Johnston_Well Abandonment_20240423

ii.riL LLDMIJ)UIIM EN1'1GUlill fur igua11utONLY: --.... — i
~,i,frin,ran bra u.e.I Cur alnele o,-multi:Al...ells
-- - —. .
---- ___ _ _
;.Nlrit t tell ac%nr LA,ranOlo„ „tt LLAIIY1iWYUI DETAILI
1" - : 4t� Dn
7a.timber of walla being abandancdt _
Wra Ccnaeciur limn.(oe •ell ow on venooai(y.Faedoaing*ill bnhliher vicinity) Fnr .eutffrlr !n)rdlun n. nort•natrr ngeply ,rrlG ONi,J' ��na ,I•• '+'
'�t- A •:,,rvureni,annden:rnr•non re,n rubmft ant fur:.
:IC Weal onlf,etor C till IIe■unn Nmvilm lb.Apprn:lmale tolnme of'rater rrmalning in n0a): 4 7D (L"I.,
N.W. Poole Well & Pump Co. FGR\YATFItBUPPIX WELLS(MI,3':
imnpanvNtme ,,I rIL
1c Typt n(Jtrlafeetaa d,t owe
2.Will Con;lraeUon Permit If: `
I.'I all op/Ambit well p. .fIs(l,r,Cuun',Stair.irarfmnea/q/erNon•r l/Inown
7d.Amount of dLlaftetaat aced:
3.Well uct 10eck well use): r _
\\'atcrSupply\Yell: 7e.5uling malerlalr aced(eheek al!that apply): a t.L.k.;&..,i t j TM I1°Agrleullurnt °Munialpal/Publlo ❑Neat Cement Grout 3rntanite Chips ur Pelletss,
l❑GcuUtemul(Ucuting/Cooling Supply) l tdentlal Witte Supply(single) G Stunt Cement Um( ❑Dry Clay i4 L �1 L��t
GludustrialiContntetelnl °RatdenUal Water Supply(d:utd) G Caere Chu( °gill Cuttings4
Glnlpvation 0 Specialty Grout AOravef -r'r'.44ot£i:t 9 s-y^-mod
Not-Water Supply Well: ❑Becnanila Slurry 0 Other(explain under 7g) Dtfii-(;Q'a Y' '
°Monitoring 011eeorery
ij tUait We'd: For uch material aeleeied'byresm'byres pre ride amount of aterial,reed:
GAquifcr Recharge ❑GroundwateRemedidlon y�S
°Aquifer Slotage and Recovery °Saitni(y ButteA-$03�. t���, �' ���J `
°Aquifer'rest °StormwalerDilnago : Aipe4y7 lizc ./ `llS
°Experimental Tcclutulugy 05u63ldrnw Control
7g,Provide a brief dueripttoo of the Aberdoomeut procedure:
OGeoUterrnal(Closed Loop) DTracer /
l Dl3cutbctntat(I1ealln&/Cooing Return) ❑OOter(oxplaln ulder.7g)_ ��T 3 � %L /� Q �G Ll
!.Date weli(s)abandoned: NJ /u`7 ,4 f / e, fjt)j777/
Fa:w//IIIy •r`n/macrr Haamm/ot)'�js� ��rryy���/j/J Fie Lill ins(If appllc.bl.) • 8, rtlRuUom ,0
DJ e drerl Clt Dij ei/(_ . �C-4. �A)! e i , �} 0)-)3-0
L)
X a Zip 15Z? 8irmlma ofCndDt o0 Contractor Or Well Gar Di:,
, JVrf!"7U/V 1�/.,7 �
By signing Au farm,d here miry that the well(i)wui(Mere)ni:aruk:,red in
:run' Prtttt idttdhladod lto.(MI) area,dMu uhh)14 RCA 02C.0100 or 1C.0100 Fell Construe/fen 5tnnd.,rds
and that a copy of this rtronl has been provided to the ire ii an r a,-,
L.Latitude end.loigliuile La degreeafraIaalea/eaeonde or decimal degreu:
tirnali Ada•one 1■Nirng It Iuifielei,t) • 9.Site dlairx 0r addlilunel well dealt::
.23.�. ,r 7 7 CI( 1 N 1 ga 2C1`IL-1- W You maym usd.tllti biok of Mils page la ptuvida additi nai wci:silt i: .::'3:r::c1f
obendonmrnt details: You may also attach additional peas If:: esa-.
