Johnston_Well Abandonment_20231229

WELL ABANDONMENT RECO" For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood
7a.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GWj30 is needed. Indicate TOTAL NUMBER of
41 65A wells abandoned: A '
r
NC Well Contractor Certification Number 74.Approximate volume of water1remaining in well(s): �L(gal•)
N.W. Poole Well & POmp Co. FOR WATER SUPPLY WELLSjONLY:
)
Conn an:Name HTH
P 7e.Type of disinfectant used:
2.Well Construction Permit#:
30-
List all applicable well constrntclion pe unit. (i.e.UIC,County,State,iMariance,etc)iflcnou7r :1/2 lb.
7d.Amount of disinfectant used:
3.Well use(cheep well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Gru�a--nrt^^^.: r*� ETQntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Zesidential Water Supply(single) ❑ Sand Cement G out"-� �d o$ y Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout DEC 2 9 2023❑ Drill Cuttings
❑Irri ntion _ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Sluha brit'ra:e1'r,".* . EWher(explain under 7g)
❑Monitoring ❑Recovery DWfQi50G
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Retnediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 'dam Af A-2V 1_
❑Experimental Technology ❑Subsidence Control
7 .Provide a brief description or the abandonment mrocedare:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) A
d.Date ivell(s)abandoned:
1-14 I .
51.Well location:
•aoi I i I y/Owner Name Facility 1DR(i f appl icable):
8.C tificalion:
-ems
Physical Address,City,and 7.ip ature o rti red Well Contractor or Well Owner Dale
0[_ By signing f1trs form, 1 hereby cerlrf},that the well(s) was (iyer•e) abandoned in
County Parcel Identification No.(PIN) accordance with 1511/VCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been,provicled to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
e field,one latltoni is sufficient) 9,Site diagram or additional well details:
You may use the back of this page;to provide additional well site details or well
' N ' �� abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachhellconsottctiarrecords)ifarailable. Farvnttltipleiiyectioirornon-u,atei•supplyryells
OA'LY iridr the scone conso•uction/abandonunetnt,you can subunit one form.
10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID/h abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb."Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iuicetion Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (iit.) above, also submit one copy of this forni within 30 clays of completion of well
abandonment to the following:
;
6d.Water level below ground surface: (ft.) Division ofWater Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,INC 27699-1636
6e.Outer casing length(if known): Q (ft.) .10c.For Water Supply&Iniectiori Wells: In addition to sending the fonn to the
address(cs)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): -� We) abandoned.
6g.Screen length(if known):
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Form G14140 North Carolina Department of Environmental Quality-Division of Water Resources. Revised 2-22-2016