Randolph_Well Abandonment_20231006 (9)

WELL ABANDONMENT RECORD rot locrnal Us;ONLY:,
This.fotut can W rued ibr sinkle or multiple i etls'
!
1.Well contractor lnformationi WVLL.ARANDONIMNT DETAILS i
Rich.Lemire 7p,Number of ivelis hying abandoned: ?
�VetFCiotYtaclorNAUM(arii�llotcn aottact}:ubauJarintgtiatlo>tlii 6,r,ptupcfly trlrrett'ae w; iwrtaietfe�l �uegfJj vd1L: ONLY wrrh h'.e sane
enrtsirrrtifiauii4runfrriirNi7at,,IVirr cR SANJGf a efrerm,
2593A
7b,Arpm:timatc v alitme of rrata-re-Waingin rt ell(:)N0�
NG\VcllCoalragorC.�:niR�iliouNtiiabcr i ..
sAEDAcco FOR NVATt R SUPPLY IYF.LVSONLY:.
C4n�p;titl�Naiuc i
7c T�pcofditinfiLlarit.usetl:'CHLORINE
-2.WetI-Coustiucfiuu Permit#:, 7607-MSWLF-2015,
l t f till itlgillruble 16x11jwrxf6 rie.ccur:rK Siete;1'nPeb te,Lrjerriuie.rtcl,fJLtutrn 7d.AnitlUUt Uf dlslufcctswl USLYI:2 OZ'
3.Wcli uAt(chectch'cl1 use):
Water Supply Well: 7c.Scaling mate�als tisstl(clacct:till•tlaac apply):
❑Agtii Illtur9I dMunicipnl/Riblic IR Nca(CcracutGtiF ��y a`' ; r i l m Rcroonitc Chips nr Pcli¢ts
❑Saud Ci nceul GmuP '' �� zt n r Clay
l7(ieotknmt(Hcaling/Cocrling Supply) i]ltcsideutint Water Suppl}•(sjngic) ty
❑lndusl"Wornmercial l7tftsidetnial Water Supply(shared) p C6ticicte'Grout " urill:Cutlings
OCT O u 202F
❑irri •tiou i7 4eciully Grout ! '-0-Gravel
Non AVater Suppl}•Wclh 0 Bentouite slulnj,6r- &: .^i1 1.0E11'Sr(exTiain under 7g),
�Murdtorine I7Rec:oten� fir`:t�1`�'Wti� '
injccticrn'�Vctl: If,For each material selected above,proside amount of.m:iterlals used:
❑AquUcr•Recltarge OGrotmdi}aier Rente_diation Neat Cem.•241b ,Wtr•144gal j'. Sand Cem.•Ib ,Wtr•gal.
O 41tifer Storage gird ft& env OSedihity Barrier
17Aqu(fer Tckt OStonmv�uter Dmioage
Bentonite.:71b ,Wtr:gal% !.
�E3petiutetiutl 1`echuuloei OSubsidelbt.Cutdtnl 7- Pmtidc it brief description of thehandnnmcnt invaeirlun:
UGaothc:tinal(Closed.Loop) OTracer
TREMIE GROUTED FROM BOTTOM:TO TOP.