-9r57 i () iI tie �r Qui gUBMITTALIN
.lrfeih;liEl{{�� f�. � t-/1 `�JII n ' fi� lf iNMoir 6r rton•tranr n7rpfy �U�ONs
,..rill OhL7 tri)),t�ri a cbnr n! abandaNlnieG ids can aa6Mlf en•brAZ.
tOa.Nor'AII Wt{(s`Submit this fuiui within:30 days ci::eipc: , ;
Wed Ilmi: abbandoumrnl to 0id follatving:
J7 11vtelao of Water ltuoureu,lufur:rrallou facer:i,L: ,
'Nisi nea depth: L1 e)5(fl,) 1517 Mall Service Center,Itaiclgh,NC 27u39-1ill
• ) �- • IOb.pur Enle_ c Neil,, In addition to aendhl f the tote la_'to c.l;;�•. !�;1:rrl:ale d:anrehrr (to.) above,Ilio iutlidit oho copy of Uds teens tvlti,Lr IU days e ::1t:p1:',:,.
.abandonment la the following:
•7r:ier•level below grounij surface: _(fl.) Ulrbfon of 1Yater lieeoureee,hudecgro:Lad lu)er:.:.l c i,:al',`;,;. ,
1636111i11 gerrtea(:colt:,ltaltt):1,rn:' -,1% 110;
a:cr tr,rl g length(If l'uUhu);,— ��._ (ft) IOC.Fill l
�T. aili11Y1.1T It_11 In addiLt.'.,c •.*r,rA
0al adibtu(b above, also eutnnil uuo copy u(tine It,, 1
' ,! ' .,
completion of twit abandonment lu the taturty health '--r, •
I I.,ruing/tubing length(It iinonu)t _ uhcre shuulun.-,I,
--__fill
••:,Iron lenrtli(Jfliuusvn)t "�
_All.)
1Ifnilr Ca ollna I)ep►thneul of latbaiwoni t,..t Ft.1,..... , .

WELL ABANDONMENT RECORD
VierpruWter fpttfori8.K,
C.V$48,•. ,,,,.Inienealieso Ye ELL ADVIDAIIWEIN DETAILS
i / Air I i , f;l.PM-GrupennulDrTee t.towd-Itner Goselnred woes twain dM%Mice
Vs,:;t,.1t1,.tc1e0:411/. wp well entslr'uefionAf N-,trod 1 Gym is.ncrtt4. NACU*MM..ti110+191FCdt of
�� �. .. s..i q.hts'&ce ingpag�l � Y
'lam♦/�Tp'.if twills nhand, cal: __ 1 ____
N....WV. `:,1„.,. ,. 71t.API);ncinrxlc volume of orator rrnwininq in..veto<,5/c /a,.d.;
IN AV. Poole Well& Pump Co. i_filt\v,\nnt surPLY WF.I.LS ONLY:
1
W.vr;•mra,Name ---- (-NTH
! 7r.Type of Jilin fee In ni tried: j
Z..wif¢iE Coast ruction Permit tie 17 {.�— I
i;;wr„N;afry�,eakir xea.mra,acrair,,....rltt./AIC. nt.,me.Oo,0 i-oe ,ita...,•)r/knm,w 1/2 lb.
