a b miry wd;tGe &d of lWa page to provida addiumd hell Isilc dc[aila or well
andonmwt'deinl .
' la; You may alsu allach addlllunal pages if nccessaly.
.drlBdh'�11+1 l , ,r r
,rnlli blir �1� jr'�hk` �'•cb1iY �.' f8 6 d bri.Br.rrvn�tratfr'ngrply• 5` e el�r)'dFihiihf,j dk ith rubltilr orrr vrrn•t
ssn,Weil I ! ION.For`AII:W'irr 5ubinit Uds frnut 'Munn 30 days of c°mplcUon of tivell
" 1 abandod¢nerillolltc:Collowtng:
I '
hbi'.Tolnl well UepRrr I71vlt10q•of lYater)iereurces,Infurura lion I'trocesslug Uull,
SBnlce Center,Relclgh,NC27.69314
617
3Jor0ole dlarnetcr: lob.
(In,)
. Ir,r "I•"1rPit ¢1 In,addlllun fun
to sending 010 n Io 1110 address In JOB
nb„ nd,ldao�ilbp{lf ofia
a(r vopy of oils frum, WIMI 30 days of complellon or well
artdondienl(cf.010 pbll°wing:
:a.11'elerJcvel belon•grolll'ii!furfneel.
(n,) Plvlalon.of;1Y91irlicrqurcts,Underground bjectlen Coulrel prugrnut,
Outer
i63G}4rill�ervlce Center,Rnleigb,NC 27699-16J6
c.• eniln�lewg¢jx(I(11i1Uhh)r ,
lh5 ad ' `Ea':ii$ III addition to scn�lrlg Ure fomr Ili
alio submit ono copy of 00, form SviUilrt 30 days o[
Inner easing/ltiblog-Jen l!t I f• �,.. cotnpleilofi of Will;abstrdoninenl to
( known)t nirtxc nbnildonai, U1e county health deparlmcnl of Lim cowity
III :r•-.Screcll�..lf'nj�lll,(lf,liiipivit)i• I '
R)
'I ` Mott}rtilltUllhtbtp'ltlrnerd'of$aib6tumnlendN..,..ty-:_:._..• :_ .

\1'1 1 L.A13A N 1)0 N A11�1'r 1tLC0adU rM lntrrnal llst ONLY' I 9 `j ( � r�'�J
1,Well r'nulrnrtor'Infin'mntlon: 11"FI i Al3r1VU0`1M1 iYf llf:fAll,$ `'►•• ® 2023
Bar ry Norwood _ 7n.For Grn probe/UI'7•or Closed-Loop Cen I%Yells having the same
!t'ru%vino^,y„r Vprnr rM++ill o++nn perct+nnlh'nban+laninp++tll nn hichtr t•nY'rrtyl Well QniStucliou/depth,only i GIN-30 is need �H�t��Gtt rl�ifffl{;(AI{b il3F,;�$of
wells nbandrnted: ram"C�,��
4165A
_ a
v+ \1'rp 1'rnhrrlM t?rrilirn;fan u, 711.Ahprnttrnnle volume Of 15'nler remnlnhl{t In 5Vt11(A): (gis
M-1 )
N.W. Poole Well& pump Co. FOR WATER SUPPLY wEL1S ONLY:
C"f" —,Nnmr HTH
7c.'fype of disinfeclnnt used:
:.:vWrll('oncu'licmnn Permit k; 1/2 Ib.
f „ll,{r;•lrrrt.�lr Aril rnmrnr�fnrnlyrn,itr(t r,ill( Cnrrngt,Vnrq lnlrmlcG err. ! %poor
7d.Amount of dlsinfcclnnf used:
3•Well ime(check q'cll uce):
%v'mler 5uppty vv'rll: 7c.Scaling materials used(check all that Apply):
❑Art ticulwrnl
01,1unicipnl/l4dplic �Neal Cement Grmtt >Bcnlonite Chips or Pelicts
('Gcolhermal lllcatine/Cooling Supply) itcsidenliai Writer Supply'(single) O Sand Cement Grout ❑Dry Clay
❑lnduslrinl,rCommcrcial ❑Rcsidcntinl Water Supply(shored) ❑Concrdc Grout O Drill Cuttings
❑brit anion ®Specially Grout ❑Gravel
\-1—werSupply well; ❑Benlonile Slurry O Other(explain under 7g) ,
:7Alonitoring 011ccovcry
Injection%%'ciL 7f.For each material selected above,provide amount of materials used:
❑Aquila P.cchargc )' ❑S❑Groundn'atcr RcnicdiaWn n���/ ,c-f �- r/' AIM
DAquifcr Stornge and Fccovcralinity Barrier ���1ry•/�'���L�•,F/wy� �AiY�YJ �����
CAquifcr7cst pStonnwatcrDrainage
OLxi>cnmcatal Technology OSubsidenec Control
OGcothermal(Closed Loo 7a.Provide a brief descrintion of the abandonment procedure:
p) OTmccr
❑G 0Otrer(explain under 7g) P II
eothermal(Ha�ting/Cooling Rcutm) IL//�f � •y `� v--i
4.Date wcll(s)abandoned: ,�„
Sa.Well location: J/n�3
Fa6lity/Owner Name Facility ID#(ifopplicable) 8.Certification:
Physical Adduces.Cit•;and Zip
Signature orCe and Well Contractor or Well Owner Date
Coon_ By signing this fonn,I hereby certh•that the well(s)vas(were)abandoned in
Parccl Identification No.(PIN) accordance with iSA NCAC 02C.0100 or 2C.0200{well Construction Standards
515.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy ojthis record has been provided to the 5rell owner.
