Wake_Well Abandonment_20240903 (14)

WELL ABANDONMENT RECORD For Inlrxosl Use ONLY
This fom,.,irf be used for single or multiple Wells
1.Well Crintr•actnr Infiirntanion: WELL ABAVbONMENT DETAiI ti
Scott Hunt, Jr 7a.Nambernfaellsbeirltabanduoed: 1
Well Cbtatador Naar tot well uNti.Y perumtlh Aurd,uuifg Nell on lmliel property f V v mnfipk oilfthm or rrwr-rdrrr n,plJi .eNs ONL) rah Iiw ,,wit
,matnrin ra,n di'4L"Amew..frw om nihmir i.wc firm
456]A
NC Well Coos ncaxCetrif lion Nufitirr 7h.Approthnate snhntsc of vs atrr rrmaining in w cll(sf0 SAEDACCO FOR W VI V it SI'PPI A U F I 11 ON I 1
Cl opam Name 7c.'I N it of disinfectant nsed:
2.Well Construction Permit 4:
!,anli.Mae.!dnwiry baro—f.elc.,itknurn r'r n
"d.Am(wnt of disin(tt-taet used: �'
Milli
3.Well use(chafe w ell nse):
7e.Sealing material.ust•d ri•heck all dint apply is
Water Supld� Well;
OAgtncultural ❑%tunicnls;drPublic N Neat Ccmcnt Grntu f] ecntoneC Ch !d bt Pe�lefs
136cothermal(Ncanne/Cooling sumh I ❑Resideranal Watcr Supph Isingle) ❑ Sand Cement Grout ❑ Dn Cla}
❑Irdustrull'oninicnial ❑RcsidcrYtal WaterSupph Ishared) ❑ConcrelrGrout ❑ UnllCullings
❑htt •hull ❑ Spm-lalh Grout ❑Gratel
Noe-Water`uNil%hell: ❑BetaonRe Slum U Other(explain under 7g)
amonufonoe ❑Recuten
hijection Well: 7f.For each material w1coed above,provide anrotrat of materials wiled:
❑AquiferRcckrrgc ❑(iroutdwalerRenfediation Neat Cem.:941b ,Wtr:7gal. Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Rccaen ❑Sahruh Hamer
❑Aqunfer West ❑Sionrnsater Dranrunge - --
❑E.Venntctual I aclu)olog.% ❑Submdence Control Prm file a brief description of title aibantktninent procedure:
❑Geotherf(Closed loop) OTmoer
tremie grout location from bottom to top and cut below
OGeotllerio d(Fleatin -Coolin Relum) C300wr4 explain under 7 ! _ --_-_----------..-- -- _
surface
4.Date aelli,!abandnnc,l: 8-2-24
5a.Well location:
Bromfield Road Landfill
Facilih'flu rcr Na., Facility WN(Wapplicabk) S.Cefdlicaden:
/ t 8/7/2024
,l
2600 Brownfield Rd- Raleigh, NC 27610 a/, /
I'li•sfuf l.Addrese.CM.and Zip 1 1,ae 0!,C vn+ .ad Wel Conrraclx or w'01 Amer Dale
Wake A .uKllrrW lhrs J6rnr, 1 hereby cerhA fAat the well(s) was twerel,afwokAwwd in
('ddul, Parcel Ideatdtealiim No.(PIN) ai<anliarcr with 1 JA AC AC O:C.0100 or X 0:00 rVell Cmixo tton.%mdards
and that a cy"ojfhfs record gas bear provided to the well owner.
5b.Latitude and Inagitude in dcgrres/minwtcslsecrtnds fir devimal dft,rres:
ql,icl!rrld mil:La bn i,.iifhcvit 1 9,Site diagrain or additional well d(hails•
You mat use the back of this page to litcn de additional%ell site details or well
N « abardonnt(ent details. You nun Aw arlach aMitiunal pages if ntec:essan.
CONSTRIA-PION DETAILS OF W'ELLtS)BEING ABANDONED SI'BMiTT.AL tNSTRt1C nONS
.,w,i; e,i;r„aslrro—z n,—rd,sr a ;%whkk hw nmlople injettimr,r anon-iiulc7 wpph
-0,0.1,1.1 »nh the.qmr i,m,an ahmd,vte?orm lna. For All Wells• Suhnut thn lone within +0 dats of completion of,cell
6a.W'ell IDa:
PZ-3D abaidonnicnn to the following
Disisito of Neer Resource,Information Processing Unit.
lib,Total we11 depdc 52
1617 Mail Senice Cater,Ralcigb,N('27699-1617
Ift.1
Inb.For Inkylion Nclls: In adituion to sending die fom(to life address fit lua
abuts. also strbnut one copy of this form wnhiu u)d:ns of completion of well
6c.ikirrhole diameter:2 (in.) abandoitnfew to the folbw7ni;
D4ision of Water Resources,t ndeigniund Injection Control Program.
6d.R'ah r kw 0 hdaw mvonnd wriacc: 10 (fl.I 1636 Mail Senice Cenic r,Rrlci,b,V('276"-1636
Itic. For N%mcr Sunwnh& Iniettinr Wells: in addition to sending the form to
6c.Outer casing,lenorhIif"owni: lftl Ilfe Adressies( abuse. also subont one copN of this fort within iu days of
completion of"ell abandonincm to the cotnnti heath detwnmerft of the counn
cchcrc atnrsdonfcd
fit.Inner rasin-_-,'tubtn-len:,•th fit kni,m : Ift.►
fig,Screen Icwgfh(if knownt: A)
Fomr GW-iif Nunh Carohm Depsnmem of En,ironfnenf aid Natwal Resowces-Dh rsna of Warcr Raoma-s Re,red August-1I4 i