lit.Amount of llisinfraiiit used:
I
3.Well love(dtcels wcll use}:
\s rater S„ppts\Ycu: — 7c.Scaling materials used(check:ill Mat apply):
a\gtradttiral °\lunici tat/!subtler• c f •:
I 0 Neat Cement Groutj3cnti; lc Clips Of Mat t.t_4:otbc,lr.ai lco:ngLx6n•Su (' �.••I 4 I.,_1
(' b Supply) Water Supply(single) CI Sand Canon Grout G Dry Clay p
C,n,i,dtrial'Coe:tnct dal ❑Residential Watcr Supply(bared) 0 Concrete Grout f1 Drill Ct,ttu,f APR R 2 cl' 2024
2Itrl,,ais+n ��
a Specialty Grout ):gavel
Non-water Supri.Weil:
Caolutrnm, 0 °commieSlcan' 0 Other(explain tinder7,}•,,,,:,,ii i';':.:")--:^
;al:Ctiml tYdi: Vie.C,30e3
7r.For each material selectee!above,provide amount of in,le,iab used:
5.\ciaitc:Reehatgc °GroundwaterRuncdiation �'.d 6,od LeS
C.'+,u::r Storage and Recovery °Salinity Barrier f j/!�/��j�J�T � 7
c:I;:r:est °Snonmeater Drainage I'ar,n',a, f
.1.".:l:\,er'.:tcrtal l'ecitno:ogy OSubsiclencc Control
7p.Provide a brief-description of the abandonment procedure:
'-U.c,hc:ina;(Closed Lapp) al sect J
1 CCcr:hcc::al i:Ic.uingiCooling Return) OOltcr(csphrn under 7g) 3 loam //" t L4-
fr --
J.Date well(s)abandoned: 4) / __ J_ 4) iA
5a.Well!potion: / jF l. 1�c
C`� . Its eeir)r1 � 1f /%�Y t �L`'j�� AliG fll�
.a-,.uvrOwner Rai c n,-01"''
2 T, lily ID/1(if aptrficahic) y.CCrti /////) � /
� /�� ;P. /.—i / s L s,c..l A,,,..•Gly.and ZIP 7 L Alp. UM Oil'. train!Well Comma°,or Well Owuu
i/^' ,,mil , 7�.
— �� Dr.ugrmtg this fares. /heir/).,'cirri,that the t oral i Ngent ailtcdllumd y
Cowl) Parcel Identification No(PIN) accada,c,s i ii,15.1,VC.tC 02C.0100 a,-2C„UIN■dCelscria.S.unrc6l is
raid that a Copt a(tbs1 drat ti has Lice,,pruv,efeni re li[■deer70;
51).Latitude and longitude iu degrees/nu uutcs/Secoudn or decimal degrees:
,,ei:'iel,i.r,.e Im/lone s sufliieicnt) 1t
-� r-4 _ i �( ` .Site diagram or addilinnal well Benno
-5.,W 6 ' Q. 7 N 1 V• 4 I p )-9. W You cloy use the back of this page to provide addlidined lull'no or eel
abandonment details. You ntay also attach addition"paws if n cesney.
CONSTRI1CTION DETAILS OF WELL(S)BEING ABANDONED SLI111b11'Tl'Al.INSTRUCTIONS
..i fad''rcff cau.tb union I cow(I l tfavailr.(ud.Fes nudnple infection orrnnu-orator to,ppli,welts
I;Al.I ,all.in,.Mart rrn,i;ncuorranaininnrncnt.pa,can rnMurt cud/Irnl
10a. For All Wells: Submit this loan within 30 days of tattoofe ne of snot.
Ga. ,::;I WitabattJanntcnt In lbc I'ollmvinu
113is•isian of Water'Resources,Inl.siiuiO1M hp IZeingUllid.
,••,,:r'•+rii eeptll: / (It.) I617 Mail Srrviec Center,R:dci�.I11,BQ„ B 0 22lsf
106. Far Injection Welts: In addition ODi jlbe konn osibe Maness aa 9C.
above, also Sllbtnit one copy of thin foray{i/dt as 30 ten of entollone,0f well;
abandonment W the following
bc'ot+r,.quu,lsurface_, -_(I't.j Uieicmrtof\\'.IlerRi«n,urccs.UeOtanneenllineelitee Cron tregriM..
