Durham_Well Abandonment_20230127

Iltie fonrrcen be used for eingle or•mnttJpl•e wells 1II8I Use ONLY,
uatrxetor Into resell nt .
Well COntnetor Na K
(or we I ow pner enoa 7L Number o[irelb being Abandonedi
alt}abmdonlnQitiUbnhle/hetpr°Prrty) for
muiflplr Irllrcflon or Harr-rroler rLwply trrllr
aonrnvenon/aborulonmrn{yov can rubmfl one form, ONLY ufth dre mme
P!C 14e11 Cobuxclor Cerrll>caUon Number
N•W. Poole Well & Pump 7b.ApproilmatevolameorwAterremelninglanell(s):
mp Co.
Cmupany Na_, FOR WATER SUPPLY WE
2.1YeU Covetrnction Perini(N. 7e Type of dbinfertant nred:�/ / /l 1
4r all applfcoblr e�ell prrrnfle(7•r,[ Srare, D 1
crlarrer,lryecrlon,ereJ(/,tn�o>m "--
3."'Ell use(check n•ell trae); 7d.Amoonf of dleln[eeiant need: /I.
Water Supply}Yell: ----_
ClAgrlculturnl 7L
C1Munlolpel/p ubllo Seal
>rrl�at gtro^ed`a�check_all that
ieaUng/Cooitng Supply) VesldenUalWatrSuPPIY pOOeoUrennal(
❑ludustrial/Comec >ey
ct ttonite Chips or 1clicsd ❑Sed CmenOrout ply).'
01tri allon ❑R sIdenUal Wafer Supply(ahtuod) ❑Con"e�NtQtl 2 7 d Dry Clay
Non-Water Su I• 2023 0 Drill CWUngs
pp} Well: Spevlalty Orout
IJMction ing 0 13m,
,� 38��Una �Oravel
Injection 1Yeli: �Recov O Other(efrpldn undcr7g)
❑Aqufrcr Recharge 7r.For each maieriai eeiecled abov
❑OroundwalerRemedldlolt 4 provide amount brmalcrlals used:
dAqu er Stalage artd Recovery ❑Sai(nll Berrie V,
IJAquifcr Test y
oCxperinlcnlnl Tec)mulogy 11Storrr1MterDminag0
OCeolhcrtnal(Cfoscd Loop) OSubsidenco Control ff
❑Tracer 7g.Provide a❑Othe brief des
❑C3coU eriplfoo of the abandonmeni procednre:
tcrrnal Fiititln Coolln Return ,
r lain under:?
',11n1c»ell(s)AbAndoned:
3n.Well laeAtlUtl:
!3 I'ecthly/pones Name
FacNtyIDd(If Ucsblr 8.CeM111caUont
tom•
rtty I,iaale,,,City,an zip
p�— (E✓� 8 ettat vCC �edWeUCajltnelar or WeU owner �
bete
C uty Uy rigrdn rho
Pateel Idetdlneadvn No. 8r I hen ctr[(fy!Isar the )vrll(sf tear(weref aGarrdaned In
:Ib.LaUfudf andaonQlluUd In de�reeti/mlootedtaeconds or dedmal degn�; dndth to i}6ffli ell,
XCUC 02C'0100 vr1C.0200 P 111 CWUlnfdiof!Standards
(Irnell tleld,ono 606ng Ir iuF9cleot} o1u1 rhaia COP3'Oflh4 Mord has been
�, /j��y, prmided to tl!e well owner,
y2 7�• �1 ,Site dlagntm or Additional treU detalfa:
N 1 Al�J You may utd(ee 18.' of lWa peg°to provide addi(iond Well site deaib or well
ebandonmwt drlalla; You m
f HY also eltach addilional pages If necessary.
