Granville_Well Abandonment_20231229

nildik:. : •® N co •
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Il»a fuoror con bo nerd for Jingle yr mtilUplb mile
1.well Cur rn dr Inrurmntiont
•
Well Contractor iJarne(or well owner personally ebrndoakrg*ill hlUher rrt 7a Number of recite being>tbaridonedt
�` prop y) For r:ulaple 7tVection or Inon-water ruppIy rrel: ONLY' u•lrl: the Jame
� ..p- corn+rvcrlon/nbandonmrn, rout
cart rubm!s oar jornr.
tIC Well Comreaor At
CerUnu,uon 1A,mucr • Th.Approximate volume of haler remelning In nell(a): aL
(�l.W• Poole Well & Pump Co. —� —lg )
F°Il WATER BUPPLY WELLS UNIX:Company Islam
2.1Vell Construction Permit fit
7c Type of dlrinfeeGcnt need:
act ail applicable well pem: j O.r.Cmmry;Slat,,rear{arrer,)rt/ectlo, rte.)frbnaxn
7d.
Amount ofd rctanlnsed: 1/?-'4"116—'‘.
lslnf
3.Well use(check well use):
S
11'nkr Supply Well: •
-
dA ricullurnl 7e.Sealing materjelr used(check all Utel apply):
❑Munlolpal/Publle 0 Neat Cement orout-..
j 0Gcalhctmal(1lenling/Cooling Supply) Xlmldttalal Watts-Supply(single)) C1 8nnd Cement Orud1'L Mtn Chips or Pallets
I dindusuial/Conunercinl 0Ilm►deuUal Water.Supply(ellerod) 0 Concerto°rout e Cay
ol
Lulni nllonbrill CulWlgs
Non-Water Supply Well:
pecinlly grout
DE 2 y 20 r)°tnvcl
Olvfpninning d I]urlmrhaSlu„�
1.Infection Well:; ❑llccov tDfil 2P1?f!?t�1y0 ��plahr under 7g)
'[JAqut(brllochnigo 7f.For pith material relecled a r
❑Ot�undwelcrRemtxllnlltnt !prvvidc eat not u•f rnalerlals used:
IJ/lyulfcrSlotnge and ltccovety ❑Sallnl(yI3art{er • �""`�� ^ � �, ����
!7llyuifer'1'cgl ❑SIUCfl lcrDrelrtego t , �'
IJ6xperimcnlnl Technology .
❑Subsldateo Conlr l
C)°etilhemtnl(Closal Loop) d1•�acer 7 .I'rorlde a brief deacripllon of the abandonment procedure:
I.DGcolhctutnl llcrilln' Coolln. Return ❑Other lain undcn7 r '
I, F�,r�n
Dole well(s)abandoned: .RP"- �, ' g�� � �d r�
' Welt locnliun;
t'�;cill / caner Name
•
b' - Facility II:4(If appliceble) • 8._ 1nn� w
+hl+tlnl Address,Ciq+and iIp a► ��, •
—,f
C�� � g �a 1.. 81anrlt nfCelli& Contrr �rorWellOwner
P.iii.- „�- bat:
cuuty
•I1y signing 11dr.fvrrn,I Jrert�y csri(fy that The WOW:Par()rcre)abandoned in
1'alcol ldonil6c8dorf fln.(I'!N) occortfartdr tt•!fh I3,1'NC4d 02C.0100 or 1C.0200 Welt Coruin:ditlll Standards
•
SI,LnUtutIe nnd:I gltu
Ond e In degrees/rnlnutei/recondb or decimal dtgreu:
and that atit Hell f dd,dad IxUlbr g li iiiffecleiet) cop) of fhb reeonf ha.;been prurfded to the well on.ner.
�� '� ' ��� , � ,it_ _
re 9.&Ile diagram or additional bell(hull,:
N ► 6 b _ jY You may U:si to'back of lilts pogo to pruvido addlEionnl wci(silo details or well
absndonment'dclnlls: You may also nl(aclt addlllonnl pages[(necessary,
.drlucti'llbl/ rI.a; • 'r.ki.bll 111,1
11r'o � E v , .r,.,.,,;r 15! r I.1:a O er.non- UCTI ON5
"�T ltirl,l)i'llrtr'' )d cdrif)rcrltlr[1cb'alldririhiFril ifk iralir'ngpty
• r j o-br r'ubd'r/f orie jotm,
"'' tl ell II)N: lUr' Irvr:hllYe)Ii: 'yubtitit tills form willdn 3U Joys of completion of well
abandoritnertt Io Uto Following:
•
1','I'otnl Well Ucpfh; `�' fl) ,
( DIvlilou oflYnler11esonreel,In.furwe(Ion Procesolag Unit,
1617 iilill Service,Center,Raleigh,NC 27699-1617
•
,. . • IOb,jrvi,Inlec fr',ri•In.
lorebale dininelee t Irof this.foaidc,to sending 0 form In the address In I well
(In.) .•,shove, t o'silliiilItbnb copy of Uds form w)Ihbl 30 days of completion of well
. ebandamitenl id..did following:
'•Witter laird bcld'n•grnipiii irdrfaeer. .
(R.)_ ()_______
Dhlalon ofaYrilerIiertiurera`,Underground infection Coulrol Ierugrnur,
Pam"'' 16id killEler•lIce Center,Raleigh,NC 27699-1636
_ .___z_i)______
":•Outer ensing length(IC IlttUivit);
(ft.)
10 e. •Um ad : In addition to sending Ulc form to
'.liiii1iii,oleo submit one coley of Ulla form within 30 days of
'Hoer enshiglhihing length(If lmd>sn)r� ( � eomple(Itin of wall:abandonment to the county health department of Um county
t ) where ebendtntcd.
3cractl'.ldnlli'(If;livrijl;i,
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' North.ColiniIitbrpiattbautbtr....i „-..,.. „_,. ,_ .