Brunswick_Well Abandonment_20240624 (3)

WELL ABANDONMENT RECORD r,:,,rlr„tnt:ell k�,NI,
This fonn can be used for single or multiple Hells
1.Well C'nntractor Infcrrmatioa: WELL.ABANDONMENT DETAILS
Stefan Smith 7a.Number it(rtdls bring abanduacd: 1
Well Coauacsor Name(or well owner penatialh ahvnkiting well an Imlier proper i F,u rrnlnpk ai/ra 7itnr ,#- rVw-Makr .npfll .ilia Q�'f.1 o- wn,
r',NtvrMl n,Nr Q✓•,7tNhAiat,7Jl IYin tYtn VIAMl('Ole Punt
3576A
'b_Approximate uilame of water remaining in Nelllsl: Igal.l
NC Well ComrKint Ccgif►:alinn Nunlbcr
SAEDACCO FOR WATTR SUPPIA WELLS ONI.It:
Cotv"p Name ?c.T)pe it(dfdnfectam umd:
2.Well C.atrretion Pertdt
f .r;dI„frrhtalkweilpernoRr(i.e.C...Mille.Iariance fgfawlirmi,erc.iif6nuwn 7d. Amoautofdisinftt-tanlused•
J.Well use(check it(Al use):
Water Suppl} Well; 7c.Sealing materials used(chock all that apple):
f]Al2multurd ❑Mumcipal,'Ptibhc fl Neat Cement Gran W Hcnnonitc Chips or Pclkts
❑Cicothemtal(Nctinal'oolin_Supph I ❑Residential Waier Supple isingici ❑ Sand Cement Gran ❑ Dn Cla}
❑lidustnal:(ommercial ❑Rmidenwi WliterSupph isharcdl ❑ Concrete Grout ❑ Drill Cuttings
131m•••two ❑ $pedalo Groul ❑ Gravel
Noe-Water Supplh Well: U Beritoutte Slum 1.1 Other(explam under 7g1
S klonuonng ❑Recos en
Injection Well. X For each material wieeted above proaide amount of material,o wit:
❑Aymler Rechugr ❑Grounds ater Renlediwion
❑Aquifer Storage aid Rec(n en ❑Sablut. Barer
❑Ayaiferlem ❑StommitrrI)mtmge Bentonite.:81b ,Wtr:gal.__
❑Erpenmenwl Iochnolori ❑Subsideme Control
7x.PrNitle a brief description of the abandonment procedure:
❑Geothcnilal(Closed Loop L1Tracer
i IC-Kothemtal(Heatin Coolin Return) f]Other tcx am under 7 )
Pulled tell riser but screen stayed in place. Had filled
well with uncoated bentoni.te pellets.
4.Date"elliiiabAmintird: May 24 2024
ia.%1r11 location:
t
Koppers Carolina Pole Site
8.Cenificatinin:
res:dq%Q"irrNairic Faciliq(DN(itappliciblc)
1901 Wood Treatment Rd. Leland, NC 28451 � r3i 5/31/2024 —
Pli,sica 1 4ddress.( G 1 rare •.cenified Well Conuractar or Well rhl mr Dore
Brunswick_ M..signing thLv finest, I hereby cernA,An the well(s) was lweret ahark acted ur
(l�a,in P.a,cl Itl:niilx:asni w, :1•1\, acrorthowe with iJA NICAC 02C',0100 or X 0M(Nell Construction Vimdunls
oriel drat a cop,of this record has beefy provided to the well owner.
';It.Latitude and longitude in dtMesNninutirvu iinds or dec•inial degnea:
(d%%ell field arc Ian long i...idiicicia� 9.Site diagram or additional we(l detaAth
You nun me live back of this page to prrn We additional cell site details or sell
34.250844 N 78.074457 W abatdountenu details. You niaN a6o allach acldntonal pages if naextian
CONSTRIiC-TION DETAILS OF W'ELLiS)BEING ABANDONED SURNIMAL 1NSTRUCT1ON5
.1((oah wcil LOVIN llfitlt rtaaual'.J it oLwlahie. h.w inalnfile awLfiun ctr rerin-Vi, o •isppi
wefts ONLY with the:wait ctAmir witiur atlmnAmmear iw can srrbmo ate Won. 10a. For All Wells: Submit this limn uiilum .10 days of completion of Nell
6a.Well[D/T -6 abandonment in the tnllouiK,
Divisianof Water Resourve%.Information Procnsing Unit,
6b.Total wall depth• 10 (h,) 1617 Mail Sioux Center,Raleigh.NC 27699-1617
Illb. For Imlectilima Wells: fit addition to settling the form to the address in l0a
abo\e. also sirhnul one coin of this fonn "nnhm 10 days of completion of"ell
be.Ittorrlwde diamNer.1 (in.) abandonntcru 10 the following
rid.Water let el brl n; ground-Atrfacc: 6 (ft.l M%Woa of Writer Resources,I.ndergntund Injection Control Pntgraan.
1636 Mail Scraice Center,Raleigh,NC 27699-1636
5 1(k. For Water Sustih &or Water Iniecti m Weill: in addition to sending the fomv to
6c.Outer casinglenVrhldlmo"ni: (ft.) llw address(esi abme. also submit ooe cop% of this form Wilhm 11) daps of
completion of wd1 abatidoruncnt to the.ounlN health 11cpanntcrt of The court
6f.Inner t:asin>r''tahing lenyKh(if I:nownl: (fY.l tt here ahirdoncd
6k.Screen Icuillo(irknownl:5
Form GW-.10 Non Carolina Dcpanliters of Ern wontncnt and Natural Resoieees-Di%stun of Rater Rcsouives Res vied August 2011