C1Grotltemial(HeatiBEi'Coo ling Return) COth6,r(e. lainuodec7F)
d.°Data n'cU(s).ahandoned: 8-22-2023
&L%Yell luesilim:
GREAT OAKES LANDFILL PZ-4
[aeilit}lUivnerNairc tr~ility1DV(iE'npp1irab10 $•�et1lRcatiau:
3597 Old Cedar Falls Rd, Randleman, NC 27317 - ~`tom _ t� :�P/Mw_C► 9/6/2023 -
PitvsicalAddre�,City,and Zip' $iejtahiriYof t_.-=ill�vl tVe1i Cousu.wtar or Well Ovwr Dale
RANDLEMAN 41,:vgnft this foavi, I hereby certify deal lire irellfs) erns(trere)ahemdoned in
Cocittty Nice)Idcntifi6itinallo.(,PIN) riot,•urt4wive with l M.i1GiTCO2C,0100er2C.6A' OrMellCoir4hiction inikr►ds
aqd firat a cppy oflhis t ccprd Am beeraliiroviticct to dw-well ottxer:
Sh,I.stitude and longitudei,in domes/minitiesiscemids or.devinial ctcgrecs:
(ifcr cn rakl,urn t ttllnrty tsatitili acw? 9.Site diagram or additional well den.Rs:
1"ou may use tlr bacl('of dits page to}iio(i&additional stet]site'.details or will
728757.95 �* 1777783.10 Y(' abandonment detail,. You way also attach ndditioual page s if txcassary_
CONSTRucr.i(1N DETAIL_R(IF wELL(S)1311M.ABANDONED SURNITMAT,INSTRE C.TiONS
:Ifirxb 114 twatitrile7 rue'ritvreilsi-1,utWldilo .Ptir itidupfe Llecadje nr mia-weavr atrlplp
u vita ONLY a JrL l!w strna•consfnxi)oir'rrl,dat,4iix!icr{t.j+an rnm sutvmit err Bunn. 1pa,For All %V&ts: Submit IbLs farm srittdri 30 days of c6tnplctron at wll
6a.%Vcfl ID#•PZ-4 ahniidokimcat to thv fol101iing:
Dtpisinn of Watcr Rcst mccs,information Pructsting.Unit,
6h:Total ircll depth: 70
_1617 Mail Scnice Center,lblcigli,tit 27699-1G17
{cif.
1011.rite'Infeello»Wells: In addiliotl;fa setldiug deefattm to the'addiess fit 10a
Gf 13oielcolediantctcr:8.25/6 above;also subutit olio-s tit py of this fbhwi lriii 30 days Of coloo'letiou of we il
('iu•} j.
ubatidonritent hi tilc,Rolldwing:
6d Watcrlc'c1.beMts ground nrrfacee (ft.) -Division of Water Resources,Uuder};round hi jection ContiA Pi dgratu,
We,Mail Sc icc Ccntej,Raleigh,NiC 2769-1G3G
Gc.Qutca eosin Ic (if Im<!nv); (fG1 loc.Fnr\V itcr Srannh.C.inrccfr n�Ycila Hr addition to sending the fomr.to-
g �( the:addtess(es) abwe, also submit bib copy of this Sofia Mtbitt 30 days of
completion-of sv�cll abandonment to the
county liealtla department of the county
6f.Inner easiaWtubing length(if Lmown): (ft.) where abandonctl,
6K,Scre'c-n length(if
Form 0V-.1T Nortli Carotlm DepJamcm ofEmiioatnent and Natuml Resou ces-DlPislon of Water Resoumes! Rcve;cd August 2013

i
a ,
WELL ABANDONMENT RECORD FurintOrt lUmONLY„
This fann pn be used for singiz o r multiple�5ells
1:Wctl Contractor itiforniation: ♦ FLLABANDONMENT DETAILS! j
Rich Lemire 7a.Number of rrclls heina 410ndoot :
l♦'c)CCottracforNanac.(arwell.O%v crpcamiail,'utxsod ttbwetloniais€jt rprupcny) For w1dople fnletfaar ar mm-mirer .npp.�- iavlLc ONLY w1h Me smxe
carasrrncfi[xa.inh:r,kltviraaaar,,tram ctiur araMror cureJhrm
2593A Ip
N6
7b.Approxiinate Vol-nine of watts rtrit:lining in iiell(sRNE (t►L)WdtCoalractarG.rtifiaaLiaa Ntiva6cr m •.