/,//^' 1636 Mail Seri.ice genres.Rebe ly,21f(`Z9 -1tL7d
r,.. .. ,_ . •,t-(•it ow., _ ` L .�L it IUc.For Wale,-tinpoly.1;Fu fee n,ut\\eltzc bRaGlY4+aaoio.lcsRtlYe$a+mxe 9=
.ukkeNS(CO Am.-.•If,,,',"1",,0-",*:•'1":-i‘rikik DNA*ram DI Ain dj ..-
of well abaudonntcut to tiro ,xm•es hca:11 atratillalli Or Cho c,an,s soAaexc
, :.. •h I,math f,.iii-non); II:) abulnknu�d.
tli)
.. r,•.,,, ,, Iu..I r ,,,,,uu,,I 1 u t,:,u,,.:utat,.lompr i I net,,,n _.,+act 11.C..Yr..s 1 2-*2-20116

1 i.;l..1,,MIA N1)0N NLENT RECORfl II ;Iln.,n.11 1..,,rtl.,
1.1113di krdlif Tat rm:Won: WELL MI NDONIk ENT up:1"Al!�
__J� __--- Ta.Fur Gruprnr/IlI`C in-Closed-lamp Geothermal wells having the um,.
R'INIt tzuln,ti 1Craeta(.A nwnC1 penamltyiko lon,ng well on hi:r'hcr ponies tyl well construction/depth,only liW JO i;neerlyd. livelicate TTjrm.41`.;Mrp79 or
r „r, A wclfs nhandnnc:l. �rj/
'alllil7�1t,.1`/.,•',-. 711.Appl nriuwlc rutmne of water'remaining in wdl(rt: f7 4-
N.W. Poole Well & Pump Co. vim WATER SIJFPLY WELLS ONLY:
\1n11•a11Y N.i:l HTH i
f�� � ' 7r.'fppr of disinfcrlaut usrrL•
2.11'cll Construction Permit 4: ,7�jf�j V. --. /
1'r:.+.dt nt•r'hentda ocrll:nr..rrl+nvmnpr cnly(te.It( Cnum•,'''''46:1r•rm1a.err)II."'" �/2 lb.
7d.Ammon of disinfecl:uat used:
3.well msc(check well use):
Water Supply Weil: 7c.Sealing materials used(check all that apply): ?,
GAgriadtural °Municipal/Public 0 Neat Cement Grout 1301tou1tc�6tP L. • L,, 1_ ' {n 4.•`
C Jcutttcrntal if-heating'Coolmg Supply) °Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay ``
Clndustrial,'Cuurnrcreiel °Residential Water Supply(shared) 0 Concrete Grunt C Drill Cuttings AI- 2 :• 1024
Clnigation a Specialty Grout A.Gravel
Non-Water Supply Well: 0 I)cnlanilc Soart �
Gtilunlitarutg pRccwet ) 0 Other(csiid ie under 7sJ„ ,':. <, '.�+T
y -,-.c C;$304J
injection Well: 711 Far each material selected above,provide amount of um lei halloos&
❑Aquilc:Rccftalgc OGroundsvatcr Rcmcdiahon 3 WY_ r 7/l Ad/L r,
°Agmfer Storage and Recovery °Salinity Barrier �r ,/ 1 �a lX/
CAquifcr Test 0Slormwatcr Drainage i;E:{r l�,J1t 60J / Ly ^D 4
°Experimental Technology °Subsidence Control
7p Prnvide a brief description of the abandonment proceanrc:
u Gcadlel noel(Closed Loop) °Tracer �1./ /
°Geothermal I leatin Coohn Relent °Other(explain under 76 i / 2 C" -4V si. ✓.A1 re I
4.Date well(s)abandoned: / fr7�•n pr FR" -T�fi -rep
5a.Well location: 1/� Q�f
Fan::ny/O.vncr N,mc Facility ID/(ifapplicablc) 9.Certification:
-
?hysicat AJeliess,Cily,and Zip .S 94 Signntorc of Cuuliet Wall Contractor or‘61 O.,ncr p,Itc
•
.37WA;5 rc,ti'
Br stynuty this.form. 1 hereby cardO,dint the u'a/tO war aiawiessdm
Cona0. Parcel Identification No.(PIN) nccordalsea 1:al)15.!MC-IC 02C.0/00 err 2C.0200 II'el1��rSr(daci:
and that a copy of this record has bee);prurrded to the well anana:
So.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if..di field.nnc 1a14nng;;vofficicmJ 9.Site diagram sir additional well details!