(if well field one hroong is sufficient) 9.
� 2q Y Site diagram or additional well to provide
"t rN ^2g�7 MG W You may use the back of this page al provide additional well site details or well
35 G abandonment details. You may also attach additional pages if necessary.
CONSTRIiCTION DETAIi S OF WE A,S BEING IIA nONEn
:frtachrrellconsnuuianrecord(s)ymnilable.Fornttdnpleinjecuronornao-reatersopplynrlis SUMMI TALINSTRUCTiON'S
OAZP uuh the sarne cotrsinictioarabanrlontitett,you can subma one form.
10a. For All Wells: Submit this foot within 30 Jays of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
61).Total well depth: (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
IOb.Fnr Inicctinn%Yells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
Gd.Water level below ground surface: (ft.)
Division of Water Resources,Underground in eetion Control Program,
1636 Mail Service Center, lalcigh,NC 27699-1636
Ztlle
6e.Outer casing length(if known): (ft•) lOc.For i%'AtrrSnnnly&infection\%'dlc: In addition to sending the form to the
addresses)above,also submit one copy of(Iris form within 30 days of completion
of well abandonment to tile county health department of the county where
Gf.inter casing/tubing length(if known): `~ Oft.) abruidoned.
6g.Screen length(if ltno5•n): -� (ft.)
I
form GK'-30 North Carolina Department of Gnvirammental Quality-Division of Water Resources Re%iscd 2-2 2 201 e
I
1

CORD �� il!tml U�c Thisb u ONLY:
rnnn-Olin b sed fbr e[Qe,yr mtillJplbmlle
i.\YcII�C,ulreclar lnrurmel(on,
. k j
. . ��r�),2ALIMENTDET tt q .
1 r
11 ell Canuactor N une or welt ovvocr en vmber of ireltr being�btlndvnedt
p oaal(ytbmdonln1$i0,Dahl ar [ 1
�tnulllplr Injidlon or non-xaRr apply xrlh ONLY nfrl, (lie romr
/�ppI� (J ronilrve(for✓abondortmrn{you ron rvbfilf etr[f01'tn.
rJC Well oul:netor CettlticaUon Number JQ N 2 ® 2023
7b.APprosJmate volume of rraler nmalning la Hell(:): �®
N.W: Poole Well & PUMPCo. (gal.)
�� WAT>"x'Urrt x W�z.Ls oNl xt
Coropnn?'Name ,,9 •„ •'r.
2.11'eU Conalrncllou.Perwlt H: �/js/ �0)? 7.TTte ord(slnfectant nredt ��•
Liar Orr oppncab}r mrll pill 1r.[,Couv,ry,S/ofr,Ir amr.I,1rreNorti uc��fr,
3,Well use(cheek n'ell use): 7d 00ot of dlslnfecDtnt used,,
Fu
Supplygrloullttrnl 7L Sel l(ng rnalerltde Used(Check all(het apply):
codtcnnal(I�ealing/Coolbt Supply) 'C1MunlolpAl/pttbilo ❑NwlCemenl Grout. .
A PP Y) ^"esldtx Ud Waler Su I tin e ❑Send Cement C7roul Dry Cl Ile Chips or Pellets
❑ludusUiaJ/Cornntcrcl,d PP Y( 81) ❑Dry Clay
❑RtsIdenti,V Water Supply(ehtutd) C1 Cvnatle Grout-- allutt 0 brill Cuttings
Nan-1Y4ler Supply}yell: Npeclalty Grout Cl Orevel
I7hfvniluring ❑Benlvnlle Slung 1A,)cr(tatl Well: ❑IlccoY d Otlter(explain undo 7g)
OAgttlfcrRcchorge 7f.For each maltrIld le tied abort'prmlde�tm lux
C7AtlulCcc Slotugo and Recovery,' ❑Qroundlvelerltemoctldltnt e �
❑Saltally Banta J f
C1Aqufer;'1-esl ❑Sill ,� .tmwalcrl)ralnago �� f�11¢=';�'
0E3"xperhnenlnl.TCohnolOgy
,DCeolllennrd(Closdd Loop) � ucldCnCoCvnlrvl
7g Provide a bNe[descriptlon of the abandonment procedure(
��Jl7enthcrnlal calm' Conlin`Rchirll 91.10r lalrtunda.•7 � 14L
4,Wile lt'ell(S)AI)AlldtltlCd'
3ny.�1Y�eU�lv�eallvul .
rartllly/Dnner Nemo Feolllt IDll(Irq,pUo[61[)
S.CerUnca
IJA
/�[e�.
