Hoke_Well Abandonment_20240731

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Borror 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
4308-A construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume ofwater remaining in Aell(s): 63 (gal.)
Blllrs Well Drilling CO. FOR WATER SUPPLY WELLS ONLY:
Company Name ,! yi i 7c.Type of disinfectant used: HTH
2.Well Construction Permit 4:
List all applicable well construction permits(t.e. o to-Y i etc.)ifknw,n 7d.Amount of disinfectant used: I bS
3.Well use(check well use): Irv( -%ftc•.- 1>k
Water Supply Well: :_t; 7e.Sealing materials used(check all that apply):
❑Agriculttual ❑MunicipaVPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Cl Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
DIndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
ClIrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: O Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 175lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pulled pump
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) —
Measured depth of well and SWL
4.Date well(s)abandoned: 1-1 1-24 Disinfected well
5a.Well location: filled to top with bentonite
Farm Chemicals, Inc. —
R.('er[ification:
Facility/Owner Name Facility rD#(ifapplicable)
2274 St Pauls Rd, Raeford, NC 28376 , — 1-11-24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Hoke By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 01C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) 9.Site diagram or additional well details:
34.956290 -79.193872 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructioniabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID0: abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 53 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
1 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (1L) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (R-) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): 00
Form GN-',0 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013