AdticM7li [
ir1' cff)Hl `Crltht)abalidOhhrilr/,�tiir ;,rubrMit Die -tralrr ripply Mwa&zM=Qa6
3r,1YeI1 II)H: 10a,
°band°°mto Illi rvUoubmit Lids form Within 30 days of complcliolt of tyell
rb 'I vial tr•ell depth: UlvUlon of Wafer1lejource.,Informai(un
1617 Precaring[loll,
(fi.) Mdl 6ervlce Center,Raleigh,NC27699.1617
9
130r•ohole diameters lob,Fvt nl ellnn N.u.
(In•) ebovq dlso dpe' t o" 'ho p ol°�s�J�o�°t Bending U30t Jays l t We addrr of ttv II
".Water level below gratifia ttlriacer. . abandonment ltl Ute!allowing:
(fi.) Dlr(alba Outer cating length(If knUfrn); ol�lYtlErKesdnrcca,Underground InJecflon Cnnlrnl Frogrnm,
1�Slift dervlce Center,Raleigh,NC 27699.1636
(R) 10r.
Inner easing/fdbing length(li•lmdwn)t (f �0 ed ; In addition to sending Utr Conn to
'.ibttvti,"alev aubmlt one copy of oil,t forth
�v w lac abandoned.11 ebeitdottrnrnl to the county health de Winiln 31 days of
( ) department of Usc county
_ 5ereett It!n�lF;,(II)Inntvti)I' """
(It)
,nrr OW30
NostlrCtrolln�beputravatb[Isrlr ..r _

���L1�r:�,��.UU!`�YIEIY�'RECORD �p(p•� f f r
711ie fonrren"be used for aIngle urmnlUplte"Us W t"�I V�ONUY.
].11'el ontractor In rorwellunt
�Vt ontraclor N e(or well owner en iUbn 7L Namber of Wtjls being abendonedt
p oaal{yebendn*1* hle/berpropeny) For
multiple tn/eentan or non-xaler etapply trrtlr ONL1 urtJt die Jame
cenrrrvener✓obondonmrnr,
11C Will Canuxclor CertlpcAUoo Number Yet'ran Jubrnll one jots,,
Tb.Approilmile volume of meter remalning In nell(s): al
N•W. Poole Wefl 8� Pump Co. (got.)
Conrpnny Nautc �3� FOR WATER t9U1'YLX WELLS q pM,yt 'I 2.1yeU ConatrutUnn Vermlt ll:1-22
7r-Typo of dblareetan(need: Xf
LfJr all npn/nroblr N•rinrermul(1.r.Cc"q arerr,ierlerc rleJ lfb,oxn
3.}yell use(check well use): 7d•Amornl ordLlnfeefAn(used; � _�
1VnRrSupply lYell:
DAgriculhunl 7e.Selling malerj d$rued(check tall that a
oacculcnnal(1-feating/Coolln s� 1 oMunlolpabllo 0 Nest Cement(3rout. pp1 y)•
8 PP Y) l/Pu
Xesidentlal Waier supply efo e ❑Sand Cement "�� '•� �• o Bcnlonfle Chips or Pelict3
olnduslrlal/Comntcrclnl PP Y( g1 ) Clay
❑Uri atlol, oRwldMI111 WtIerSupply filtered) o Concrete C3rvut� .�e--r �� E E Y
Non-lYaler Supply'}Yell: O brill CulOngs
0 ullilurills ldtyt3rovt JAN 2 ? 2O23o Oravd
❑Recov f3entordto slurry �pp
1n)ecllon well: InfocsQ'ra�+?n Pr;3C.loiex &tr(cxplydn under 7g)
❑AqufferRecharge 71'.For eachmaleNalleft r�
❑l7roundwelerRemod(allort 4pmvfdearrouu(ofm Ierielsuaed;
❑Aquifer Stol>agr and Recovery oSal�l 13attia /�i�
13Aquifer Tell -------
❑Cxperitncnlal Tccltnology, �SlorrnwaterDralrtago
❑Geotlacnnal(Closed Loop) o5uba(dcnco Control
oTracer 71.Provide a brief deavipllon of the abandonment procedure:
I.00coUlcnnal Jcalln Coulln Return
170lhcr IeUt under.•? /f� �a�7� l E/a
?.1)n(c nvell(s)abandoned: J" dw �_ f�� ✓ r
3n.Wed locallull: `1
1 ecil3lyJproner Name r A
. `/ i-� FeolUtyII)d(Ifapplleable) 1. 8• er11(Ic>tUon:
'6yrlcel / eta,Cily;and zip
�'� gidneluri of Cyr d WeU Conbaolm or Well Owner
Da(e
�ounly Parcel lder(lde,dod N n 111rdnglf
o. IN y
rn� try Out//it )vell(ij teat(were)abandoned in
ab.LRU(udb ardJonQllude In degreedriilnntes/secondl or detlmal degree; °ccortlmtca ukli lJd NCfC'O1C,010O or1C,02001Ye11 Colutnrdiorl SJandarda
(irn ell:laid,one lat/Ibng Ii iuFAcleiJr} and that a"W elldr record h=beers prot•tded to the tt'e11 onvner,
N 9-.Slle dlagrym or addiUonal Well detABI:
You m¢y wd'tho bade of lWa peao to pruvido additional well site details or well
l
abandonment d'W" 'tuu may also attach addlifunal pages llnccessany.