P yelenl ddreta,;Cl Yt and Zlp ^ � -cni liae��
� — / 81plimd of cd will onlnrrotur ur}YeU btraer bale
Cu (y / Dy rlgnfng Ihlr Patcel ldeMlBcadtrtlNa, form`"'Ire rer*Hurt 111e)POI sJ teat(vcre)abandoned In
(pW) dccorddrlct 1Gjf/1IJ.�'NCill;�01C,0100 or1C.0200 Will Corulrudlon 5tmidarda
gib.I aU(ud6 aud:iringlttiiip Iq'llegreei/rnlnutet/seeonds or decimal degrees( and rhala roFJ'°f tldrrer°rn'har been provided ro rhs Hell vnner.
(trn'rll'lleld,'ooe leVlbtig li iiiF[ielei,(}
9,Bile dlagrtlm.ar addlllbtinl r eU-dclAlls:.
You mkp tttd tfie,6`adk of 11i1a pogo to provido additiunal Well site dc(nils or well
r.
--_ ' abandotunwt'delalls' You maj also attach addlUOntt1 pages Unrressaty,
nr.11}bfYfi Iifkr` stt �,
rrt' AN '- a':, , ..;,•f.;:)il f7)f,' TN bn.6n rron-kartr-ngrply'trlUil7'baNdvBniihl,jil"N'Eeii 46rtik orir John,
in.}Yoh Illti IUa,]rvr: Il:`FY lI�( ,Submit UO3 fora: within 30 days of eontplclJon of well
abandoli to(il16i}tB'rU11vWIng;
':gib Tufal hell depth: blvbioq U�lyalerllerourCes,Informativn Processing Uull,
(f0). 16.1714iill&IlgCe Center,Ri lclgh,NC27.699-1617
=C lob, r.Ilorebole dlarnetcr;. - Lt.In-addlifull Iv sending Ole funn lu Ulu oddltss 111 IDS
(fO.) above,al/andotttien tri s'ilHiiiltt ofib dopy of Utls fuml 1vlUthi 30 days of completion Of hell ld'Ilio tbllowing:
��'•l•-Fl`alerlcvelbclii'tygrotlioiiil:rfaeer.-.: "�'�
(R.) DlYldon.vft}ititbrAtiources,underground Infection Coulrul Prugrnm,
jW-Wil:tlerrtce Cooler,Ralelgb,NC 17699-1636
;:r..QulC,r CailnU lehgllti(I[Il►tUhh) '
The Ad In addition to sending Ole Cornt to
n�'.,..•olio Submit One ropy Of Uds form WWII 30 days of
r:Inner e,asinghtiblug•length(Itjmiityn)(: = CUmplell6h of W4�abahiluninenl to Ulo county health de
ParUnenl or Ole courtly
=_ra Sctce(tii�ti�(fi;',(if;lloiyttjl '
(a)
Nottl(�eirilln,boltirtmetd brpArlrbnmam>na rl.,,».,»_._.._.-

YYz'iL1�:,c9B;�IYD•plY�'IEIYT COED
F I>3ictaal 771ds form-can be used for etngle or•fitlltlptb well UoINLY:
s.\Yell Cont ( '
Nell Contraclor Name(or well owner penooal(y.6,ade' 7a.Number of hells being Abandonedr
j„_bJ 76t Yetertgp r•,•. ° or mulllple ir�rellon or non-xater supply }rr11r ONLY H ld, the eels
8,,.,1(,,,t v a c3nrrrucrlon/vbondonmrn{ym can itrblnlr ant farm,
NC\Veil Contractor Cettlf"Uoa Number A
. pprozlmale"lame ofwater remaining in ne(I(r):
N.W: Poole Well & Pump Co. JAN 2 0 Z(123 7b cg )
Company Name WATE$BUPpLY WELL,q ONLY:
171
2.Wep Construction fl 7t.T3�of dblafeefant aredt
Lrsr on!apprrroble wrll perTnnrs o.e.Ca,a,7 5ra'rr,Yarlamr,�rr/rcNon rrcJ f/6taxn .
