Rockingham_Well Abandonment_20220815

WELL ABANDONMENT RECORD For Irdemal Use ONLY:
'Ibis fort can be used far single ormultiple wells
I.wen "praetor Inibr®atlon: WELL ABAkDMONbMff
ILoz , S?;n 7s.Number of wells being abandoned:
Wag ComecturName(or well owner persowly abaadonmg well on W dW property) For muW* lVedron or normflo r art+ nv0s My I" flee smnc
C MutrueYtowabnndanmeat,yvucatart6mlr, mi*;i
NC z� Number 7L Approximate volume of water remaining in well(s): (01.)
J FOR WATER SUPPLY W1�3 ONLY:
Coate Name 7e.Type of disinfecfaot used:
2.Well ConstractionPermdtd:I&auaPPheable wa0permrrs p e.Cmmq; m,A Vmtmw,hVeWeA orcl llkmmn 7d.Amount of dblafectant Used:._,T_ /�,[1
3.well use(eheekwctl use):
Water Supply well: 7e.Sealing materials used(cluck all that ap*):
"Agricultural unieipal mAis ❑ �t a Bitetfiipaorl?dletn
oGeathermai(Heating/Cooift Supply) ❑Residential Water Simply(single) ❑ Cement Grout ❑Dry Clay
Diodustrwicommatial ❑Residential water•Supply(shared) Q'Canm to Grout ❑Drill Cutting"
❑brialtion a Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry a Odra(explain under 7g)
Monitoring ❑Ream'e3'
7f e8: .For each terial selected above,provide amount of materials mad:❑Aquifer Recharge ❑GroundwaterRemadtetion v --
❑Aquifer Storage and Recovery aselrmly Flamer
OAquikrTest aStotmwaterDrninsge
aBxperimema l Technology ❑Subsidence iCotdrol 7g.Provide a brief description the abandonment proeedor,
Oaw mmd(Closed Loop) "Tracer
aCeothamtak(Hest! ' Return ❑Odtar lain under 7
4.Date walks)abandoned: --- § �J �,
Al
So.wa location: AU 1K 2022
FacOhytDO{ifeppiicabr) &CertfScatlon: Inf���ti��•
iiity/0wnerName '::2!
P4gaMal Adaress.Ct, and zip
S' eft Corrtracroror a
By soft dds form 1 hereby cao that the weA(a)was owe)abandoned to
CI&My panxl Iderrti mmunNo,(plN) accordance with 15ANCAC 02C.0100 or 2C.0200 Well Constrra tlon Srmedards
and that a copy grthfs record has been provided to the wolf owner.
SL Latitude and longitude to degreaslsulnutedseconda or decimal degrees:
(if wan field,one hMong�int) 9.Site diagram or additional well details:
You may use the lack of this page to provide additional well site details or well
N / W abandonment details. You may also mach additional pages if necessary.
Anack va ao revue on reaWA)0 ammabla For and to*140 dlon or narswaur nR*
w&ONLywgmetome couvwdoomaitmummm can submgawfam 10a.For All WAIL Submit this farm within 30 days of completion of well
/ abandonment to the following
68.WellDii: �,.,_��
Division of water Resources,Information Processing Unit,
6b.Total waif depth: ) 1617 Mal Service Centw,Rakig6,NC 276994611
10h.For Infection Wells: In addition to sending the form to the address in l0a
__�.. a ff�.this farm vvidria 30 days of completion of well
6c.Borehole diameter: (in.)
i
6d.Water level below ground aurlha: l,) Division of Water Resources,Underground Iqf ecdon Control Program,
1636 Mal Service Center,Rsh4%NC 27699-1636
10c.For Water WMW&Infection Well: in addition to sending the form to
6e.Outer wing length(if known): 00 the address(es) above, also submit one copy of this form within 30 days of
completion of wall abendonmeal to'the county health department of the county
61 Inner csd"Itabrog length(if Imown): (fL) where abandoned.
6&Seras leso Of known): UP
Farm GW 30 N Catalina Departateat ofEnvitonment and Natmnl Resourm-Division of Water Resources Revised Anguet 2013