Alleghany_Well Abandonment_20241001

WELL ABANDONMENT RECORD �\ Forbaemml Use ONLY
This form can be used for single or multipke Hells r
1.Well Contractor InfirrmAtion: �' 1\ N'F LL ABAVbONMFNT DETAIL S
Rich Lemire \ 7a,Number of wells bait alwndoucd: 1
Well Conanctof Naar lot bell uN wr pcmuulh Auidonin6 yell on ha;hef propem f F,w w1do ik. aloei. * uw rear-*,If r SUMA. rem ri%Ll rffh 14'. "wir
r'r Nl+frryl f,r Nt„�r)fkltWAN'1N,lrfq l,nl,NIViIJf rNa'fFlrpr
2593A
7b.Apprarinute vnlame of water'tcmaining in well(NPONE Igd.l
NC WcIlCoratackrtCcnifrcalifm Nnnilcr
SAEDACCO FOR%ATFRSUPPIA \\FI.ISONI.Y:
Conalwa NarrK lc. I N Im of ditinfectant rased:
2.Well Ceastnictiun Permit
!turd!r,yryilaUhlrlvrlllir,r,",ttu.«_c:ai,tri•.57wr•.lanarw<• ln;r.rnn,..k �fAtw—
'd.,\mtwnt of disinFixYant uxtil:
J.Well"me(check.well ore):
Water Supply Well: 7e.Sealing material%used IcMcck all that apply):
❑Agwilturai ❑Munkipal:Public ®Neat Ccnicot Gmlit ❑Betwonitc ChiM or Pcikis
❑(icothennal Mcanniir''('ooiing Supply l ❑Restdctatal Water Supph isingic) 0 Sand('emery Grout ❑Dn('Lay
❑lodustnAComnicicial ❑Resideratai%Valet Sitpph isha d) G Concrete Grow ❑Drill Cultings
❑Ira 'tknl 0 Spec'talh Groul ❑Gravel
Non-Water Supph Well: ❑Benlonne Slum Ll Other lexplain uoder'g)
I➢Motyronug ❑Recovrn
Injection Well: K For each material selected abase.pr aiidc atafraat of materials axd:
❑AgmlerRechrrge ❑Gromd%%.twkeuiedtaiton Neat Cem.:3761b ,Wtr:24gal. Sand Cem.:lb ,Wtr:gal.
❑Agudin Storage aid Reco%en ❑Sallliitl flamer
Bentonite.:71b ,Wtr:gal.
❑Aquifer Pest ❑Sromws atrr Drainage —
❑Espenmrntal 3 eclmobg% ❑Substdewc Cotdwl Prmidc a brief t1mr'i,>;. prior of the ahan%immcet pnattrlun:
LlGeothemial i(losed Loop) U—fracer
TREMIE GROUTED FROM BOTTOM TO TOP.
[)Geothemral(Heatin Cook Return) (.)Othcrie ainunder7 )
J.Datf`wrll(xlabamdouet 9-11-2024
��.11 ell keel noon:
SDWY 7947
t-auUN Ihlirl N;ur>< P.i,:.ihi,1T)N lifapplicabkl R,Certification: , r^
306 N. Main St. Sparta, NC 28675 'h ��jfwri..t� R'A,.a'"3• /411/2024
Pb seal.Address.Crt�.acid Zip �tCrcil iiR Of_.•.itFprt WCII('AnRiC1At or lYen(Maier Dale
ALLEGBANY B'i .vigning test n, l kemby cernh,them dw e/l(:j was(were,ahmtdooed tit
t'oafn. IwelldcatibcallonNo 1PIhi ncronh»kewittlt.�,\Y ICO.C'.Olf)Ilur:(' (I.U(3llell(ivtslnrrrton,�'lan<>Gtrd.K
imd rkat a cry oJdris record ibs bef.7i provided to rke well owner.
Sb,E.atitudc and longitadc in dcgrrr.rminutr•,.ccnnds air•dremial degr rs:
piwetl field,one lat-long a m0ficiew) 9.Site diagram or additional wcil detail%:
You nun use the back of this page to ptcn We additional well site dcidd5 or hell
N W abatdeninery details. You alai al-w auach a Witfunal pages if ncLesan
('ONS'tRIA TION DrT.AILS OF\\E:LIAM BEING ABANDONED SUBMITTAL INSTRUCTIONS
.dfaair w.i7«r2rlfnO,+nr nar,rd s:+;al—,AN•. t,rr nui:f±pie 0 1,1Ocn,,w er n-w.ilcr snfq'h
wrflr ONLY irifh the vuar tumbi*funr uh enknxnrnt icm can mhmN more wrm l0a. For All Wells: Suhinu this ki m within +0 dais of completion of iccll
6a.Wen ID/•SB-1 abandonment to the following
Division of Water Resomtcim,Information Pi-vivo ling Unit.
6A.Total wcU depth:
25 1617 NWI Senice('cater,Raleigh.N('276M1-1617
(tt.1
lob,For Injection Wdliz lit uillilwti iu.cidmg the fool to the:rddirss lit loa
atone. also submit ore crop% of this form wnhm to dins of comploion of Bell
6c.&irrMtic diameter;2 lin,l abandonnicia to the"lowrne
bd.\\atcr keel hrlaw inirand wrfarc 19 (Ft.l Division of Water Reviiorct%,Underground Inict ion Control Program.
16.36 Mail Sen ice('cater,Raleigh,N('27699-1636
k Ilk. For Water Sanniii S Injection%'ell%: In addition to sending the form to
air.(Suter casin
g length lit (R 1 the :ddresslesi above. also slibimi ow cop} of this form within In dais of
completion of wcil abandotanew to the court) health dcpannicta of the:outs}
(if.Inerrcasing.+trlrin>:ktir>:th Itf 6itown): 15 i%Ixtc ahinidnncd
if7.1
6r.Screen length Iif lnown1:10
Form(Ak-;ii Nonh Carohm Dcpannrn of Enl in»inkir ud Natural R�wruccs-[Nl tsa a of W'attr R�oaa�s RL%yeti Agwsi N11