3,11'c:l use(Ebeckwell use): 7d•Amouniordbhrfeetirntused,
11'atcr Supply 1VeU:
17Agr)culttunl 7G Sealing materlair Cued(cheek all that apply);
l7Muniolpelftbllo 11 NMI Cement Grout. .❑GcoUtcrmttl(fiealing/Coolhtg Supply) )teafdentlal Water Supply(single) C rout ❑Send Cement G Bu lonfle Chips or Pellets
❑ludustrinl/Comtnercltil ORdidentlal Water Supply ehsrod) 13 Co cMd Grout ❑Dry Clay
C1lrti aline PP y( . 0 Drill Cuttings
Non-WalerSupply Well: rwpeulpjtyGrout d Gravel
[7Monilodng ❑Benttndto Slurry ❑ Other(explain under 7g)
1nJecuun Well: EO]Recov
0AquffcrReciterge 7f.For each maieN❑electII0rvuned abavy prnvide arnonnt bf materials used;
❑Aquifer 8loragu and Recovery• 1]Salhil d Barrlaemodfallon , , —
❑Aquifer Test ❑SlarmwaterDmInag
❑Expbdmental Technology
❑Subaldcuco Control
00coUlennal(Closed Luop) �Tractx 7g de a brief deacdp[fun of the abandonment procedure!
17(Jcntllcrntel cello' Conlin' Rctum ❑Other (dn under 7 �
J
1,lJalc wells)abandoned: — ..���`� �T�A �nI l
de,Well location: ! ^
Pact UlY caner Ne e
�—� FaollltylD,tlr,(lfeppporble) 8•Certltleatlon: 1�,
Phyelca Address,Clly,and Zfp �J
Ay �i� i else oiCettlfte -e Cantrselor or b0 t?rrner
�--
Co°"`y BY rf8rdrt8.fhlt,rvrnt,I hrr.?y cenyy Una(flre 1pell(s)1par(were)abandoned in
FetalIdentlBeadmiNo.(PiN) aceorrfdrnds:still�Sd'NC,lt;�01C.0100 or1C.0100 Writ Colufrurffon Standards
3b,Lalltudl; .61RIA inylhiflp.la'degreei/mlautee/aecondr or decimal degrees: and fhaf a
r°py o1'rhLr nctmf her been provided to flit n•eJl turner.
life•ell'ffeld,�onelsVlbrigli}uf&nleiit) ,
��• n U Iq IL+U .. r LS��Pf� 9,Slle tilaertim.br a dif oW.Treu Beta l"
_` N j� You mty itsd tie0 of:ilia pug
o to prnvido additional well site details or well
' abandonmeat'deitnlie: you may also attach addiNnnal pages(tnecessary.
�t7ltidA ;
,rel/it7)�''f�}lt )f,lRlt iri 'ebn} 'CrJtltfltrbcfkTdnm;f,fi3'dpetrhtubrillrCNefarm, ,.
, ••- ..,:�. �.' i cti 6r rrog•Srarir'ngrply' .
5n.Web am: 1Va,Forte: Submit 0ds furl within 30 days of compie0on of well
abandorllttefit 161ho,toll6wing:
6bt Total well iiepth:
blvbloii of WaterResaurces,Information Processing Unit,
{f!) 1611 Mill Stryice Cen(er,Rxlelgh,NC 27699-1617
=G Narr bole dlamelcrr lob,. F> ID1ra-- 8tt..r Jn,addlllon abovo, iv aeuding 010 form In qlo addrrss ill loa
(In,) tdro'aulltill�`a a;opy of 011s.form wi0l(n 30 days of completion of well
abendonrne ld'
'd•!Vales level be)iity A nl lho following
Bra trfaae;.. :
• (fi.) 171vialba.oftlYJilbcRetburcea,Underground P. InJec0n
_. I63��Mi1l llerytea Center,Ralelgh,NC 27699-1636 v Control Program,
:= Outer caaln�lehgttt(I[liuu�vh):
(ft) IOc,gg����W��
tho ad' e�an We In addition to sending the Corm to
)F.Innereasingllt(binglpngtlt.(Ifknrtwn)t it'�'vrW61 `ab dao submit tmo copy of Us form wi0dn 30 days of
comre abah o ivoll.abendonincut to the county health department of Utc county
------_.�(ft.) where eba6donecf.
°t..5crCeulau tdi,(IC:woirti)I,
r,txm 41V•3o ..
1�orth�srullna bepYtlraeal bf Earlrboanot Yod Nrlttnd Aetoitoei w Dfrltlnh'nrw.,..t,.........

I
f , ,i�lllll)•pIY�YI�,jYr�' P� • 1
lllis form can be veed for single or•rntildplo wells aIU�ONUY:
- - ( .
