Harnett_Well Abandonment_20230428

r u1.i�:cc�,11.UU1`I: I11 ' Cpfnr . .
This tones can be used for single or•mdlUplb•w Ur �tn'�(ct>ml U�ONLY.
I.Well unt actor inromalion:
•
Well i / •N
r
Contractor Nuns(or welt owner ,err la,Number of ireils being abandoned:
woefully ebendoning VIIIbn )ayerproprrty)• for multiple ! eellon or
. '� non•trofrr reapply wills ONLY Huh the aamY
w. murrverrar✓obondonmrnr,you eat:tubmlf one farm,
idC Well CmrUactor Cetdnc►uon Number lb.Apprvzlmale volume o[irater remaining In Heil a: (gal.)
N.W: Poole Well & Pump Co. O
FOR WATER WELLS ONLY:
Company Name
2,1Yell Construction Penult II: ® +.�• 7e Type of dlslnfeelani need, //TA/ ,
List on npplfca(lr mall rrnglr i
p (f•e.Cowl();Slag, orfoner,lrt/relloq reef(frrrotrn i
3,Well use Wreck n'cll use):
7d.Amount of disinfectant used; / s
1ti'afet Supply Well:
❑hgrlvulltunl 7e.Sealing melerielt need(cheek all that apply):
LlGcoUtcnnol(I[celing/Coolie Supply) 'DMunlolpel/Pttbilo U Neal Cement()rout. •8 ail t1al Weler Supply(tingle) XSand Canitavet Uroul �❑ Jry Clay Chips or Pellets
Oluduslrial/Corttntcrc(nl �'�"�'Clay
t]Ilealder:Uel Water Supply(strafed) ❑Conn,tc Uroul
.0Irti anon n;;. `9� I 0 brill CuttingsNon-Water Supply lYetl `�'"a--; C'Spr l JIy Grout 0 Otnvcl
CIMpn(loring • d F3adonite Slurry Cl Other(explain ultJcr 7g)
1uJeellun 1Ycll: ., oY
0Agillfur Recharge
7f For each mahNatl selected aiwry pave lde R' nut bf auaterinis used;
• ❑Atluifur 8lotagu and Rnforo++c sort PeoczegiVitilfsler Rim cdWhat S3 l�
r} r•` ' ]Sallrilly Barris _ `
❑r�quifcr'l ant ❑Slnrmwolrsl)talnego
•
iJlfxperbncnitti Tcohnulogy dc •
• • rid
t�Ceolltennnl(Closed Leap) C]Treocrrtsa Control
f; �J.•
g Proride>t bri e rite � J —g,
ption of the abandonment procedure:
00u:them:al -1ealln' Cnvlin' Return i!Other lain under? _ :`• e
_ •
•
ri.Dolewell(s)abaudoucU! '_; _
6n.'Well lutetium
Facility/Owner Natna ?
+. r Feelllly IDd1(If y pperble) 8,Ce °r p . , 1. 1 m Ege,._ 1 L• • ..
�9 ,'1 0 :
a
phyalenl Adafreaa,.Cily,and Zlp •
• t
�' �" '',filter uro of Cettllibd Well Con ar or yell Ostler Dm*•
�r ti ;
County • •By rlgning Ode fonry.1 hcre�y tangly that the ipeIf(s)ivo(wen)abandoned lit
?areal ideaUfeaUod Ile.(P01) aiccordar!at Ifilli ikliC4C 01C.0100 or2C.0100 IYtll ConsIn,dlon Slandrirds
5b,1.a0tud6 and:(bngll01,6 hi liegreei mlhulet/seeonde or decimal degrees! and i/tatd copy al fhb record her been provided to the troll sneerer,
(it-mittleid:60 Ial/f64li idillelen() ,
9.Bile dlagraUu or arglllolixl well details!
IQ You mky il"td liiti. as .of Rita pogo to pruyido additional well silo dctalls or well
obendonmtxrl di lnlia;'You ratty also ellaclt addlllonoi pages if necessary.
.4rlaMIi.d f ;
"MI Ulir "' f;:gt ' 0 eii 6r neff4reffr'ngplly Dili OW m,ebri►' ref`'ebaikldr;rri;iii,iillrcot;subriilfisprjotrrr,
'"'Weil IbNt 1Ue'IrortAl r 'Submit lids furor within 30 days of completion of well
abandodlnotil Io lliii Colltiwhtg: .
• [+b,'1'otnl n ell depth: Dlvlsioai'aflYaterResources,Iururmanun Processing(Jolt,
(fl'). •
• 16(`!$Idll tiin)ce Center,Ru►c1gh,NC Z7,G99.1G17
lobe gpj oll''Sy _
r.,Borehole dlatnetcr:. •
_____CgY_____ e Ire ,lnl-eddltiort Io sending thelimn lu the address hi IUa
(In,) „ebovc,•Alao''s'uva{Il bfib copy of this fore! wiUthr 30 days of campiclion of well
• , ellandoitf!lonl iiilllofollowing:
•:ti.Willer level belun••grntlnil ihrfacer.-,: •
(n) DlvLttun.vfr}YsilerIieIburcea,Underground IrriecUon Control Progrnut,
i 'K llilwriteCenler,riadelgh,NC27699-163G
if.'..Outer eaiing.lahglhi(i[ititUSvb)i
;_____,,,, e_______
((!.) _ • toe, • : r
lha ad : In addillmt to sanding the font to
where abaii o 1rob aband nmcip b�lo the countt um y health departme of thls form nt rof3Uta county
_::Inner cvslrigJlilblug length(Ifltn"rltpn)! —® •
� (fb) tititcrcebairdvnecl.