sAEDAcco FOR\YATF-R SUPPLY♦VE1,13ONIx:
CQaa�aaa}'Nanas 74 T�ype(ifdiiinfeTitdnt psell:CHLORINE
.2.Well Construct€on Permit#:, 7607-MSWLF-2015;
1Ad irll ulrplhirbla uefl Aarirrlii rie.Cawr n.Srt1i4)w aiirnee.LJedrr,r;,elr.l iJkaautrai 7d Amount of dlslnfcctant ltSlYf 2 OZ
3.Wel use(checkivell use):
♦ester SuppW--Well: 7e:Scaling:tioatcHnisuse+l{chccl:altyita¢00ply):
C]Aaricadhtnl C]h8iinicipallPitblic rA Nralcciuctitl3raait' 2.._r p FG l3cNonitc'CfiipsorPellcts
E30cothormal HcadnglCanlln-$ ty) 1jPr_5 ettiW Water Su & J7 Saud Centertl GtvuE ��'' °:,i iu Quy
{ a aFir ppiy(Sin to) ry
❑lndusirialf(:dmmcrcial ❑Residetuia t Water Supply(shared) 0 Concrele'Giout ^ 13 Drill Culliy°ts
❑irii tioa O Spec€ally Grout O C T O U 2�23 .� Gravel
Ntrn�V;ttcr 5dppfc}VcII: 0 Bentotute M r 1 n_ ; -plain under 7g),
MMattltoriire EiRc'covc;tv rJrvt,7 �r
Injection Nvcll° X For each material selected above,provide anlountof:niaterials used:
❑AgtriferRcchargc OGriimtdnalerRentediatiari Neat Cem.:241b ,Wtr:144gal. , Sand Cem.:lb ,Wtr:gal.
OAquifer Sl6mge surd Rebvery C]Saliirity Darner
❑AgltifetTest OStomnt�aterD•tuirwgo
Bentonite.:71b ,Wtr:gal.
0Experinreulal Twlfiwto a OStibsidetre,:CoiNraf Provide a hrlef description of the abaidanmcat procw°dun:
013codiennal(Closed Loop)- OTracer ,
TREMIE GROUTED FROM BOTTOM'TO TOP.
Meothemtal(He<tdn>tr'CooligaRctum) ®0(hcr.(eN lain ut►der.7it)
:Dyteric(tC3):ahandonctl, 8-17-2023
3a.Well Incathk
GREAT OAKES LANDFILL OW5R
Face tj'loivirrNam ra:ilitylDNtit~upplicablo) R.�ertif[ridoit:
3597 Old Cedar Falls Rd,' Randleman, 27317 9/6/2023
Physical Addre�,Cite,and Zip $[g[ghim oft_died Well Com.Kitty or Weil 4'hvwr lime
RANDLEMAN Hy-signing thisloran, I hereby cerfffy Mat Ow tre11(.q) was orerr:)rrhmadoned in
Caauty Panel ldaalit-taitlaurNo.(PIN) ,zrctc,nhinic ud111 114,ffic2C OZC.0100'or 2C.0200 rMell C mis.1h0um Stawkints
and that a cop),of llrix recand Ims becii provitlerf la 11re-well on'nen,
-5b.1a tkiidc.and longitude in demesliniquig 3ccmids or d0itiviLdegrcest �•
(if n•cli Vold,utae kulloitg fmlfrickti) 9.Sitc diagram or,addltloaat well dctaEls:
You ivay use Q e ba'&of ribs page to,_providz additionakmell site'&Oils or►toll
728363.64 Iv 1777.63'S.26- �v' abandonment details-. Youtuay also vlacltaslititioualpasiftteccssary_
CONSTRUCT I©N DE:TAiLS OF%VTI L S)11JONf:ABANDONFO SiTB1iiI7TAI..Tt♦TSTRITCTIONS.
:umb uIWJ t5orrlrtit'ifura ricru;lira aJ'arallrariFe .fro trmlfajile injrttioie nr`lx�n•rru!}r curpplt
ia�11sONGY uJfli r'r<pviuerv,cetacr/iu,Nrzr:natSuaaeuL j�n alit sidmif s ire ifvnrt 10 q;Fnr All ♦Vel Submit lhL9 fomi within 30 daty`s of ctimplction of uvil .
des♦Veil @#.OW5R ibibdotiuicnt to'the fallotiiiog:
Dtry€aion of Water Resources,infgr•mat€on Pr6cessinV Unit,
6b.Total well depth.- 60 (fp,) 1617 Dlail Senice Center,Rale't h.KC 276994617
10h.l?oa•Inleelrttn Wells: In addition;to sending tl)e form io tttai address-lu 1W
fie.Bor.eltole dianictcr:S.25/6 abort;also submit otit�copy of ibis foi n'whfdii 30 days cif ronipleiiou of a�e11
(iu:j' abaodowncut to the•folldwin3: I ,
DMsf,ou of AVker Resources,Under};round injection CoulrW Program,
rrl Waiter Icvcl.bclan proand urrfaece {ft:) i636 Mail Service Ccniei;Raleigh,NC 2769-1636
i !