35• LeC\Tj9 N 7g.5.250_s W You may use the back of this pave to provide additional ndl tint dtglily
abandonment details. You may also attach addivatal paws i{taoppltirly-
CONSTRIICrloN DETAILS OF 1VELL(S)BEING AIJANDONEll SUBA11'ITr\I.INS I'RIICTIONS
.i.v.h:1 di eunsuvchvn arc vrd(s)fm•ailaule. Fmvuulaplc injeelran names-u•ntersrgqdp wells
U.tl.I':rah:he canine G;s%trecaowa/laudnruaent.you can snhu,t nee feu rn
lac. For All Wells: Submit this loran within 30 days u(:0, n'r_-. n .r •*;'
6a.Well Mil: abandonment to tllc following:
Division of Water Resources,Information Ford° ,:r IAtr.
Oa."I Mai well depth: �J (fi.) I617 Mail Service Center,lino.-ilk NC 1781/0-I617
IQb.For Inicchhau Wells: In addition to seat nta IWe Will So Ilk abbess iR!Oa
(n;..Borehole diameter: r' (in.) above, also submit one copy of this foton within 30 asps of asapkias of wail
abandonment to the following:
.
Gd.',1'alcr;cvc1 bclury grnuud ssudsier: 5" (ff.) Division of Water Resources,lhldcrground Gnjtaetiar("ana4rd Pexnryro„
Il k,(Mail Service Center,Ratatiigk.ihiC 27. -1(rj(
<.:__fH(trrrntic(;'la:gtln(if Inww* 5i_ (It_) Inc.For Waled Snooty&Inlet'{Litt W iradiYeay wthaggigfain36 Oet
addressees)ahuvc,also•:,manna mar caul mldlik lam*alas IS Asps ofco..s$att. 0
of well abandonment 10 OW away We:dMt depaama of rib:avanry alias
`-_
61.lama CLrsui.gttutaimij!-tenth ifkrN/lr llJ: .(ft.) .IbandOned.
'.y.J a en ln.npil:tit l::nr,:ul: _ Ill.)
•' ••/ lima,1_.4411114 Lldnll\la..11i at LIDH1m11111LLW.11 i/hullY'I Lwallli.4(5 110 itr..nn.r. Iltar11d131!!loci

WELL ABANDONMENT RECORD ,
irw.ii.„0,.#tr.s11111t.V
4
ll.,NAMII Ottiokftar lasnisativam MU.A IA‘1.4 tICVNIZItigrainal
7a.For I.ropt elteVer fir Chordt-Lsorp Gedbarvirall W broils the IONE
well On;,fl,illnitilbt"011111 OW-XI lif tweet. lorliatie ram WOOER gti
*sin ntilitecNnintlier naellosinierpornen akotrissaismall so Miler imer51
,,ells.thainhnteet:
) ' 9-fk-
71,..10118uNiiiiitte%minute nil vow reorioi—eta in.01hp %IL
NI,:wv..1-,:voimxik,-,ittax.sthem)awnit".
W.Poole We &Pump Co. rf ni IVA MU RIMY WEI../.S IRAI.V:
I-1TH i
,,,nt,,,,,,NA.*
7e.1.yrte ol tlicItilectiiii!Ned:_____
7::.AO Otionionvistivi hook iltp.6.1:9/267 7.51
1/2 lb. i
""t'""m"""ems"""""" 'ft'''''t lc‘-'"'"".S'' . in
"'"'.''''''I A".".' 7d.Amount of disinfectant used: i
_
s.Ns eil use. cliecti well tuset
..
