Franklin_Well Abandonment_20230127

Ms form can be used for aingla or meltlplb weileQN,Y.
1. Yell on paler lnerdrtnalidnt i�j�y�/� /� - - —
Well Contrecldr Natne(or well owner penodalty abmda 7a.Number of*dta being abandonedc
p /] /� ;� °i4tit►1f>mhla/baprdprrty) For multiple injection
or ndn-xafrr supply udb M N(tit dre
/ rr-1f/— conirrvcHo✓abandon ern{yev eery nbntlr one forest.
NC Well Coottnctor Certincauon Numbs 7b.Approijonate toluma o[water remelning In well(a): ( all
N.W. Poole Well & Pump Co. Iwo - --(g
Company Namm Fl)R WATER BUPYLY R'ELL9 ONLY;
r
2.Well Construction Vernal,H: ,,. 7a Type o[diAnreetant tired,_ T
.r_Isr all oppllcablr wrll rrm!/.r
P (,.r,Cmatty,S/arr, iarimrc�,hV.ador;era)Erknorm
3.}}'ell use(check n•ell use): 7d•Amount of dljWtttant used: A—*--
}}'atcr Supply}Pill: —
OAgrlcultural 7e.�+�l�! 1Rlrtued(R that apply):
C1Munlolpal/publlo ❑N RCtme74t..Skdut V;' y
CJOeoUlerrnal —(Healing/Cooling Supply) — y 0 13mntonfte Chips or pellets
pp y) Mesldenthd Water supply(Angle) ❑sand Cement O ut �1 'l Clay
0WdwtrlaJ/Commercial ❑RealdentialWalerBu ❑ContxcMeC#rbuly �`'23
OIrri anon PPI1(shuod) ❑ Drill Cuttings
Non-}Pater Supply Well: PJVF'rac""UrA O otiivcl
l7Mortlloring ❑❑Recov mlvn]lor� C1Other(cxplalnundcr7R)
Infection}Yell:
❑Aqulrer Recharge 7f.Far each malerlid etletted abort'pruTide Amount bf materials used:
Mqulfer Storage and Recovery' 11 allnl d� QemailAla,
DAquifer Test /r /
❑5tormwglrrDnL,aga ��e'1- ��L'
1013xperin,e,ltal Tevhnology, 05ubsldarco Control
Doeolllennal(Close{Laop) pTraoer 7g. orldt a brie[ trip on of the abandonment procedure:
100caU,cnnal cello Conlin RCtUM !]Other fenhilnunda7 '
11.Date well(s)abandoned: � -4
Fa
38.Well location: •�► ,� _
l acluty/Ow tit r Neme �v Faculty IDi�(IrsiTueablr) d.Ce �
k ❑I �
s A
rbyrlcal Addreee,Clty;and zip
8 snrhad o[C ell Can or 'e lhrner bale '
Cduot Penal IdOdficadotl Na, W pY rlgrdng llrf;fvrrp I hrn�y crrt(ly u>ar me ll rn(a)war(were)abandoned in
!p ) dccorddrtcr>fillh lJ.�NCIC 01C.0100 or 1C.0100 Wrll Construction Standards
b.Latitude and.lungltude In degreei/minnlea/aetonds or deelmal degree: arrd►hat u mNvf tlrls rrcvntf lraa beenprrnYdedto the Well turner.
(if nellfleld,'une IaVlbng it iiifBoleitt)
3�1 00( L I-L nn 9.Site dhgntm ar additional cell detxUj:
N _ 1 LJ ( LL You may wd.the 6 cc of►)its page to provide additional well site details or well
abandonmtnt deWls. YOU may also Mach addlliunal pages If necessary.
,lridchYlii
reif}ti)Y 1l t 1H' m' ebxr 'ttlNrt)abaf►ddirr;;�n%yv'k pan ri rm+ho� 'xorr.ngtply g
t.s.Well MY! IDa' Fur•: 11:.Sy I •Submit tlds fvru, wiliw, 30 days of completion of well
abandoriinei,!Io Iha fvl]dwir,g:
^bk Total well depth: D1vlilac of}YaterRrsvureo,Information procening Unit,
p (fb) 161E i 1411 Service Center,Relelgh,NC 27699.1617
��/ lob,For LeleeNbn S}' It.
iJorcholc diameter: a — -. .�r In eddhlon to sending q,e farm to tlly addrrss In f0a
On•) above,also'subii{It oho copy of Ulls form within 30 days of completion or lvell
abandonment fd life follay4ng:
t.Walerlei'el below groundiurface:.
(IL) DIv1Abn l�ervlte C
of}Y,ilerltesoarces
163�}Ifi,� enter,Ralelgh,NC 27699-1636
puler caiing lepglh(If kntf(rn)t '^
the ad In addition to sending lilt form to
,inner casing/lubing length(If•knvivn), Completion f Well•abaaJ duriment 10 ti;� ry hta Ua dmp�aflmenl of3 the dcowaly
vrf,cre abandoned.
,•5creetr Idn�lh(lf kitotvn)I:i:, "'
�,nrt,,4}Y•3o
NorlhUrulltu DIP utrnaato[liaTlrbnmeal gad NruaglRetairael_r1k ki, --