Bladen_Well Abandonment_20240617

WELL ABANDONMENT RECORD GApnrinkrnrlC�ONIti'
This form:an be used for sin;!1:of multiple wells
1.will Uontr•actnr Information: ( �� FELL ABANDONMFNT DET.411S
Brian Ewing \ \I 7a.Number of wells being nbanduned: 1
Well Cotivacsot Name for Nclloun►r persorulh abatdosime well on lus'Iter property i Pali twWripk oue,lror, „r ,ww-rater "qrA welk ONLY wish /he apse
r.N,vf/Tf r/rNI„�.,r.nl+wm.nr Wu rror.wlvnrr+wr F,rm
4240-B
f, �Iprt,�ini,ncknlutaaeaYwaua rrmaininginwcll(sl: (R�1
NC Well CoMrador('enifacation Nnriiher
SAI,.DACCO
r(r1:11 t 11:It SUPPLI"WELLS ANLY:
conyom Name -t. 1.%pc of dr.infectant used:
2.Wdl Comstitiction Penult N:,
Lvj<dl,grples,o4k well prrnrax n.e.4',man.J'hme.I,iriame Iigaarinrt ese"ifkmsww
"d. �muunt of di.infivtant uxd:
J.Well uw(check w ell use►:
Wmcr�1,14111Vh %%CIL 7e.Sealing natenal%used u•heck all that aPph):
OAgncultuml ❑Municipal-Public M Ntat Ccmcm Grose I I Rcnlonitc Chirps or Pcllcts
06cothemul(HcamiLY'oolin_SAiMIN I ❑Residerrial Water Supph (single) ❑ Sand C'eniett Grout ❑ Dry Clay
❑IndnstnaUComnicrctal ❑Remderural Witter Supph(sharod) ❑ C'oncmic Grout ❑ Drill C'numgs
❑Nisi^troll ❑ Specioln Grout ❑ Gra.el
Non-W ater Supph VL'ell: 1i Bervonite Slum I I Other(e\plam urider'gl
o0hlunuonue ❑Recosrr.
injection%ell• 7f.Foremeh material w4ected aboise.prosside amount of material.n.cd:
OAqutferRecharge 06mundwaierRemedtmon Neat Cem.:471b ,Wtr:3gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Recrn en ❑Sahtuly Barrier
❑Aquifer Test ❑Slnrnw.filer Drainage
OExpenmctual lechnolog\ ❑Subsndetce C'ortrul 7R,Prailide a brief description,d the abandonment prucedurr:
❑Geothermal 40med LAoM OTracer
❑Geothermal(Helifing/Cooling Return) ❑Other lei am Wider 7 ) TREMIE GROUT FROM THE BOTTOM TO THE SURFACE
1.Date wdlisr abanaMned:
5-16-24 ' V
5a.Well kscation: f
Ward Citgo Mittniip,; Pr-.r �'4M 1 tail
VA11 , <n•.•,.I`,,I. rxilityMN(ifapplk.th4, '< t ,rntic.ttfun; `�•e`b,+'W
10236 W R Latham St. Clarkton, NC 28433 - Brian Ew i n g �••d 5/31/2024
Ph.sical Address.Cm.and ZW tit❑"n r,A t.-1,1,;t,..l i .u;::,.t.t al(firmer 11.::;
Bladers By.eignnrig thLv fim rr. 1 herby crmfy(tier der wellfs) was fwerei abmishmed in
t'uuuls (PIN) atwonlatie with 11.4ArACO2r.0100orIC01190 FEW
Conslruc7ionSYanrksnLs
and that a ropf of dris record has beer prtrvwW to the well owner.
ih.Latitude and InnRitmde in dettrieestivil mlexAmind.m ilevimal ds:%rem
(if well f cid.one Ln'lung a wffi seem 9.Site diagram or additional well 411eta0v
You mat the ilk back of this pail,,:to pros ale additional well site details or well
N W abandonntem details You nits also attach additional pages if necessan-
ONSTRII(MON DETAIL 4 OF%'ELIASI BEING AB\NDON FD SUBMITTAL INSTRUCTIONS
.(lhuir"ell ro2rlruch+rr n.....1—N a,whtl,le 1,v mulople oi,,,u.or„r,*m-mvi rMFP6�
%el/sO!VLIr with the e,unrcrNrxt>vathm,d,vr<knmtrn[tuvcaft"hmjidmf an IDa. For All Weib• Suhmn Ibis fntm within 30 da%s of completion of will
6a.Welf lD#.Mw-3 alsandoinncn i In the follnw►m
Disision of Wmwr Resources,Information Prucesstiop Unite
1617 Mail Smice Center,Rmlei,h.N('276"-1617
(.Is.Tuul well depth: 15 lft.)
hlb. For Infection 14O&: In ackhitwn Iu sending die form to the address in lea
abntc. aLw sushirut one copy of dos fonn within 30 days of completion of well
(e.lktrr•lwde diameter:2 tin.) abatdomitenn Io the killu ime
Diaision of water Restiore,r.,I nderground Injection Conlrul Pro(;rama,
bit.N ater keel brines gnrrund%urfarc: 00 1636 Mail%mice Center.Raleigh.N('27699-1636
5 Inc. ►h c. For%mer Suo & Infiltiasn Wells: In addition to sending the form to
Ise.Outer casfnglcngthOfLitownc 011.) Ilse addicssiesl Axne. also subeim oak cops of This font within tl"I days of
completion of Heil abanitknin[nn to the counl% liealth departmcm of the county
wl><m aharidnr►cd
6f.Innercasing4vil►ing length(if known): IA.1
6E,Semen length of known 1:10 (h.l
Form GW-3ir North Carolim Deputnxa of Err%irontnerst and Natural Resotaces-Dh goon of Wanes Resources Res iced Atieasa 2013