Harnett_Well Abandonment_20240617

WELL ABANDONMENT RECORD For UNtntal l w ONI Y
This form can be used for single or multiple wells
1.Writ Contractor Information: WELL ABANDONMENT DETAI(S
Stefan Smith 7a.Number of hells bring abandoned: 1
Well Coraracior Name tot acll o%uLi petsotull.s abatdomng Nell on Im,'het propctts i f+o widol-lc .ri{V,h,n, or I*Mrti rer su{y4) wells ONLI wib flit, uwie
„xrfrN.n+�t.,'+am6,nmrnr,Ir,N(M tWlin0I,vW Fran
3576A
'It.Appnnimate toluene of water remaining in wcll(%P 1 (►taL►
NC Well Canlndnr Ccntftrtdints NotiANT
SAEDACCO FOR WATER SUPPLY WELLS ONLY:
Compam Name 7c-Type of disinfectant used:N/A
2.Well Coustttictioo Perot Q:,
Ittr cdl,qa+G:or+4 well{rr,NNa n.e,Culd.,Swk.l artaw-e i/ryrcttrnr,ear.,tJ,lnrtw,r -
7d.Amount of disinfectant used
3.Well ux(check a ell ux):
Water Supply Well: 7e.Sealing materials used(check;it[that apph►:
ElAgrwulturll ❑Mtlmapal Public n Neat Ccmcnt Grout IN Hcntonitc Chips of Pellets
06cothcrinal(Hcaroe-C'oohrig Supplyl ❑Rcsidenual Water Supph tstnglei ❑ Sand Cement Grout ❑ Dn Clay
❑hd isimil 'omnicrnal ❑Rcsidennal Walcr Supph isharcdl ❑ Concrete Grout ❑ Drill Cutlings
❑Irn^ uott ❑ Speclalty Gtuuf ❑ Gra\el
Non-%ater So pply Well: U Bef*omte SJUML H Other(explain under 7g)
Nklomlonoe ❑Rcco%cn
Injection Well: 7f.For each material w 4ected alltaitc.pnnide runintnt,t(materials med:
❑Aquifer Recharge ❑Groutdwafer Rernodt:ntun
❑Aquifer Storage and Recrn en ❑Salmity Hamer
,
❑Aquifer I'esl ❑Slonmlater I}ratnage Bentonite.:71b Wtr:gal.-- ----
DEspenmelual Iechnotogy ❑Snbsnderix Control -e,PI-IN I&a brief dcscriprnwn-it the JI1Jrldt+o lllt'lll I/I fit l'11111T:
DGeothenllal(Closed Loop1 UTracer
Pulled temporary well aid backfilled boring w/ hydrated
DGwilmnml(Heating/Coolingml Retu HOthcr icy ain under 7 ) _ _ _ _
bentonite chips from the bottom up.
4.Date weMff)abandonek 5/20/24 ,... ,
Sa.L1 rat Arcation:
JUN 17 2024
W. Cumberland St. PCE Site
I",AIn(hr 1.r FacilMy IDtt(if applicable) tl•Ce1111ica111N1: irAi:AA r n iii-,•reow--r
1200 West Cumberland St., Dunn, NC 28344 �!" i 5/27/2024
Ph.sisal t.aa,_., n..ewl,r. —Ito -.Centred Wes Conaaclor er Wes CM net Drat
Barnett By.signing this firm, 1 hereby certify Aar die well(s) was{were, abati,lotwd ur
tti,oa. 1'1t.111&11111x111WnN.1 .1VIt ncrorikowewidtl3ANrACO2C,0100w1C.0JV0WellComhve•tionSkmlkirdx
and that a cnpv of this record luau been prwrded to the well owner.
Sh.Latitude and In igitude in Ikgrreslmilwtesixctmds nr decimal defines:
(if"ell fwld one La kmr n..nnu:tctf 1 9.Site diagram or additional well detaNr
You ntat tnc the back of this page to pros ide addiiiinlal well site details or well
35.314064 11 78.622259 W' abatdonnletu details. You nun also attach additional pages if Ilccessan.
CONSTRU(MON DET-411 S OF W'ELI.IS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
:[fnucir NrJ1 cn¢r)rudant n•n,r.I•.v r!�rm!„4le. l2V Irtl,Ihf+lC alflltLrn,P IYNa•Nilfa7 w{ydl
welbONLY with fhe m~tvAmourfN,fr aftonk,Nnen/.i•xr cart suhmtt,mw Agri 10a. For All Wclb: Submit IN- form wthln 30 da1's of completion of well
W�IDf TMti_3 abandonment fn the follouing
Disisioo of Water Rvourcm.Information Processing Fait.
bb,Total odl depth: 25
1617)fail Senictr Center.Raleigh.NC 27699-1617
tft.1
10b. For Injection Wells: In addition to sending llie forn to the:address m l0a
abuse. also submit one copy of this form mthm 30 days of completion of dell
6r,iktnlwole diameter:1 li0.t abandonment to the tollown g
Diaision of Water Rawlturcc�,Cnderground Injection Conitsal Pnrgram•
tin Water keel hrlttw Qllauaud surface: 12 A) 1631r Nail 4nice('cater,Raleigh.NC 2'699-1636
10 ilk aFo%mirr+.b pol% crIn b nNt1 in Wells: fit addition
fomt wain III form to
of
6c.Outer casing leafut,1 if knoa n I: !h►
completion of well abandoruncnt to the counIN health deparment of the coum
6f.Inner casimy-tubing k-nLKh of I.nn tt Ivic atxnndonedw n 1: (,h.)
6g.ScrcYn lcny;lh(if knonn1:15 lft.l
Fomu GW-Vi Nonh C'aroliza Ikpannlcre of Em ironnlenn and Natural Rcsotuces-DIN tsron of Water Resouacs Rcs tied Aupsi 2011