6c{Outer casing lcn h(iElmonrt): (fp) 10c,For♦V:iter Sunnis Rt inreetrZi Veltc: In addition l©9ending the foun to
the addresses)abode. also submit oab copy of ibis form within 30 days of
completion of ivelll abanda nra:nt to Oct ci uniy health department of the conn4r
6f.Inner emingltubing tmn th(if lmawn): (fit.)
�vha:rc alxindorecd.
6g.Screen length(if know-0): (f4.)
Fornt W-30 Nontf 6rvlim Depanat m of Fm ironment aail Natural ncsoumes-Divisian ol•Natcrltesoaua;s: Revised Augurs 20 t3

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WELLABAND.ONNIENT RECORD For Imcim.I cONLY:" j
This took ran be used for single or mtdliple isi:lis'
1. velt.Cantracior luronuation: WFLLABANDE)Alh1LNT DETAILS
Rich Lemire 7:i Ywniicrofiv��lslieingnliilndadctl:"1
14e11'Cratdtactortraart(arwrllotitncr tsoiiatlyutti�tatdfi�+g'ueUonliisll>Lrtnupcnyl 1a' reulople timer. ur frrA-tlYrft,I slrja uelLr 0,1'LY will tlx .saore
" cvrtstrnctai+ri'rt4,urctniirncrit;trot c�vr srrrvfiff are�frrnt
2593A fC
NC Well CvntrigarCenifiattiou Nii,r�cr 7h.Approximate r'olnmc of hater rcinuininL jn irell(s)NO
( i
SAEDACCO FORWATE'It SUPPLYWF,I.LS QN fly.
I,
CQnrp ntrNant¢ �'
7c.Type iif di>Sinfi'etuut used:CHLORINE
2.Wiel1'Consttuction Permit ii:, 7607-MSWLF-2015,
l f3t 4,91 tflrjfltavble+relll¢rmltc(i.e.C-fm tr,Sfafij Aar&Ynce.LJccurivv,rtc:_)ylnowir 7d:AtnAutil ofdlsinfect:itit LtSlYl:2 OZ
3:�ti'c]!use(ebccl:%'fell use):
Water suppl.�Well: le,Scaling inatcrials,usvl(check all.fliacailply):
❑Agriculturll ❑Montcipamililic. 12 Neat Ccment Pro,nt !a 13cmonitc'Chips or Peliets
OGcotitcrm tit(HcatinrJConlina Supiily'} ORcsWentiat AytitcrStipply'(r inglo) q Sind Cenre it E; u / %� ?��' Dry'CLiy'
❑ItuiuStrialIcbmmercial ORcsidential Water Supply(shnmd) 0 Conccetc.G bu.r'� "` ❑Drill Citttipp
Mitigation E3 Speciait;Grout GC -O'Gravel
Non VAtt;r sopply Nycll; 13 Betdotute Slut C7-0iher(explain under 7gj•
�Mmilloritig l]Recoteri' s ..Irti F�:i i�r:: w,�_ Un-5
injcctien Well:
7f For.each ttiS!(t�'r%d s 4 dltai ;provide amountof.umterials used:
DAgitifet.Rcchar a �Cromidi}�tcr Retuul'wtioti Neat Cem.•241b ,Wtr•144gal., Sand Cem.•lb ,Wtr•gal.
