Randolph_Well Abandonment_20240910 (2)

WELL ABANDONMENT RECORD Fox Im' cn;tivt'ONLY.
This foi►n can be'used for single or nuMple wells
1.Well Contra'cwr hifermation: •)YELL A ANI)ONhiFNT DETAILS'
Tyler.Brown 7a.Number of tt"ells being alraudanc&
1ti'c1CCantraetorNattu+(orttiello�ccrrpe6mrally r��tmilri;xell,antusltrsrprapcny) For re+rrinpk .tivectlar or roa-1 of f lsrrlila}. vdk 'ONLY wtd) Ilk .saunc
' cartsfrtrchon�utratchuirraerrf,}r)nremsr+Mn)r i+ejfrrni,
4625A
At.AlipnAhnatc,wntunw of riatcrref:lining in it`ell(4i)2.5
NC)Yell Qmtrac'tartkttlf=Mon Nutrbcr
sAEDAcco FOR'1VATRR.SUPPL"IEL1S.ONLY:
Conganj Nams 7e Tymc ordisinAYtant used:
2.Well Constructlan Pet'mit 9-,
P.f a41 a tryf"61,k%I/Per &4e-c-,aN,41fi1a,YtirJruxe:Ivervii",_cic}tfkmwn i
7d.Auiouut of disinfecttutt us�vl:
3.Well use(chedmell use);
Water Supply Well: W.Scaling materials uacd(cliccl;all that apply): ..
I7Agti>nttitrrl. pMtinicip iI1Pt(blic M Ncat Cement Grout ❑Bcotoriitc Chios or Pellets
❑Geothermtl(HcatitrgJCaoliug S►ipply) ❑Residential%Vater•Strpply(single) ❑Sated Cemept Grout ❑Dry Clay
❑hidtist6l(Coutn►crci7l ❑Itcsideutihl Water Supph•(sltitr d); ❑.CctitcieteGrout -.CI DrillCutlinds
❑1ri 'tiou ❑Specialty Grout ❑Gravel
Ron-Water Supply Wclh,- _ ❑Bentouite Slurry ®'Other(ea-ulain"under 7g)
ImManitoring.- ❑Recovetp.
Tnjcction Wcll; 7f..Forcach ruatcr7al selected uboyc,ptntidc:tmourit_of.tiuttcriaisnsed: .
❑Agtul'erRcclwrge ❑Grduiuitrner.RentedLUian Neat Cem:':941b ,Wtr:B'gal. ; Sand Cem.:lb- ,Wtr:gal:
❑Aquifer Stontge and ltecovety' CiSaliuity Darticr I
❑Aquifer Test ❑SIbrurwater Drairutge 1.
[IF-VetintetualTechnology bSubsidenceCot►irul.
7g.Protidc a brief.description of the abandonment procedure:
❑Geothermal(Clo5cd Loop) . ❑Tracer " . " i'
Tremie.grouted from bottom to surface
®Geotherial(Hearin.WCoolinRReturn) ©Outer( lair under 7g) r-t
4.Dritewell(s).ahandoncti: 8-22-24
5a,Wen location:
Powersecure' 6 a- li'E
1C�.:�''.rlc'
Faviltt};iOn`ncr Nmmc Facility 117u(ifupplicablc) .8.CertillcaCioir:fr^�� Q+rSi ti tit-"
1410 Coltrane Mill. Rd. Randleman, NC 27317 � /✓�` 8/22/2024
Pliy'sical:Addre s.City,aid Zip St rUhtA sttfical'4'etl Corura.tor or Well Ot+cur Uate
Randolph lly+signing INS form, I hereby cerNfjt that Ike irell{s)}ras(here)ahandancd in
Cauaiy 11xvil IilardI&i 11anNo.(PINj Pnci tracts Wilt t t VA 0-.010,7.ar 3C.:U.OU R'elfCuns7rticfiura Swrrd MIS
and drat a cqpvof,&s record I=he en provided to the treN au`ner.
Sb.l:'ttihtde an8 lbngitudc ht d��t•ccslminutes/seconds nr dccidt,•rl dcgrccsi
(If!sc11 Card,arse Ltllong Urfiltict») 9.Site di.►>sram oi'addldweal Rcll detafL: "
You►uay use the bacl:of tltis.page to.provide additional well site details or teell
N 1V. .aband'un"I details..You tmay olio aotaelt ncluiiiorwl pages if necessary.
CONSTRjl(c.-ItlN.DPTAtiA of W Lrdti)BONG ABANDONED SURhtTTTAL tNSTRTIC TtONC '.'
:Neatly tirll cvrs4rarfnur racvrd(s)V'avaJI4'k. Fur mrilNplr irr�eitiun'ar re=n•nxr+ir srrl. ly
uxlls ONLYulffr il,�N svurcccuisrrt rtlom'ahanrdarrrreru.iuu rnn grf»mtt arefurrn 10a.Pur AII'tVclls;' $ubrnit this fotn► within 30 days of completion of nrll
abandonment to the follo;vin :
6a.Well IDd:hiW-.6 � 5�
Dis`W6a of Waterltesoucee�,Information Procriung Unit,
(
25 1617 Mail Service Cctitci,Italei);6,hC.27699-1617
6b.TotaYtvclidcpth: (ft.) �.
10b.Fa .Tn lectlon Walls; I»addition to sending the fornt_to the address in 10a
6e,Borehole dlatneter:2 (in.) above•ANo"submit one copy of this font mithin 30 days of cornpletion of hill
ab:itidowrteiu to the follatvirig: r
fed.Water lcycl.bciory wound surface 9 (ft.) D his(ott of WaterRisonrc s,Undergtuund Tnjecgon ConniA-Prdsratu,
1636 Mail$mice Ccritei,ltalcigh,KC 276*1l 1636
6c Uutcr c tsinglerrpth(iflarann); (fwl roc Wa Frir fer Sutin "A ty Lrlmlo �Yella; In addition'to sending the fomt to
the addresses)abode, also submit lobe copy of this"lbtnt within 30 days of
completion of well abmaiaiunent_to'the county liealth depi trment of the county
Gf.inner casin;/taben};P.eir},Kh(if l;nasvn): (IY.)
tivhrrc atiindoncd,
6M Sueenlength(If k6ortn):10 (fG)
Fame GUY-30 Nonh Carotin DzInrlatcm of Pnvimnrocnt:ud Natural nesou_ices-Dk'isian of W'atcr Res,axis ncviscd August 20 t3
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