NN.tic St,11,1".•\Veil: 7e.Sealing materials used is-beck all dial a iiiilp
.•Ar........tii.....1 rlklittucinal,Pohl le CI Neat Ccntent Grout ':I licalMiltdillatildlenA .4 r/ 2 :.. zorti
.:.5c,„1„..1,1-:+4.3:inttOviing.Stittaly) emileittidl Water StInttl (single) 77 Salld ecinclet(5"11 71(11/7 Clipy
Vow nerelai .1.:1Zesidelitlal Veater Supply(sbaretll .:..1 Cortetete Unita
r-i Drill Cr111.15X'A..i.:i-il;-) '-..C.I.V444.''74;:fritii
. Zliketts Lieu. Scicetaltv timid 0 Gavel trficci30431
Nina.'aibiterSoire,,ell: ,-.2 other(evitia=ti 7 t-7 :4;
El 13colimite SlotQ..
.:-Nloottsti tie CR.:covet y
I:Ito.lieu NV-XT.---
7f.For each material selected al ,,,.tit is ilk A IIVIIIIII 411..,I'.11.4 use',:
•t
e edd
.ZINII: l..:Ilge OCIVIllItiWalet IteinCillatiOn Ahii&i$1,/tCArrA1- 4 '' .77)1. i ' -
—
-
,,-.',,;;L:1'...•;Storaip:X liew.C1, °Salinity Banter
I :A.;:;1 1::1- CIStorinsvater Dtattlav
I
_-„:\,:1citioi rCcise101el,p' 0Stsbsitlencc C.7.ntrol
7g.Provide a brier description of tise abandonment procedure:
7 C,,s;i:el-as;t Closed t......tp) 0 I i neer
r"..... r- • 1--
Cot:bats!tenor) Z'Other(c%plain IllIda 7f;) riii--t-;) ‘1,1e;14FRAfril .771E 443070.40C
' k4)1./1. ,0._, ''.7e4.4)/ 7-12.. -
_ ,,, 1,.y 1 z,_
4.n,,tern CHI'S)I11.1.18:411/1ILLI: ftlet"..,!IC.....L...7%-*I-
fr-L144 '/JP
‘N Cil lcation:
19-r./11/i k i Aft•)/--)k Z4110 Jer.61.411X.
71/24117141), 4.fic_-.5
— Facility ID/I(it 31,1/11c41.) N.Co tar.a.tn ....
3Z-:::_S-.-7-i./ -/..;'ir-. .3 Wie6 AO lifit.A. 4.4-Al, • .;'. .„
146.24e4t...v
,:.9..„-7.57, SIO. re efC.-oi,firtt I Cootractor or Welt 0... Dile
_ iZire.. 115(Z:11 /
ay vpung thil.frn to I het rbr ceJtfii,that the II eilai,EaS(,sr L''.:emiliegeti tv
....:: .,,.. Parcel Idcinilication No WIN) necareinttee li eh 15..1.V1:..1C 02C ri inn or 2C 0200 If ittj C011101001161K SittrgeoW726 •••
and thal a Cu.,,of thus record has been pl,,t1.der.':.I the welcomer_
I t'wride and loa7ito.le in degrees/minutes/set-nods or decimal degrees:
lni iro6 s sm.m..)
l 9.Stte dinrant or tulditinual well details:
-3 5 -7 5 7. C N — 7 . 3 ' .D._-7 NV VIIII may use.die baLli of this rase to Insaeids:ashlitiert.30 wadi slit didaiis ar sae,.