Ar1ceMY4➢ • '
re11 i t7)V i 1h'fh}'.. , ebn! 'l
ttltit[)a'bei►dd ' ! 1' i c'n 6r lron•irolir nyrply MMIAL� G
hhtihl,)r3k etrrt eub�t3(thejolm•
Well IMI! Jul,
abandon(nenr o�g�g t gas fear: wil)ln 3U days or completion of wcll
b,')Dial well lep(h:
{ft) DJvlJfori oflYaterRerourcer,lnrurma((on Procenl 1617 hlall Servfcc Center,Raleigh,NC 276 ctillu7g Un((,
Borehole diameter: lob,
(In•) .above, (dao'-1t bmll blip cop of'additionin is fomr wiU�iGnig30a days of complC funn to Ole etion oIlli log
v II
ti.Wll(er level Wow groulA iilrracer abandonment ld die following:
((l) Dlvf[Ion of:lYrlirResourcca,Underground In)ecdon Control l'rograul,
Outer ca�ing lehglh(If iJnuir•h):
16U ka 6err(ce Center,Relelgb,NC 27699-1G3G
� "��
(il.) 10r.
tbo ad Ul addition to sending Uro Corttl to
Inner casing/tublog length(Ir•kaown)( !i� 'fie° �bQilt one co
comple l6n,or W61�abendontnent to the cow health,d rm walldn 30 days of
�iure abandoned, t partment of Ole coul,ly
•5crceu Idri�tH;,(Ir k4oivp)1;
VQ
,�Yn 41Y•30
North Cauullnit bcliiutrnaut bf P„rlrn��,..,._,.,_. ._

�r U1a1�:�AIyD QhMNT IUD �pIp�
l7ds Conn cnn be used for tingle or•mnluple wellyI
Uu ONLY.
1.Well Co ctor lnrunnntlon:
}fell Contncfor Ntrne(or we owner personxl(y tbtndonlnQ itiL on hJ�ber 7a.Nainber o[irelbs being abandonedl
property) For multiple tn/te
eo utn a,' non•xafrr rrgrply IWO, ONL1 uhh (he come
v mrrveaor✓obandonmrnt,you can evbmn!our form.
PIC well Can cloy Certlntauon Number 7b.Approximate volume of crater Rmalning In nt(1(t): aI N.W. Poole Well & Pump Co.