�ilgleifer Sttant5e:uxi i2cxro%'en OSaliiti( Darner
Bentonite.:71b ,Wtr:gal. i
❑Aquifer Tasty ❑Stonnyva[er b'neindge; ,
OEyierintenlnl Tie lhuo[ogv pStihsidet>`e.;CatNrol 7g.Pmiide a hfief'dcscriptian of thc.aWndonment itm&duar:
CIGt:othennat(Closed Loop) Mom
TREMIE GROUTED FROM BOTTOM,TO TOP.
®Geothermal tHtwititurJCoolinttRenim} CiOEhcc(e�•lain under lay ,
J.a]atc+ca lt(s).iibandnnetl: 8-31-2023 -
4 vven Wdtinn:
GREAT OAKES LANDFILL PZA-20
Iuailitg/t}nncrNw% rmilityy 1Dm(Tr4plicab1o) &.Ccrtif[t iitioit:
3597 Old Cedar Falls Rd, Randleman, 27317 J' � _ _� ._.P/Mwt.�. 9/6/2023
Plivsical Address•City,and Zip 5LL,0il'ott_._i010 Weil ComirKlar ur Weit Owmi U Ue
RANDLEMAN fJ),s"Wfing it, form, 1 kveby certify'ihm`a&-u•e1i{.vj truss(irere)r7bandoned fie
Cautuy Plated ldcatirki4 ainNo;(PiN) ctecrfnlrntee n•ith'1:54 iMIC 02C,0100 ur 2C.0200[Veil Carfslrur.Uort Sliinikffds
agdthat a copy of this record kasbcatF; r Iti Fatf(o them;eN otir'Mr.
•5b,LaWade and longltude In dc9r+tea1idiotitcs/scco6ds or tlecimIll
(It.y eu Co td atrc a iritn+t;fs�,ttf3uer�} 9.Site diagram or additional well dom'lls:
729080.22 * 1778294.86 You ivay.use tUe.bkk:of-this edge to pdoi;iiia:,'additionat nti;U site.&Oils•or%%eU
A �V :.abandonment damns: I od tuay also attach i"iiai at'pages if necemn.
GONSTRtlf:t1 V DETAILS OF W1 LL(S}BEING ABANDONED STTBAiri rAT.fNS'fRucmoY5
Atrrxh uWl tdmV4 lca&j rumrdjs)Jj'ai-ni&aGfe. •!7u•wflaple mjecifurr ur-mia-uxrtu•suppti'
u ells OYLY vJfli t!�aaniu runstrnctdofc•:aLarrhzxfarru.J+�tv eYlif s;ilugit cure jGirflt 10a. Far All Wells• Submit 1hcc fomr.iiithin 30 di yVs of cdtirplctidn of u ell
PZA-20 abatuhiutticnt ta'tlaq fallowing:
6a.wet[D€1: .
Division of Water Resoucc ,Information Promting.Unit,
Gb:Total ecll depth: 57
1G17 Diail Senice Center_,itale'i h,NC 27699-161-7
((It.} b
upb.For Inlrediau W-OW hi addition"to sending tho-f6tmi,to lbe address ht 103
Gc.Roreltole dianictci;8,25 (u.} nbni�:also subenk one copy or this 1'orm'%%ithih 34 dot's.617 cmnpteiion of,well
abitudomiteut to(he folld%%'inl:
Gd water lcixl,bclos griiarid utrfacre (ft} Dicisloa of�Vdtcr Rcslurc ,LTudcr-round hijecilou Condrvl Mgratu,
iG3(i I%Iail Seriice Centel;Ralci;h,Ii('27699-1636
i �
Gc.Outer casing tennth(if knotrn); {ft) 1pc-For Water Sunah.cc Tniecftan Weiix: he addition to sending the fonu to
the addtess(6i abode. also submit ©tie copy of this.fbini within 30 day% of
completion of i'Al abmdomnent to thc'criunly beatth department of the county
6f.Inner cashi hubitiq Cmgth(if lno wn): (ft.) %vltcro abandodcd.
6g.Scr&%length(if Wtotrn): (ft.)
Fami GAY-10 Nattli CarOHM Dcpantmq d1'Fmiroomgat and N:tturui Resomces-Divistonor WatorResamcca' Revl ed Atipm 2013
i