abandonment details Tait may also attach additional pain if smosial, -
,--()•,,..-TRI crioN DET.stiS Qf NVELL(S)131f.1iS(;ABANDONFD svitivirr-r,1/4r iNsTiturric),Ns -
....,,...,...,1,010,,,Coolle)11-cariShrilir :Ali IlitliOpic flquctom al-noir-water mipplrudis
,,,,,'.) ,.,,, .ILI,titoe cletettnttitot tehIfilth.11111014)lni,:illi Jlthrilf olti bear
I Oa. For All Wells: Submit dos rot on ....Wan 311 diays of carolictimm. of%CM
abandonment to the 1011.m.ing-.,.•.`....:.I:.r;:
IJistston of NN'ater itesourres,Infom ratiots Pe
(IQ llerillime Omit,
1617 Nlail Service center.Rai:nal.ZN.IC nen-1417
Rib.For lutes:lino%Veils: in.tils:it.a...,to,/,,Ii.,•,...-,.., .,, - -Ibe&jam ui lOa
attune,also submit one copy ,,I du, lot an N.d.:iiii..;./..:...es,...‘cusilletani of.ti 1
.., •,., 41:iingevert gg 1414
ah.ttichumielit to the 1,11,,will,
....---
;!Tliu ad suer- (ft.) Ihvision tit 1Va ter II VS0111 LI'S,I ilditi'21-401111141 WeenninHaCeithylrrograisi,
I(.St,N lad Set s ler I'en WI,1.Z.LleijellOSIC 27699-1436
_.
-..,.... •..•..,;!'NtItilkli OK Luinattle I It.) Ink,1,toN%.x ter Nu pistv A. In dee t4au NA sill:. ax idiitittato Ito icristida:the farm lei.'.,...
.1.1.11CS A.'S. II,.....,,.11,..si.b11111 OW 01111.1.4111 tan 101.11111adeilllik i•D AV'S 0.1r4IiIrtr..0.,...
ot ...ell :III.IIIII01111111.1 I., the s ,WIrt rt.t.lith 6410,12.0ftalli id LIC ZrM11111.11, .hs.'-i.r.
......-
i :..,.•: ..'...;!..Li,,ogbilliggialintIrt.11): (II.) al,,enionud
-...-_,
, i:,,,roi. ittatoa 11.4...11.I.L.U1.11 I Ilollin111...111.11 duality-I hvi,its.1 rut W211.3 Itg,i1114L'es

WELL ABA\110()NNIENT RECOUP ,,,„la a44, 3INILY:
1,V1d� IitiMwnilirrc \CEILL ARAtNDONAIrN-r ftr rA1r c
_ �� �:r,h,•rGrnprnhr:pPl ru 1 In,r,l 1-n.qrr.,:ttli..r>dAYl�titfniuSMlfar
WWII• n;.Mn � wer � .tt-i +dkrrr.q;,rvl jka
tr II n.1),I,u n 4•plh..rail. I r I I . ri.a Ir+dYCMImGU.l�A 7r'af
wells d m I n d /
71i.Appnrvunale tnlortne r!I svalo yr.:wan on 4_4
\ 1\'. ._.,,,,.,itevv@i apumpco. Fnit%\':\T Enslrprt.Y WELLS ONLY: f
HTH i
• 7,i vpe of ilicinferlaml used• J
.1\et Cottso u:tun o'er rod B94(V __
. .I 7d.Amount of disinfect:11d n.vcd: r
ill
?.sv.•tt uv 0:40e4,art(trr ;:
i\\ t' \\1-1 ". eik -- 7c.Scaling materials used(check all Thal apply):
_..4;+.uttural t'\lunicipal/l'ubllc Li Nett Cement Grout la ikaalt�( w ;�co.'C.i sL-..L.,"1-+•:ac;:
u.:L' ;L• nai.11•4rabny'Ca., n;,, Supply) 4 Cs:denlrat\Eater Supply(sinK(el ❑Sand Cement(-trout ©�rym! p r jj rc!u>:ri;ti.'h:,tuncre:nl tORcs1dt teal Water Supply(shared) 0Cnncrcte Grout 13 null CSC_ APR 2 ' 2o�Y
i lcclalty Grout 7 Gravel
\tin-AN r M:I•ni,-Wei): I
I 1t..n.. 0 13cntunue Slimy
Other fctpiaxinmtc iT}.+ ''• �. ^"F •._ 'Jell
t7Rccoset v I}.rt 4.J 4
lajccoonn♦\ell:
7L Fur cock material selected:;bore.provide amount of rat rii.415 used:
\,;c::::Reeliat,_c OCtowldlvater Remedtanun y/ / �sY / /^�1 -jt J /�j, J s(/,�� c
c7.',:tit':Sirta^c a:lc i@ceilW,C1y f/�Vl/' _�/���t/!/1Yr'�41! /f /,[s
CSalnuh'Ramer �{l
=.l{t.aer.:,>, OSionn.vaier IJraotape
I _-.\;+e:I:ncntal l•cch;tology GSuLsidc ve Cantwl
y'e'`,e"' 'i 1C 1.>acd I_,�up; t]itacct 71t.Provide a liricf description of the aba ndanne at procedure:
1��:a;I:ermal l-ka:utLtr'Cao!n Remo) C011ier(e\plata under 7 ) I flit' t Ai'�f G? iejq��'fil� y-�/2.- l —
3,bate ssc!I{s}:tblulllmlcd: ' a�:..., ,/.j u.. -�'� l ff— f�— r
`a.11 ei(location: / `�,
..,.. ., O,.;:,•Name Focally IDd
Uf••mnccablcl S.L rhficatimr.
