Surry_Well Abandonment_20240325

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WELL ABANIUN1VILN'1' RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
64 1 4.0'''�'"s t/`� c �hArly 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
\\ell Cnntractoi.Kante for well owner personally abandoning well on his/her property) well construction depth,only II,W-30 is needed. indicate TOTAL NUMBER of
3 E 7‘ 4wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): d',--'/ (gal.)
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Betfs �-4/(/i/'Di✓./rP,,�a� FOR WATER SUPPLY WELLS ONLY: 1
Company Name .
7c.Type of disinfectant used:
2.Well Construction Permit#:
Lis'all applicable well e•unviruriiun permits rise. C/C.Counit•.Slate. I atiance.vie.)it known '- I
7d.Amount of disinfectant used: •
3.Well use(check well use):
Water Supply Well: •
7e.Sealing materials used(clieck all that app):
❑Agricultural 17Municipal/Public ❑ Neat Cement Grout 1.Vtentonite Chips or Pellets
❑Geothermal(Heating Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 1t 0 Dry Clay
❑Industrial Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout i ❑ Drill C'ut(ings
Ohrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: •
❑ Bentonite Starry ! 0 Other(explain under 7g)
L9'Clami��toring C;Recovety .
Injection Well: If.For each material selected above,provide amount of materials used:
❑Aquifer Recharge DGround water Rentediation ie icI/�5 7o /&/404-'lrc-
` J
/3ea✓rL uov.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStormwatcr Drainage
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:jExperimental Technology OSubsidence Control
7g.Provide a brief description of the abandonment procedure:
:.::Genthennal(Closed Loop) ❑Tracer jp� f'
D(ieothermal(firming/CoolingReturn) ❑Other(explain under 7g) /30,'et`I/eS 6 d"(rep(Ai:W.Le.v4o.4.11-e-
pre/le71s init.-.0d.,c e,Q A,/ S'io i.e.'. y re-,Vii it t o w
4.Date well(s) 2 abandoned: -28' L/ ��`'L`/
a.rTQT Cc�.1Cola1 1
c"-'y �Yi•- 0C/Ni-
• 5a.Well location:
l
'A A. W. ade,S
Faeility Owner Name Facility IDn(ifapplicable) 8.Certification:
3 g7s f�w7 2�� S';/oaMllVc �7��' G�J , y 3-1-1-2_1(
Physical Address.City.and Zip Signature of Certified Well Contivaetor or Well Oo lie Date
S.:v r I^ 573 019 919.2 By signing this/om. I hereby ccrli/i' that the n'e'l/(.$) was mere, abandoned oi
County Parcel Identification No.(PIN) accordance a with /S d.VCAC 02C.0100 or?C.0200 Well Cunsevclion Standards
and that a copra of this record ha.i'been provided to the well order
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
Orwell Field.one lad long is sun ieienn 9.Site diagrams or additional well details:
34-3 L/ g 7S N 'ct�o 5 9 /7 W You may use the back orthfsl;page to provide additional well site detail or
(7 abandonment details. You may also attach additional pages if meow<arw.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
:mach li mr/l cnnstru iiun re cord's)i(u1 uilahle. For multiple inleriiun or nonarener supply ire&
OJ'L F it Ph i/u'.cane comp'u,thin uhuudrmem.run can.cahml roc in ni
}��i �-,, 10a. For All Wells: Submit this form within 30 days of completion of ssc11
6a.Well ID#:A)EJC'6/ /, , ,a K `�1"%r:,, Fhb to the following,
_i a 5.
MAR Division of Water Resources,Information Processing Unit.
6b.Total well depth: (ft.) 2 c. <��� 1617 Mail Senlice Center,Raleigh,NC 27699-1617
• )THJ of, , n ._'s'`'�+ UnI0b. For Infection Wells: hi addition-to sending the arm to the address in Ina
la''c' is.G above. also submit one copy id;this form within 30 days of enmplcuun ni sill
6c.Borehole diameter: 2 .2 s (in.)
abandonment to the following:
Division of Water Resou ices,Underground Injection Control Program,
6d.Water level below ground surface: / © (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending ihc!Orinto tli
addresses)above.also submit one copy of this form ss ithin.0 days of comptctiot.
of well abandonment to the county health department of the count vs Kr:
6f.inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) 1