•
:rr ScreetltieiiOij'I[.1 `
•
t't+rus a1V•3o
140rlaAttillnilleplfftlteMbfEntU6otnenter,d14.r;..1n.:_:.:..• •_. ..

sewomenemee rruL111:ccyD pIyIyri'. CARD ( f
71tie forswears be used(br eingle orrntiI J ehre ; • I"�ONLY,
1.Well n rnclor In runnel'uat
Ntt er of lnelnpebda Well Connector Muni(or well owverpere malty abandoaingiillbahlg/herpioperty) FarnwIpl, In/talon nortwt`rrupPlY wilt ONLY nid theE yr
eomrrvermr✓o6ondonmrnt,you can submrr oar fonri.
NC Veil outractorCettintiuouNumber lb.ApproximatetolumeofwaterremelntngInyrell(s): E' I (gni,•
N.W. Poole Well & Pump Co.
FOR WATER 6U1'YLYIYEf,fy ONLY:
Comply Nam
7e.Typi of dGlnfeeiaf uredr1.Well Cons trvcllou,h crud t H;4,,Agicg_-_,fia'LL-3 ° "'
rUsron cable writ pre-rifles fte•C liner•IJir ' hi. of dJthfr [*11t non!: ff9'14P.'
3.}}'ell use Wreck well use):
.Wilk!.Supply Wells
I7Agrlcullurnl 7e.Sealing materitdr used(check all that apply):
•DO midland(1leeling/Cvolht Supply) ❑Munloipal/Ptthllo U Neat Cement Orout.
g pp y) i:stilt:VW Wei Supply dole and Cement Grout C1PDry Clay Chips or PcIIcLr
Olndusuial/Commcrclel pp Y(thigh) llry Clay
❑RaldenUA1 Water Supply(enured) C]Canuete Grout rti Won _ O Drill Cuttings
Non-Water Supply e,11s 4 Y, ❑'Specialty Grout
• .... ❑ Osnvcl
Non-Water
pringU 13cttlmthe Slurry ❑ OUter(explain hinder 7g)
Injection 1Yc11: ❑IZ,000Y
❑Aquifer Recharge APR UL 7f.For yeh maieNal selected atrory provide amount bf materials used:
❑Otowldwalcr ltemedldltnt •
r
❑lltiulCorBloragrgquitttttrnce? :i'r.rc�ca�;r , '�'
�1Ily Banta
DAquifcr'fest _
17l cpbr{rncnln)Tcohnningy ❑Slarntwalcrbralttego LIVeel m- , _ ._
ClSubsldcnco Control, •vcr
JCeothennai(Closoci Loop) OTtaeer 7✓*• Ide tt brief dtauip(lou of the abandonment procedure:
�
Odcolhclmal(lletiling/Cnoling ncltitttl ❑OUler(eaplaht lutdtx7vt
lei) �•�s
i,Bole well(3)abandoned; dam` : �
5n.11'all loan lion! •
.....4...6 ).....423RA3
'M� ' �
Peciliiy/bt<rrer Napo .e, FecIUty ID#(If sppllceble)
y s 8.C ytL]t n1/411W % f c `11,2,/N•
a f.r
Phi/tient Ad ess,•CII andill, '. > `' -'fir yr er tte ''!
/.. Blandta�ofCndfled,'•rill Contrzolm or1'lell banes /—. -0 7R '',
bete
couu'v Dy signing Ihlr.fvrnt,I lrcri miryt/rvf the well(s)tour OPEN)abandoned In
Pavel Idontltleatimilia•(PIN) dCUorritigde 1rhN13,1'NCAt 01C,0/00 or2C.0100 Well Cowinrcflon Standards
b.Lnlltudb coil lnngltuiid lu'degfeei/minutei/seenadr or decimal degreut and that a copyoJlhtr nrortihar been
(lrn•eif fleid,'oue IeVlbnk li iiiffleient) provided to the well Oliver,
9.Re i1Ggrarn:yr agltion al well detain: •
N • You inky il'tL'ec
dlli`e, of this page to proyido additional well site details or well
oballdonmwt'deinlie, Xptr may alsn attach addlllonai pages if necessary.
.IriadH'{ i l •
+rnllf ali�' 1l it I/cr in'i•cbrir `erl a !h n, d ri'uEreiti bJ6 rtroan Jrarfnyrply• 10" lr' :y'tirt •dubinst lltis furui wilJir 30 days of completion of ell;aWeil that
•
abandodineiil 16 llilifollewb,g:
i+br'lnlnl trell depth; •
blvGlvn'oflYaferllerources,lufurma(tvnProeesafng Unit,
• (fl•) •
1G17 Mall Service Center,Raleigh,NC17,G99-IG17
• lob,Borehole dlatue(cr;. t •In.addltlot to sending One form In Ito address In IUa
g4q___(In.) .•ebove,•tdaul•ilUiiiil liiib dopy of this form wittin 30 days of connpicllon of well
/ , alrandorutienlIdlllc(bllowing:
•`d•Waler1ei•cl beidn•grotlriil'ihrfa it:..: ( Illvialbn.oftlYritErltesources,Underground Injection Control Program,. • 16.4dittkl1 Serrlce Center,Raleigh,NC 17699-163G
ec•puler enslug•letngll (It ltuU'rfn);
• ([t•) - lUe, , �-�:iblectl ou lYgl_1�r hi addition to sending the town In
the ad ' Es'•IttniVi slap submit ono copy of this form within 30 days of
Sr'•Inner easing/titbing.length(It•iwbryn)t. where
of ivoh;abt,ndoninent to the county health department of Um county
_ (fh) compI ebaisdmtal.
:r:Screen}��n[ill;,(If;liilri u I l'' • i
t+ttrpl 01V 30 1
' Nandi•ilaIUiln►bepirtopeMbfgnyhbnmentim114.i....te_:-:.:..•