r— /j
,9 / Synl!tnue o,,„..dc !Coutncr„r or Well 0..3,3 pet
fit prom,drys Junk 1 hereby c-ert,•that the i ettrr{ teat memo ath:waw d el
- i'amel Identification No(PIN) acraoekroce n uh 15,4:VC:IC 0_'C.IOU ear 2C_fk200 tI'elf l:aller'rntaa Starnfs'ill&
. Sa;:,le:Indlongitudeindegrees/minutes/5CCandsW'decimaldegrees: .ate/t/hetaCa/TI'�'.'/drirrotarflrmcAlmrrrwilerNaduekq/�rtp
l.:il
'. ;'k,d.:-:e::;Joe,/.s sdtie:aor
7�(r--•- 3 ( _ 7 �['' 9.Site diagram nr midi nnnal Well del ail.:
`/_•�• 7 7�tR' N I c•. 1?'3a' \V You may use the hick of this page to provide additional wit Site gicijitT gt,•n::i
7 abandonment details. You may also attach addnccdlal pages 1foccessary.
rn'crrltl(-t tON DETAILS 1)F%V1?LL(S)BEING ABANDONED
:1 r...:...:aurli,r.urr afl/Carat/able /'m•nrn/up/c'mediate tit nnu.rm .v• .r .ppjv,rVIG mini! INSTRUCTIONS
L% ,,,11'cr,q.qt unrru:tiumrinnmclm.pall Cnn 5011111 one fo or
111s. For All Wells: Submit this limo within 3(1 days of atageietomn of off
.:.',\cif Ili,: abandonment to the lollmvnrg
r � Division of Rater Resources,Information Plrrcoains
I lrl.
..., .ei;dept!rr (ft.) 1617 Alai]Service Center.Raleigh,;is('27615-161.7
\
lilt).For lnicctinn%Veils: la.addition to scndnt%doe b in 10a
r ; fin.) above, tdsa sahnut one Copy ul this fc:tin t.ith!n 11 anis of ompktioo ofte
ckt
-,"�[�� ah:unlonntenl to the liilluwotg:
... `.. It 'r'I;tlut+•;rrvund curt:r•:e: :_ .0 (fry) Division of Water ltesottrees,IIodergrnund Injection Ciwtr,dProgam.
• I636 flail Set sic,Ccuter,li.rlei;b,NC 3701-141K
-+
( . ..ag lemgd.',I itnnwo,: (ft.) Ilk.For\\Liter_`Supply X IIllevnuu Wells: 4.6.hltinti666 60 1001
addrc:;slcsl a,,,,,,.al...t slrbou m l e..'pr,.I dud Lim un�iin iOlAe
laiimi
,d well Lib:ut.L nuucN I. the ,,,•.a le i:ulkii aquommous o(lir county
'i •- -••.,,:,•r,:�u•r,t l.a-o,uf'.. III.) abaurGuocd.
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,. ,,..r t,.I•- .,.„t h,, o,.m..,,r.,l, ,.du. I .r r,.:.r i/.,,_.a:.-...u.. . Issvred 2-1..3146