Lee_Well Abandonment_20231229

WELL ABANDONMENT RE CO" For internal Use ONLY:
116uW
I.Well Contractor Information: WELL ABANDONINIENT 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 1 GW!30 is needed. Indicate TO'rAL NUMBER of
41 65A wells abandoned: i
NC Well Contractor Certification Number 7b.Approximate volume of water!remaining in well(s): (gal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLYWELLS;ONLY:
Company Nvno ` t HTH
7c.Type of disinfectant used:
tv Ir
2.Well Construction Permit#:
List all applicable iiell construction pe•niris .e.UIQ County,State,Maritime,etc.)ifloi0tru 7t1.Am 1/2 lb.
ount of disinfectant used:
3.Well use(chccl(wcll use):
Water-Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Muni cipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Coolin Supply) esidential Water Supply I ^+<�>( � g i p y(single) ❑ Sand Cement GrplrF�.,, � Q�*£�� Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout X — ���I Cuttings
❑Irri ation IN Specialty Grout DEC Non-Water 2023�tGlavel
Non- ater Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery (i1 0(rli&:12D Prot .W,
Injection Well: 7f.Fm•each material seleMWail it Q' Qrovide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Environmental Fill Yards
❑Aquifer Storage and Recovery ❑Salinky Barricr 1
❑Aquiver Test ❑Storinwater Drainagegn
0
❑Experinienlal Technology ❑$.ubsidence Control i
❑Geothermal Closed Loop) 72.Provide a brief description of the abandonment procedure:
( p) OTracer r-:b v
❑Geothermal(I-Icaling/Cooling Return) ❑Other(explain under 7g) � � !}
-77
4.Uafc well(s)abandoned: a e
5a.11'cll location:.
Facility/Owner ame Facility JDH(ifapplicable) 8. ertilieatiolt:
t
Physical
}�Address,City,and Zip wad
Sig i oC e c I Wc11 Contractor or Well Owner Date
Count 1Jy signhrg th form, !hereby certify that the ire!/(s) was (here) abandoned in
Parcel Identification No.(PIN) accordance with 15A tVCAC 02C.0100 a•2C.0200 tVell Construction Standards
5b.Latitude and longitude in tlegreeshninutes/seconds or decimal degrees: and that a cope of this record has been provided to the well owner.
(ifwcll field,one laYlongg is sufficient) �7 9,Site diagram or additional well details:
3`5, 430519 N --ICI , �j t�Q�j� 111 You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF IVELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachu,ttllcanstruciiotrecord(s)ifarailable. Far•nnrltiplehYeclioro•non-nratersrrpplywells
ON/.Y wish the same consti nictiotnlabardonrnernt,yor cat subunit allefornn.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.WeII ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: c (ft.) 1617 Mail Service Cen,ter,Raleigh,NC 27699-1617
10b. For Infection hells: In addition to sending the form to the address in 10a
6c.Borehole diameter:_ lL_t� (i»,) above, also submit one copy of this forin within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center",Raleigh,NC 27699-1636
6e.Outercasing length(if!mown): (ft,) .10c.For hater Supply&in'cction R'ells: In addition to sending the fionn to the
address(es)above,also submit one copy of this form within 30 clays of completion
_ of well abandonment to the county(health department of the county where
6f.inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): (ft.) j
it
Form G W-30 North Carolina Dcpatiinent of Environmental Quality-Division of Water Resources } Revised 2-22-2016