Jackson_Well Abandonment_20240624 (4)

«'ELL ABANDONMENT RECORD forlraern:111.WONIY
This form can he used for single or multiple Aells
1.W'cll Contractor Information: FELL ABANDONMENT DETAILS
Brian Ewing 7s.Number of wells being abandoned: 13
Far Mu !m,lr U,et11,vf w• r*W-wafer yup d1 wells t ST) rear the aver
Well C'owtacra Naar fur well uNu►Y p�esonull}:dia118011111`e'Ne11 On tllSrl><f prgicm I 1 Il.
r ./1."o(l,A'1,d1,'Whmp.,W 1rl0.,a/Njyhx f,mte K.F"i
4240-8
-1) lippro%in►atc%plume of natty nmaininr in'Aell(N: fxal.l
NC Well CannmparCeninralii.n Nuabct
SAEDACCD F(IN\1 A'fF:R SGPPI-Y NELlSON1.Y:
COS Now -c.I)pe of diunf►ctim used:_
L Wdl Callistrection pernit A:, , WI0100715
!%teal%aWkuhlr well permey fi.e.l,Bale%.'t:xr. i o,wwe bryrdrorr,rnr.l 11 krises
?d.Amtrtrnt ul'disinfectant ux•d:
3.W'til uve(check n ell u%0-
Water Suppt%Well; 7e,Sealing material%used(check all that apply):
❑Agricultural ❑Munncgm[T`tibK- n Neat Ccmctu Grotu Q Acronac Chips or Pellets
❑Ge»llicmunl(Hcattg4(•oolrnp Snrpplt l ❑Rcsidcrial Water Supph Iainglci ❑ Sand Cenmer Grout ❑ Dn Cu-,
❑Irldustnil,Comnwrcial ❑Rcsidcritud Water yupph isharod) ❑ COncteteGrout ❑ Drill Cuttings
❑(tti •twn ❑ Spec:ialq Grout ❑ Grate%
Neer-Water Supply Well: 1-1 Bedonite Slufn U Other(explain under 7g)
❑Maitonue Okcco%cn
Injection%'ell: N For each material Kiected Aw.e,Ism%idv anitumt of materials ww. d:
❑Aquifer Recharge ❑Groundwater Remediauai
❑Aquifer Storage and Recoven ❑Saltrit% Hamer
❑Aquifer Test ❑Slomn%atct Dtatuage --
❑E.Werimenhil lechnikie> ❑Substdnite Conitul 7z ptnride a brief description of the ahandtinment prtrcedurr:
❑Geoibarmal(Closed Loop) 1_1Trat:ef
BENTONITE HYDRAULICLY PUSHED IP-D-1-25(ODDS)
❑Geothemmatl(Heads 'Coolie m) 0 Retu 01lict(C%t in under T ) _.._..
kDatrwelll%t:►bandonedc 4-24-24 'A
;a.Well kicarion:
Rays Grocery Ifi(ai ;a`f'1
Focilgllt3nirer Neer Pasilila•Will ofapplicablel
K.(t rliltc,iti n; DACa204
1674 E. Main St, Sylva, NC 28779 _Brian. Ewing 5/8/2024
Ph%sical Address.Cn....iw SgwwwcorCentfiod\4'c;l+ .,11lrJ aor,:r-VA Ilr%aer Dtwe
Jackson /ii .vigrung IbLv firm, 1 heriehy cerrfJy thin dw wellfsf was/werei rabivitlirrned in
C'aain% Iheel kkmff"lon No (PINI "tvitiAtm-ir with 114 AC'.FC O:C.0100 o►:C 0200 Weil Conshvulson,StancAMA
and Ihal a cmpvof skis rec m!hen•bet9t prt ,*W to the weft owner.
tb,I.atitudc and IonRitu(k•in dt Vve urninutrdsesnnds or decimal degivr•s:
of,%c11 fw1d ore Us lmlg iP Iitscsciv 9.Site diagram or additional well details:
You ilia% me live back of this page to pen life addatotial well site details or well
N W' abatilonmeru details. You tisn also mach addnwtal pages if niecessan.
CONSTRUCTION DETAILS OF WELL(SI REM;ABANDONED TT ki,INSTRUCTIONS
afaxfi writ cnnrlrLc leas rra,rrl.•sl r;atwl.a,h•. t•.v muloplr uyrcholr,u ronw.rler sLl,)ir
ovib ONLY work Ate vrmr cvsnerm(Hut aNyukrmnrnt-iw cdes nlMiia rgrr Jorin. Ina, 1-m All \\ell.: Submit this form aithin 30 din's of completion of %cell
t.a.\\ril 11)a-IP-D-1-25(ODDS) A MIANIHICnt In the t0110%cnnr;
Di%isiou of Water Restiurca,Information Pnict-ssiug Unit.
bit,Total well depth: 13 (R.►
1617 Mail Serve('
enter,Raleigh.NC 2 7699-1 6 1?
10b.Fur Injection Wlils: In addition to sending ilk'for'rit to the address nt Ilia
6e,Rairriwic diameter;2.25 tin.) abo%c. alNo submit one cop\ of Ilus form Nithnt z0 dens of completion of%%ell
abatdonneem Io the lollo%%in g
6d.Water knel below givand surface.: (It,) Di%Wow of Water Rcwlurres,(ndcilmound lolvction(onind Pmj,.rani,
1636 Mail Service Ccntrr."62h.NC 2?69•)-1Q6
Inc. For Water Sundt & Inuectitur%:ell%: to addition to sending the form to
6c Outer casin%Irn_•rh 6f know it: (ft•► llw addresstesl abo%c. also subnut otic cop% of this form within 11) tims of
toniplerion of %%ell ahandonnent to the tour% licalth departnicr of the county
u licrc ahuidnncd
J&Inncrcasim_tubing lcn rth(if knnani: fft.l
Bocce Icugth IIf Lion ri r. (h.l
Form GW-.o NorthC•amlina lkpaniticti of Em tro lilne'nn and Natural Resources-DI%Ision of Water Rsuurces RL%ecd Aupsi N)n%