I.Well br!jelar InrormeNoul I
i 14e11 Contrsclur eu,e( n Aer en 7a.Number orirelb being abandoned( e/
/"'� p wally absndordggiPill�nhl,lherPfuPenY) For mvl!lple In/ecnon or non-trafer , i 're1G ONLp 'u•fric the Jeni/16
�'� d 2N K, "' a ,rrucrronubondonmrn{you can Jubmtr one jorT6.
NC Well Contractor Cetddcallon N_amber
9b`Approzlmate rolame urwater remalning In eell(s).
( N•W: Poole Well & Pump Co. JAN 2 p (gal)
I p ��23 Compeny Name FOR"Al X m BUFFLY WELLS CNLX:
17K Type ordisinreetanf tj
i 2.Weil CoastruCtionTcrmlt ff: !1(s'
1131 all appilwblr rnell rrmfrJ
r fr. caanry,sane,varrmce,tryectloq erc)Usna,r„ - I
3,Well use(ebeck well use); 7d•Amonnt ordL(rIleclant used;_ r
I .
Walct Supply 1Yet1:
DAgrlculiurml 7e.Settling materials Cued(check all that aPPIY)
1 OMuniolpeUpubllo ❑Nest Cement Grout. �" ettlonfla Cb(ps or Pe(IcLs
i Olud st flat/ (mmer g/Cooling Supply) kesldend&l Walasu I (single) 0 Sand Cement Grout
❑Industrial/Cornnlcrclal supply( a) 13 Dry Clay
13Rmldrndal Water supply(shared) ❑Concrete Grout ClDrill Cuttings
.Curti slier g
N 1,Water Supply Wellt ❑'Spxidty t3rout ravel
❑hfoniloring l7 13enlonito Slurry d l?llret(explsin under 7g)
iIn)eclion Wcll: ❑Iiccov
❑Aquifer Recharge 7L Far each ma{eNai selected abort'provide arooant bf materials need:
❑Qtoutidwaler Remaflnllon
❑Aquifer Storage and Recovery' ❑Sa1lnlf Barris we
E� °
❑Aquifer Test I75lormwalerl?rahtago /,R - f. -Jr)Al,f'"� n. t
❑Cxpet{ntental Tr BY 11Su
ehnolo � `��`���
bsidmw Control "
❑Cleolllermal(Closed Loop) UTraoa 7 Prorlds a bde[deaulption of the abandonment procedure: n
O(3eaatcxt»al cello Coolln' Rattim
Olhor lainundm7 .:,AVM,� 1 4hr—,1,,6
ip
d,I)alc tivell(s)abandoned: •� r�� p !f
i58.Ivan lutWuut
lacfliiylDrvnerNemo` FaddtyIDy(Irpppscsbly) 11,C •Itlont r
�,
PllyalcalAddtea,Clly,andzip r .'_�= �' '� !
o s . sy t:. ±
l A � .0-7-s� stwfo[Cstdtibd ConbaolororWea�xner Dele
County Patoel ldeaailmdodNo. IN 'BY jlgrdng fhwu.. rn4 I hleq y certify Unit file 1pell(s)tear(were)abandoned In
(PIN) dccorddnes*0111d'WN0 01C.0100 or 2C.0200 Well Corulmdlon 5tandorda
5b.La(Itud6.and:fonyllvflp.tri degreei/rhlantei/seeonde ordecimal degreof wfd tlud a copy of thb record hur been provided ro the well owner.
(irwelf fleld,rooe laVlbtig Ii}iiF&eleitt} ,
u r dlagntm.or addJtl6iial Hell dcblilr.
114 You miry tisd;i o ibdk of s potgo to provide additional well site details or well
' abtindonment details: You may also atlaclt addtlional pages ifnecessary:
rirf My1➢E
'',' �: . iEMbii 6r.trori lrcrtr np�ply i)CTIONIi
�retlr iy)Pi PAT abn}' edd;t}cbaiidd' :::
j 't�menl,jdk ctfi eu6r'r'rlr dtiejotm,
l ;,n,Well ffiyf Ioa,For" tt,}y tl;r •gubfuit ads form violin 30 days of compleooll of well
abenda tetil Io ali rollbwing
f °b: .ralal;pen uep,b: _ e blvLion'ofWa ter Resources,lnformallun Processing Ulilt,
(fb). 1617 Mill Service Center,Rmelgb,NC 2766 9.1617
y lob,
Borehole.dlamt(Del. �1eL- a— °-- :r In:addlaull to sending are form to ate addrrss Irt IOa
„above,Also`1iflikilt:vfib copy of ails form vlalln 30 days of complelion of well
abandonnienl lo'die Following:
d•Water lcvel tt'ttrfaae:..