Conlpnny Ntwo FOR WATER SUPPLY WELLS ONLY:
2.}Yell Conttmctlon Penult H: 7t.Type of dlslnfeeiant used:
Lin oil applicable u•r1l ern,rj, •�
p R•e•Cmmq•,Ste r, or{aner.lrt/tcrlort ere) broxn
3,}Yell use(check wcll list): 711.Amoont of dlsinfectani used:
We(cr 5upply 1YtIL
CAgrleulhrrnl 7e &alin,materials used(check all Thal apply):
❑MunlalpsUPlrblio ❑Neal Cement CWV1 „ ,OOeaUlcimal(lleaUng/Coolhlg 5upply) gldaltia!WalrrSu I (single) O 3enJ Cement CJroul �DClrionilt Chips or Pellets
❑IudwUtal/Contntercllll ❑RalJartlel Wdrr Supply ahrrtul C Conaste Orout n �]'Clay
ohri nllon pP y(shared) JA N 2 7 2Q23 0 Drill Cuttings
Nan-}Pater Supply Nell: 0-9peclalty Orout a Oravcl
oNtoniloring Cl BerrtaridleSNU+p fwa4o—n Prwcz&zir, �111ter(ezplaln wider Tg)
In)ectton\Yell: DRtcov ,MaZ
❑Aquifer Recharge 71.For each maferial seleeled abayq Proyide amount of malerlals used:
OAquircrStoragellndRecovery allni(dwater Barriertmallalhxf
❑AquifcfTest y �� �'Y—•� "`y
11slorm terDra►ringe
I❑I?xperinlcnW Tcclulology 05ubaldcucc Control
❑0re0OIennal(Closed Loup) o7ractx 7L•Prerlde a brief deecr{Pi o/ntof the abandonment procedure;
❑Oeothcnnel 111kOn Coolln Rt ltitn 001her lain under.?
4.Unit il'cll(s)abandoned: l. r
:in.}}'ell localiurr; a R ,
�
ri........Owner Pbyelc ddreee,City,end Zip © IDQ
rJ lfonr too— �alpituni ofCefabd W onhsolor or Well brner
CCU Dy Idcatl0tadodNo.(pW) fi
110ng lJdt form,I h!rr y CW(fy ts(1118 lvell(s)Ivor(rptre)abandoned lit
Patccl accordralcs>611h f S NC O 01C,0100 or2C,0100 Il't11 Colulnrctionf Standnrrl3
:gib.Letlludt and;louQllutie In'degrcei/riilcnteslsecbnrts or deelmai degree,: and that a myaf fUrrtconihcu been prorlded to the n•ell owner.
(Ifn•cll Deld,one It bug fi 1iiFKelebt)
9,Slit dlagrXm,er add itibnal,tell details:
N You tniiy lied;t6"'a of Uds page to prorido addilitmrd well site dctnils or well
— ----- — abanderunent d'Wla; j+ou may also attach addlllonal pages irnecessaly.
W.
it VIM
rttli(j)V jt ljl'th}' ;n' cf1/iF (' iE oe 6r rtorr-tray,,nopfy trltliFlcbadN'rriiFrt,jvir cetir rub M1l cue/otm.
'n'}Ye4 Wit: 10a,For: ►i:.W tier Submit this form within 30 Jays of.ompldlon of licit
abandoeinent to Illo fc&wwing:
b 'fnlnlnellJep(lr; �11 DlvDtoft011Yater1luourcu,InforwallonPruceulu9Uafl,
1617'Midl Service Center,Reltlgb,NC 17699-1617
• 1Db,
:r Dur•ehole dlamelcri. LleC- 0e— - In addition to aardulg Ilrc form fo the adJrrss hl IOa
(In.) eboyc, tdso'',UUMIt biio d
abandonnieni ib opy of Ofls form }yitiltll 30 days of completion of,veil
die following:
ri•Walerlevel beloiygrounilJutfacer..
(fL) Dlvldbn uf}Yttbritesliercts,Underground infection Conlrol Progrnm,
n•Outer eating 1D
ku Mill✓gervlce Center,Raleigh,NC 27699-1636
leilgttri(l[�ufrd)l
(R) _ r.
the ad bi addition to sending file Conn to
(( ".ibdi'$, also submit one copy of lids form wiuJn 30 days of
Inner easing/lublug length(It•knuwn)l eorupletlon of wolf'abandoninent to the cowfty health department of Ole cow,ly
wilcro abandoned.
.,5crcetCldn�ld;,(I[kquivii))� ^��
,,,�,I t7W•30
North GCtJllnt bepillmeci of P�,.lm��..