Northampton_Well Abandonment_20240814 (2)

WELL ABANDONMENT RECORD ,,,, �,,���,,,
this form can be used for single or mdfipk Hells I
1.W'ell Contractor Information: WELL AR.ANDONMENT DETAIL ti
\ . 1
Chris Ruffer 7s.Number of hell,being abandoned.
Well Cotoracioi Naaw no well ut,my jvi%omll.s alvld,1111110 well Oil 119 hci rVF0PCOy) Fro mdrirlh' aueo,w ,w ww- ,ife'r yuprVI af!• OAV.1 -ah Nit, wee
t't)iltifltttfNNl rYhIUMhN1/nt'Y#,I,1M hrrm
4223-A
NC Well Cnnlr.Nanrfcnifis:alino N%n#1cr 7b.Approximate volauae of w ater n:maining in well(s): (Sol.)
SAEDACCO FOR WATER SUPPLY N FLIS ONLY!
Conpom Na+nc 7c.'I pc of disinfectant anal:
2.Wdl Constr urtiun Permit a:, _
Ll<frdf qqd edG4 u<711 •..... r r %Hunk �1N.•.i tna.e< bmrlhr...11L .141IT r 1
'd. Anuoual of diAnfixtant u%ed:
3.Well use(check:welt Usti:
Water Supply Well: 7e.Sealing mveriah used(check all Nrat apply):
❑Agricultural ❑Municipal Public fl Neal Cement Grout ® Bcittonflc Chips or Pellets
❑(icothcrtm'd(Hcaunr''Coolinp Sirpph i ❑Res1dcr%1al Water snpph 1un_Ic) ❑ Sand CeeerM Grout ❑Dn Clack
❑Irdusinal:CoemcrciA ❑RL%idetatalWalcrSiipph 14mred) ❑ConcWte Grout ❑ DnllCmtinp
❑Irit Lluu ❑ Spectalt%Groin ❑Gmel
Noe-Water Supph Well: I.1 Bedonite Slum I I Other wtplain u(dct'g)
Rhiontlonng ❑Rmo%en
Injonion Well: 7f.For each material scicctal ahinc.pesn idc amount of material%aced:
❑Ayarfer Recharge ❑ imurduaier Reniediauoo
❑Aqutfer Storage and Recoc en ❑Salon% Banter
❑Agwfcr Test ❑Sksmraalttfhaiiurge Bentonite.:501b ,Wtr:gal._- HYDRATED BENTONITE CHIPS Amount:
❑Experimental 1 ctihnolog.% ❑Substdetrcc C'orarol 7g.Pnnide a brief description of the abandonmrot procedure:
❑Geolbernral(Closed Loopi ❑Tracer
SLOWLY POURED HYDRATED BENTONITE PELLETS TO SEAL WATER,TABLE
❑ eothengd tllcahnyl.+Coaling Return) I lOthci(cx ain tinder' , --------
4.Date wrllisl ebanduned: 08/01/2024 20N
Sy.W'cll kwatktn:
OTTO HARRIS STORE (%r
t.arbn (hlrrr N:n1,' FacilNv ID:'nfappll�.rhlr R•Crnifkali(NI:
999 Hwy 158 Garysburg, NC 27831 Chris Ru ffe r 8/1/2024
Ph%sical Address.Cat.and Zip Sgyuiure of Ce111fet!Wb1I(2nareolar of Well(hard Dote
NORTHAMPTON lit .signing do, p)rin, I hereby tern*,drin the well(s) was(were)au=&Aned in
Cows, Paned Idemificrtina No (Plat avronlance wide 114 NCAC 02C.0100 or X'0200 WWI Cmaf w t'on Standards
and tkd a , oJdair rerordltm been provAdedto dre well owner.
Sb.latitude and longitude in or decimal degree%:
Orwell fcid.okra tal long n udricicni1 9.Site diagram or additional well details:
You tiny use ilk back of this page to pros ide addineuuil.cell site details or well
N W abantionnient details. You tiny also:utach ad inwital imgvs if mcessan
CONSTRUCTION DETAILS OF W ELLt51 BEING ABANDONED Y['BMMAL INSTRUCTION
.rfLkh NCI1 LYmorudaw mcuvd,.;U Jl gild-k IY,r 1RYIf1PfC fl thY01,V w1a-NVhr fupph'
NrB.rONtl'Nvrhrhr.au%rtvrnero.ru.n amm�hrrNamr.ltwemsnhmlt!�rrhNrt 10a, For .&II WeLL%: Submtl this rime within 30 can's of completion of NYU
tin.Wed am:TW-2 abmdoimicnt in the folkiicrng
Dh Won of W mer Resourcm.Information Processing Knit,
6b.Total wdl depth: 20 1617'►tail Smite('enter,Raleigh.SC 27699-1617
10b.For Inkrtion Wells: In addiuou io xidw>:dtc form to die addtcss m lua
r.c.R11n1e11edlameler:l lin.l abo%c. abo subout one cape of this foni: scnhm `0 dais of completion of well
ahmdonntcul lu the"lour g
D66-ion of W alcr Resources,UnderlInw nd Injection Control Prograar.
6d.Water kr ci below $tYnrtul W rfaee: (ft.I 16341 Mail%mice Center,Ralrich.NC 27699-1636
Ilk.For Water Suru)h A Inkrtitn Wells: lu addition to sending the font to
6c.Outer ca-ing length lif know n is (ft l
the addressic,l abuse. also submit one cope of 1Ms form icithin to fans of
completion of well ah.udrnuncm to the cotaa} heahh dcpannieta of the coum
(.f.Innercasin;(''rohing Mn:,Rh(if knossn): 5 w litre abandoned
(h.l
6g,Screen length(if hone%n 1;15 (h.l
Fan GW-3n Noah Carolina Depannrm of Ens irountesu:red N:nural Resoinces Lhs ision of%awl Resowces Re,escd August 14,1(