(ft) DIvlslon.ollYfttErRejunrcea,Underground Inf ecaen Control Prugram,
I611 QUtel'CRAIng'Iehgt �ervica Center,Raleigb,NC 17699-1636
h(IEhndtgtl)i
d, 1or.
( ) the ad y In addition to sending ale rum,Io
t !�.i$ " tone submit one copy of ails form 'Mildn 30 days of
1 s`.Inner casifiglldbing length(Ir•knittvn)t COmAl�lort or W611`abaildotvnent to ale cowtY healer do_�_(l,) where abandoned. I department of ale comely
��.St:reonl�tigl�i,(If;Irdbivti)1•. .,..`�"'
i 1`0M OW-30
Nort6GiinlLtr<Dep'firfineatbrEaT(r5ttaxallndNslundAeiou�ei%iI]1'rl,lofiofWsterRrmn,n.. _

rrUU.t�:•�,c9�1rDp
ilds fonn•can be used for aingle or•Inrilllple wear � I Ufa ONLY,
1.}yell
7a.Number of irejb be]'
lnQ abandonedr
>' enoarl(y rbtadooing iriUbo hlvber opt For mvinplr I'll
I or
non•xorer r
.pJ us e-n,rrvcrrm✓abandonmr %vely nrtlr ONLY vhrh the name
"4' • LE C n{yov can rvbmrr one form,
` 7b.Approzlmate lolume ohnter remalning In
Co. JAN 2 0 nea(s); 1
p (gal•?
FOR WATE 8 2023
R UYPLX WELLS ONLY:
�,_ Ifliuiell��1 fir. 3.'••r',.:f} c .
le.Tn"ordLlnreetant nred,
Sfa�r,Y M1
.. arlaner,fNCarlorreJ((rtrrox„ s
7d.Amonot ord"Inhclnat used:
i gr eulhrrnl 7a Sealing rnaler(aL owed(Check aU that a
❑Munlolpal/pr;bllc I]Neal Cement Grow. pp YJ:
OOcoArial C ni jeteloCooling Supply)
Residential WaterSupply(tingle) ❑sand Cement ettlonile Chips orI)dlcts
OludusUlal/Contnterclnl ( �)
.OIni adore . ORealdentlai Walrr supply Dliarw) O Corrode QrOVI O Dry Clay
Su rl
Non-SYater 0 DHU CWangs
� Pl }Nell: ❑'Speelally grout
C7M0111torfng O Bentondto Slurry Otovel
1n)ectlorr wall, 011ecov O Other(ezplabr under 7g)
OflqulrerRecharge 71.For each material selected abovy OAyuifcr5torage and Recovery ❑❑SQlrovmunwdawlearleDr rRaelrmlaegdolllcar
'� pmdde..a�o ou nt bf urlerla ls use°d.
:
OAquifcr Test OSa1rGt B�r1a Ae�_s
r]CxpbrimcrlW Tcclurology
7 P
❑Geolllcrtnal(Closed Lvop) �Subslda)co Control
'I Trace r rride a brief description or the abandonmenl procedure)
L❑Ocothcrnlal icatln. Coolln Reltim
pother lath under.•?
4.DR(C rrell(s)abandoned:
ia.11�locnliun —rl— �Ct
scililylDRner Ndme 0'r�-
a y Facl illy It!11 yrtppUcrblr). 8,C 1111CaUool 41" ,
� oar r•
i Phyrlenl •ddr s Clly,l d Zlp C,u� !`¢'ro,, ��ra rij
alpsho- ofcsrtili' WdUContnolororWeUllRner R .
(� Dale s
CcuolY Dy 11011g lhlr. �' Uy
Patcdl Ideat annuls No,(ppl) deco �° 'f hrn etrl Ulai`(he )pel/(s))oar(were)abandoned in
'b'La(lludb+rnd:lonyllud�Iri clegreei/inlaotes/seeands or decimal degree: rddricr ' tJ�NCdL{01C,0100 or1C.0200 Well Coru/nrdion Standards
dnd tlrof d cW of thLr record has been prodded to the wel/orl•rher,
(Irnall(deld,'ono lel/li rtg li}uFgIn-d
i 9,Sllc dla
• � �-7 o- QtAm:orriddiil6halneUdelaas:
on t-d .Is-- or Vila pogo to pruvido additional well site details or Nell
abandontneni'dt}jnj(a' You rnhly also attach addllionaj pages[rnecessary.
r(Ilgcll�/ 1
� a•elli(jJ� •'•'
t lltlr` irl' db11} 'art thC7c�ajhleHfriFli 3lr eb,r! ivb>ii110 a irarrr'ngrply S
1Yel1IDN: loll,
abendodtl eh o��Submit Uds fvrur wiudn M days or cornple(ion of Jvc11
`�i�''.Colal ir•e11 ilelrlh; b1vDlarioflYaterliesourcea,Informa(!oa I'recessl(ff) 16I5 Afill Service Cenler,Iinlelgh,NC27 og Urrfl,.699•IGd7
'�.IJoreboledlarncfcr Iob,
(In, �- 1Llt.In<addillorr in sending Ohc form fo llhc addrtls In IOa
I ) above,r nenj Htdj6'pffio ropy of oils form wltithr 30 days of complelion or well
� BbandonnlCnl ltl.Illc fOliorving:
=d.Walar level beldN•gratliiij iirrfaee;.
