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Well uulreclor iJam (or Hell owner personalty abendotdn qa Vuurber of ire16 being abandoned:
BItkt�., t i't1r �) t. or muhlple ryrerlon or non-wafer ruppl)• aril: OW' with the aome
• T"� eonrtrveften/nbendonmr '
111 +t4)'ou tort:rjbntrr out form.
AUG 2 5.2023 7b.Approximate ater remaining Inwtll(s):-- (g41)
ilC Well Conitaetor Cerdttcallon Number
N.W: Poole Well & Pump Co. '
^
Company Name
frrc,- + � MA WATER 8UI'PLYSYJ�I 9 ONLY: '
DV1G1s3 r 7e.Type ofdlrinfcetantbred: #
2."Well Construction Permit N "-LI :, —7: -- •
• l,Lu an nppllcablr tall erinftJ on •"T
p (i.e.Cmntrj,Sratr,Jmimrer,/trrelfon elCJ(fknoxn ALA
7d.Amount of disinfectant used:
3.11'cll use(ebeclt Trail use):
1Ynler•Supply Well:
7e Sealing materials used(clieck all that a r i :
OANticullurol i7Munlol e/I'ublle 1 p))
p ❑Neal Cement Grout. I. ❑ [3critunhe Chips or Pellets
UGcoUlermel(1Ienl(ng/Couling Supply) Restdt'trUal Water Supply(single) ❑SAnd Cement Grout I I❑tadusulal/Commercial ❑RaldcnUal Wa1erSU uut ) . crete Grout ❑ Dry Clay
L❑Ins anon • Supply(sld ❑ Con 0 Drill Cuttingsfauns Va allot: Supply Fell: e:elally Grout ❑ Gravel •
0L71�fuuiloriug hutlmdlo Sluuy ❑ Outer(explain under 78)
Ltf ccllun 1Yc11: ❑Ilecov
I0AqulfcrRecharge 71.For each material s elected iabarq provide amount to*lux lairds used:
1 IJAyulfcr 8loragc and Recovery ❑ allnayw ler airier mallsllmt �i��f n/ 6, �
rY ❑SaJlnll'y Darner 1111 Y 4 ,/ rif'°15'
�J
0Aquifcr Teat ❑SlormwaluDralnage
1 r]lxperilnenlal Tcchnalogy --------------- -
1 CiGeolhcnnil( coed I�op) ❑Tr cElSobs�datco Control
• 7 ,I'rerride a brief deseriplton of the abandonment procedure:
yGcollrcrinnl(hiceling/Covling Rclunt) . ,❑Other
(explain under.'71t1 i
1
°•Date well(s)ahnndoned; :
i
tt
•
r,.. e.
3A.11'cll location;
1
�..ecdhy/Unner lime• .t,
Fe stilly ID (Ireppgerblr) • 8•Cer nr
physlenl nJdress,�Chyi and T,Ip •
�l 8t Ur of CctliDed I'/' IConUsalor or We Owner
------14 d�K `.a ante
ouulY •BY signing ildr.for�n,IIt!re bertry flux the WOW tva.r(were)abandoned in
Pavel Identification No.(PM) ticcarddrics trhh.1..tiVAC 01C.0100 or 1C.0100 ll'a11 Com/ruction Standard.;
•
Tb,LA(limit and:hiuglfu(1e lu degreeri/rolauleifsecondr or decimal dtgreut and that a cop}eibis reconf hat been provided la the well owner.
Or well field,:onti 6Vibrtg ii EitRelebt) .
�,(.}�/„gG� ��.��0�� 9,SlledlagramoraddltlunalivIldetails:
•=�1Y_.___-__-___�n • You maj";113$;lllorack of(lila page to provide additional well site details or well
W abandonment•d'cinlls.. You may rilsu attach addlllonal pages if necessary,
•
:d tio'471.i r • ,1,,
regr'(jf(+ iii01)i'i}`rS` ` evdrhrerl abe d.,,T ,okl1)1
r1.Mir i jovn-Nalrr'ngyty. UCTIDNS
ul.Well IbN: IUa. Ir°r:Al I Wtlx: '9ublitil this form within 30 days of completion of well
abendoditrent 16 tho'following:
?b.'I'o(nl Well depth; DJvlrlod•oflYaferllesourcu,Iiirorwaliou Processing Unit,
(IL) 1617'Mill Ser ,vice.Ceu(er,Raleigh,NC 27699.1617
•• Iob,Ljg yd'SY jj I'
1Joreholc IIIAt11CICf:. „above,idao's'uUrtlh'olio dopy fdtlrla forth Width' deysrof tom le Ion oflwell
(in,) to the
•
. Abanduruitenl Id.t td following: } 1 II`d.litaler level beloii•grogiiLI Arfaaer 4S7._____
((1.) DII•lslon°MiterIlesliurcea,Underground Infection Control Program,
1636 Mill Elei-riee Center,Raleigh,NC 27699-1636
_______62.(2.__ • 10e. • ... . '., ' •
Outer eating length°(If ilitUirn)I
: on toOra.addreW a Ilkiio,`•nlip aulnnit one copybof thisl endin
form swithin 30 days of
`•'Hoer enslriglll(bing length Rimonn)r (� oompletlon of tvdil..nbandoninent to t e county health department of Me county
i ) where abandoned.
{+{acraallt.ldndtJj;'(Ih)titiYli)I'.+. • • '
. • (iL)
'•..tn CIW3U
' 14O(1}lt•'a[t1iiiiaUtrtlUinutb(Gnylrhnm.n1b...11.1...__,A .. j

WELL ABANDONMENT RECORDEternal Use ONLY:
tn r CE 1 Nic
1.Well Contractor Information: n 1,(, 211�' VELL ABANDONMENT DETAILS
David E.Meyer PM ) VV to Veoprobe/DPT or Closed-Lloop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/herF seeAtgf r., 1 construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2527-A \t: 1,4101110441,wells abandoned:
0
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Protocol Sampling Service Inc. j
P g � FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
GW-066635-2021 7c.Type of disinfectant used:
2.Well Construction Permit#: i'
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 16 OZ.
7d.Amount of disinfectant used:
3.Well use(check well use):
1:
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) 0 Sand Cement Grout 1, 0 Dry Clay
❑Industrial/Commercial , EResidential Water Supply(shared). X_Concrete Grout 0 Drill Cuttings _ _
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: • 0 Bentonite Slurry X Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 120 gallons
❑Aquifer Storage and Recovery 0 Salinity Barrier
3 yds screenings
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 1.
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) 0 Tracer Well sounded,found to be free of obstructions,drop pipe pulled
ulled
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
chlorinated,filled with 3 yds screenings,capped with 5'concrete.
July 11,2023 ;.
4.Date well(s)abandoned:
5a.Well location: '
Pennina Rowel na
!
Facility/Owner Name Facility ID#(if applicable) 8.Certification: i,
1756 Rolesville Road Wake Forest NC 27587-9677 1....,\,.. 7/11/2023
Physical Address,City,and Zip Signature of CertifieK Well Contractor or Well Owner Date
Wake 1767374878 I'
By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Constriction 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: I`
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.88624 -78.44822 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
•
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-svatersupply wells
ONLY with the same construction/abandonment,you can submit one form. '
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:WSW-1 abandonment to the following:
26 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I.
24 10b.For Injection 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:. F ,
16 Division of Water Resources,Underground derground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
30
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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):na (ft.) abandoned.
na
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016