Brunswick_Well Abandonment_20240624 (6)

WELL ABANDONMENT RECORD ffForlUseONLY.
This form ran be used for single or multiple Hells
L Well Contractor Information: WELL AB.ANDONMEN"t DETAILS
Stefan Smith 7a.Number of wekl.-.heft abandoned: 1
MAI Conux-sor Name tot welt owner pensonally abintioiang well an hasdief propene i F,w mwopic otlrctt,a, ,r wo-wirier SWTA wells rr s 1) mirth ,he .owtr
r..n•'trtt,brat e�horkRN1ON•tll.IHq mewl,about,.vtf bream
3576A
N(.'W'cl1 C'mMnktnt Ccitificatimr NgmNcr
71) tppruminmatc mnluturof water remaining in wcOtvi: (Rol•)
SAEDACCO
F014%%i7ERSI'PPI.I UIRIASONIA:
Compare)Name -L. I m pc of dmunfectant used:
2.Well Ceustrvietlam
l�sl<di rgrt+Gtun!c wrtl tvrmtla o.e.Cumari,S'Atte.1,tnawe lntrcrirm,etc.,rf Anrnn
-d. lrnonnt of diunfirtant used:
3.Well use(check:wa user
Water Supph Well: 7e.Staling nmatrrial%u%cd irherlc all that appli):
❑ARnculturd ❑MutucipaUPublic n Ncat Ceaicut Onxii X Rcniontte Chips or Pellets
❑Geothermal(Hcanng('poling Suppl}I ❑Residential Water Supph isingic) ❑ Sand Cement(inrte ❑ Dn Cla,,
❑IndusirtaUCommercial ❑Residenttal Water Supph ishatod) ❑ Concrete Grout ❑ Drell Cuttings
❑Inn •tenon ❑ SpeclaRN Grout ❑ Gra%el
Noa-Water Soppt}'Well: 1.1 Berrtonite Slum U Other Iexpiam under 7g)
SMorutonng ❑Rccomen
Injection Well: X For each material vtlected abome,ptnm idc anumot of materials and:
❑Agtufer Recharge ❑Groundwater Remediation
❑Atimfer Storage and Pectin en ❑Salunt% Banner
Bentonite.:lllb ,Wtr:gal.
❑Aquifer Test ❑Storraatet[hamnaFc --
❑E\penmental loclmoloFn ❑Subsidem a Cbittul 7g.Prom i(k a brief dritAption ref the abandmnnient limcedutr:
❑Geothermal 4Closed Loop1 L1Tracer
Pulled entire well and backfilled with uncoated bentonite
i iCnvmtlmemmal(Hearin 'Cook Return) ❑Other iex aim order' i
pellets. `•.y- ; a
4.Datewellislabandmnedc May 24 2024
J
"A.Nell hrcition:
F mole" r
Koppers Carolina Pole Site �� •
.1,. I,. ., '.,I. Facility IDN(dappltcahlc) 8,cenlficatien:
1901 Wood Treatment Rd. Leland, NC 28451 5/31/2024
11..1„ ,a r. ..iwr' . S altirC...Cco iWWdCoomactororWAOwner Doe
Brunswick _ fty'.signing thLv flan, 1 hereby ce 10,AN the well(s)was f'weret ahanckwed in
11mcclIdzitllt0.aINiiiNo 04N4 acrurrharcewithIIANCACO2C,0100or2C_0.00 Well C'onshve•fionSrnnrkm/.m
and that a copy of this rmord/ors beat provk*d to the well awnner.
Sh.Latitude and hingiturle in dcVv vminute%A4v rods or decimal degi rev:
of i%dl ftcW ort0 Lit Itmg t,.ullkmv 1 9.Site diagram or additional well demill9:
34.250844 78.074457 You reran the doc back of Iles page to pro de ide additional wtll site rails or well
?t W abandotinictu details You nm:n also atach additional pages if nec4van.
CONSTRUCTION DETAILS OF WEI.LISI BEING ABANDONED SUBMITTAL INSTRUCTIONS
.beach well"morao,"I n"—d-z.tl urmhJrk. 1•rr mnlople oyeenar a-num•wwdtr supph-
wrlLrONLY with the wain cwalrnaranr vwnbmnaenl.iv can mhtnii curt htrmre l0a. For All W'eW Submit this form within 10 dares of Completion of vivil
ba.N'ell ID>r TMf1_3 ahandnnnient In the fo)lowinst
Dimisiou of Water Re.ourro,Information ProcestiaR Unit,
1617 Mad Senice('enter,Raleigh.NC 27699-1617
61r.Total ndl depth: 13 If1.1
10b. For Iniedlon Wells: hi addmou lu scidutg die fort to the address in Wit
abnmc. a6o submit one`ip.%, of this fonn within +o days of complelion of well
6c,Mirchidr diameter:1 (inn.) abardonnteru to the"lowing.
Di%Won of Water Rmu tees,lbdergrou ad Injection Control Progriow.
oil.Water k�ol below ground vurfacr. 6 (tll.l 1636 Mail%mice Center,Raleigh,N('27699-1636
3 Itic, For Water Suixib & Iniectioa Wells: In addition to sending the form to
6c.Outcrcaunglengthiiflaowni: ( ) the address(est abome. alxm stmnin ooc cops of this form within 11) da}'s of
contplctmon of well abandonment to the county health depanmert of the coum
me 6f. Inner
casin ' bing length o I:n f nwn here abandonedl: (R.1
Ccrccn length(if Limit it r 10 (Il l
Form GW--10 North Carolina Depannnca of Etn tronnicnt and Natural Resa es-Dim twin of 14'ater Rc oum�s Res iscd August H)13