(fL) Division o!:}yr UrRespurcesr Underground Injection Control Progrnm,
1631i )A�Service Center,Raleigh,NC 27699-1636
:c•Oufereaaingleggtjt; •
(ff) IOc.
tbo ed ' ' `,db In addition to sending tiro four,Io
Inner easlriglfdbing length(If knbwn)t ' m11 submit ono mpy of tills Corm Madn 30 days or
��. eomplethiti of ivoll:abandoninenl to tire county hcaltit department of Ule county
vrilcro abandulal,
=_,5creettIdn�jH;(I[:kuarvh)I'. � �'
(a)
OMA MV-30
NutihCsiallnatie "
putmelrl bf Phrlrhn�,...r�_,.i_.. .

MMMOMMrrMild t��,11IVUl�IY1EIYT R CpRD
nlis form can be used for dngle or multiple wells �w"'u+ml Ul O116Y.
L Well entraclar Inform don;
\VellContgractorN e(or ellowoerpenooal(yabmdoniogiPii(pohialherpraperty) ForNmmbp�a°tils;p llaglrl6rapdwOedi rtpp,Y �9eilr ONLP r
i a � "'s a ... rtrrnrerlon/abondonmen{you can rnbmff one form, t iat rile ranee
I NC Well Conunetor CortiQcallon Numbs E d E
i • it prordmate volume of water remaining in well(s);
N.W: Poofe Well 8r Pump Co. JAN 2 0 2023
Coropany Namc
FOR WATER SUPPLY WELLS ONLY:
I i•Y '�n,art x. R�U Type of dbinfeeti at aced: o`.y"
truWon —�
I Z.Well Cons H. � �� J J 50
Urt all appllcab)e well permfrr 0.e.Commty SIoIe,par► � �
arreq fyterlorl,treJ(�bloxrl .3.Well use(check well use): 7d•Amount of disinfectant used: �j
_
Water Supply Well:
i CiAgtleulttnal 7a Sealing materials freed(check all that apply).,
vfunloi al/Public sf pP Y)
❑QeoOtennal(Iieating/Cool6t Supply) P eel Cement Grout. bOBcnlonftc Chips or Pellets
g PPY) ❑Residential Water 9uppiy(single) ❑sandCementGrout❑ludustrial/Commercial ❑Rpidrntlel Water Su ❑Canaolo Grout l7�Y Clay .
i C1Irt1 atlon Supply(ahated) ❑Drill Cuttings
Non-Water Supply Well: ❑-Specialty Grout Gravel
t7Moniloring ❑Roc°v 0 Berttouile Slurry Qther(explain under 7g)
Injection Well:
❑Aquifer Recharge U For etch material!elected abovy provide amount bf materiels used;
IlGroun❑Aquifer Storage and Recovery Q d B�gateremedtetion
�, ash, Jr "wf�
❑Aquifer Test ❑StormwaterDrainag S' i, 7 A,I
17Expbrimental Technology ❑Subsidence Control ���
❑Getilflennal(Closed Loup) Mracer 7g Proved!a bNetdescription of the abandonment procedure;
t7Geothenpal satin' Coolln Rattan ❑Other lain under 7 4i� 4l�r
d,Date wells)abandoned; 5
5s.!Yell location;
Fecill %OwnerNeme FatiiQtylD (if
eppQceblej 8.Ceriltleadon;_
Phyalcal A¢drool,City,and ZipfiL67-
�NLt i f 6 81paturd of ccrtmed Well Contnotor br Well Owner Dide
County ��
Dy signing this form,I he. cenYy durf lire well(s)rear(were)abandoned in
Farrel IdeetlQcadopNo.(PIN) dcsordantit 1f1i 11 I'. OIC.0100 or 2C.0200 Well Conrinldion Standards
5b,I,afitudb.t�ad:iotiQitude iu degreei/mlaotes/iltands or deetmal degree: f Q of this re'uni/;as been provided io the well owner,
(ifwell'£ield,oati lal/1orig Ii kiii$clent}
3� 1� (sue p� o it 91 Site dlagrtlm;or addltloua1 well details:
i N_ (1 ,)($ �,I(a aba may itse,tUe,Tyack of ilia page to provide additional well site details or well
:itiaeli{G'.1l6d •:.
W abttndontaeat details; You may,also attach additional pages lfnccessary,
n ell 11iVL1 i�jji iirr'tlhne cdxi')nleflt'frajcbalfdoMiirl+l jv edn�rirblii�lt cne�-water al
IDa
60.Won W#., I For ;r -Submit this form within 30 days of completion of well
abandnfime it tit Q rOH&Wing,
6bt Total well depth; SOS
D1vtrloti�ofYya1erReoources,Informative Processing unit,
1611 kill Service Center,Raleigh,NC 27699-1617
y 106, N .
6c,Borphofe.dlamctor;. .e llc-- d0--�a. .in addition to sending Me form to the address In l0a
(In.) ebovq tdso'slitfbilt:`uno copy of this form within 30 days of completion of well
Abandonment id the following:
6d.Waterlevelbclogrotintliurfaces ( Dlvisibn.ol+WtitcrRlaonrcea;UndergroundinjectionCvnfrol
(n) Program,
1636118ervlce Center,Raleigh,NC 27699-1636
Ge,Outer asking lehgth?(IEkiitS(vp);
the ad In addition to sending the furl to
! ( .`dl oYe,aliO submit one copy of this form within 30 days of
6f.Inner caslrigltubing length(Itlur°wa)t completion o Well abandoninent to the county health department of the county
w}ttxo abandoned.
6g,Satetl',.1dII r ��
Fattu(3W�30 .
NOtih('lltiligibep'utmeotofilarh runientkadNltunlReioigcei-,IilvlsiotiofWaterRerourcea
Revised Aueult 7n;:

1
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well CoiNactor Information: WELL ABANDONMENT DETAILS
t 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well oner perty9 "" "Wg11 construction/depth,only I GW-3D is needed. Indicate TOTAL NUMBER of
IV �,ivblls abandoned:
r
NC Well Contractor Certification Number n Q 7b.Approximate volume of water remaining in well(s): 7 (gal.)
r
N.W. Poole Well and Pump Companp �j c WWATERSUPPLYWELLSONLY:
Company Name y ; l�� HTH
G W-081446- 22 7o Type of disinfectant used:
2.Well Construction Permit#: 1/2 lb.
List all applicable well construction pennits(i.e.UIC,County,State,Variance,etc.)if known
I 7d.Amount of disinfectant used:
3.Well use(check well use):
i Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout �&entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ,Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f F each material selectedabove,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation / t�?
❑Aquifer Storage and Recovery ❑Salinity Barrier -� [ !/�
❑Aquifer Test ❑StormwaterDrainage
i ❑Experimental Technology ❑Subsidence Control
I PIW;5zf�7
description of the abandonment procedure:
❑Geothermal Closed Loop) ❑Tracer �/ �❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g) I ���°`-
,. -
4.Date well(s)abandoned: , A D f J A40
i .r �
5a.Well location: Well #1 � �'�I� � I�
PL
A Squared LLC
Facility/Owner Name Facility ID#(if applicable) 8• Fruircution:
235 Grand Avenue, Raleigh NC 27606 1� _n
) �,
j Ph ical Address,City,and Zip Signature of Certified W ontractor or Well Owner Date
Ph
By signing this forin,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identificatio❑No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
35.793819 -78.717315 W You may use the back of this page to provide additional well site details or well
N
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBNIITTAL INSTRUCTIONS
Attach well construction record(s)if available.For tnultiple injection or non-water supply wells
ONLY with the sane constructionlabandonment,you can submit one form.
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 4a— (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Gd.Water level below ground surface2 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection 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): ®@® (ft.)
III Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I!

i
QIake' Co uny..INeli �apaiepa JNell�ead '�sp�cion request
mw
Wake County Well Repair pel•mit#
1 �r,,.�•677 Owner:
:,lr�►Ml�• CR(kN(oR�
Site address: ..
pL d Owner contact phone number: 61
! CIty: h b=drK s"r ZIP Code:
Well type: Well tag located? Casing depth:
�s��tt,ED �5
Static level; Water zones: a
WPII yield:
Camerd Inspectlon?. Existing liner or-screen7 Well depth: \
Evldence of original grout: Total depth of liner or screen: Wellhead above grade?
_ ,
777777
Well depth: 1
��.� Well yield: n G
Water zones ; Static level; o�
Water zones:
Liner Installed? Uder depth from top of casing: _--
Screen Installed? Depths of screened sections?
Well hydro fractured?7' ''
o
Wellhead raised above grade?
DF F2 A,.. SeIf P
.,.T
PE
Contractofr7TiR'
A//Z L 5' NCIVCCC -Ceitlflcatlon number:
I
Signature of contractor: Datd:
Contractor phone number:
I �
Wake County well re
Pa.ir xeport7/09ver,