Alamance_Well Abandonment_20230825

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l,Y,t'i1��: 3AD0 'CpD I' uur yy
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77tia form ern bo uard fora mile em mti1Upl•v tulle ���9lCl[(la�U . ,
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A.Well gott nclur Inror-mn(lun:
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Number or abandoned'Injectionnnte r /y
trrlr ONLY udt the aomrVell CunlrarlorIAJa n(or well owner tenvul(y ebendotdng iieolilUherpropeny4 Conrtrvttrnn/nbondonmnt,you Con rubmn one form.
1iC WeII Coonxr,ar Cerdnudon Nurvber • 7b.Approximate Tolnme of l Ceder remaining In nell(a): y® sl.
N.W. Poole Woll 8� Pump Co, l ! �lg )
FOR WATER EIZ S UPPLY 3YLL9 ONLY
Contpan}'nam
1.W'et'Construction Perml(H: 7�Typo of disinfectant tied:
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l,Lr!oil applicable well perndls(i.e.Cmm j(S1e$.Y,,,-hr r,/r/eedon,ere]I,'knatrn s ff
7d,Amoun(of dlslnfeclanl»sod:
3,Weil use(dhech well use):
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15'nlct'Supply Well:
OAgticulhtrnl 7e.Sealing materials used(chec(all that apply):
dMunlolprd/f'ublly ❑Neal Cement Grout I UGcoUtcrmnl(I•lcoling/Cooling Supply) esIdenlal Water supply(single) 0 Sand Cewenl Grout 0 I3vtdvnhe Chips or['edicts
10lfdusuinl/Conunerclnl ORtraldcntal Wrier Supply(shared) 0 Concrete Grout 0 �y Clayo
l.dlni anon pP y( � • ❑ Drill Collings
Nun-Water Supply` cal.-��`�' ie9pxlally Grout d Gtnvei
dlsiuniloring � i,/ � l7 Jenlottha Sltury 0 Other(explain under 7g)
I In)eetIon Won:
't�Aquh'er Recharge AUG 1�2� 7L For each maierial selected aborq provide amount bf nixlcrlals used:
Uroundwmerltein,dhavrt • JdpW _&-��
t 0AyuIfcr 8 tong c iv Prcc f✓ �o
I iJAquifcr'1'esl PWQ/ 0G S Ranier O ssi'
tCLxperinteninl'fcolt»ology Islalmti3xlrxDralnago .
1 DOeo41tcmtnl(Closed Loop) DDSrn I1datco Control
7g. 'rondo a brief description of the abandonment procedure:
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I_1geothermal I•Icalln• Coolln" Return . ❑Olhcr lain Undvr7 • •
::•Dole sreil(s)abandoned: 14 • �14'='�- •
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3s.Well local on; .c6 �/'
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Ycillty/Utener Nnmc .
PaallltyIU�(IfeppUeeble) g,Certl
!'hysh:nl Addrese,•Chy,and ill: e r
14.!ci flisneluro of Cettilltd Ws oio iiotor or Well Qirner Ual:
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°,ury •By signing(bh.forny I?te cerf(/y(drat(lie well(()war(were)abandoned in
PaledIderdllleadod lin.(PIN) dccordmlcr With 13ANC.4d 01C:0100 or1C.0100 Well Cwulnid(on Standards
Lt,Lalllutib and:IongltuU ih
e In degreenlnu(ei/seconds or decimal degrees; ° Om!a r
c°p)obit's reconf her been prodded(a the well onvrer.
(if mil feld,'dnti laUlo'rtp'li iiilrcleiA) •
`� • se II
_��a -•� 9.Site disgram or additional trell details:" You may iib lffo back of Vila pogo to pruvido additional well site delails or well
N abandonment'drtullo; You may also nllaclt oddllional pages i-necessary,
4fie e'illil 1 , 1.
clla()!ti' 1(1d Ilr"l)t}`J�iifi cirrl} olive brkldhnr`rr.15'tik ( I iRldfr Or.aim-hour n r l
it•:r.,•.:ti:... �1, Spy O t) nbtr r'ubtill!Brit jvhn, •
%''Weil IllN: Ida'Iror`AlI W Uat •Subtitit tins faun wiOdn 30 days of completion of well
abandoninent 16( Tvllbwfng: '
b,Total hell depth: • Division ofWaferliesoureu,Information Prucessiug Unit,
(ft.) 1617 Mill Service Center,Raleigh,NC 27699.1617
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e•.11t»Fholc diameter:. (In.) • IOb, lloig Ist Irt•addillon iv sending tic furnt to tic address in 10a
„above,(dsv'sillfiifll'ofib copy of Oils form wllli(tt 30 days of completion of well
. nbandorunenl 7d.Oid following: I
t•Wafer level bclo'ri•grotlriif tiirrfaee;._ _7_
.: • Division a!<lYtiler lies oureea,Underground InlecUun Control I'rugrnin,163f MJ 1111ervlce Center,Raleigh,NC 27699-153G
:'•Outer eniing leuglll((rufrn);
_____3(2_([t) ior. • .
r In addition to sending the form tv
the.addraiKti',..i'dyq'also auks-Ill wnc copy of Lids form within 30 days of
inner ensltig/hibing lenglb(lac Boles-c a on of tvoh nbnitdnnincnl to!tile county health department of tic county
�_(fl.) where abandoned.
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ucicell`.Idn(lli'(Il Iiilpivki)Iti.
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Florth taltiiIna 15epittrneut Of Carlront.,.nt e.,r v,,.__r.: