Rockingham_Well Abandonment_

WELL ABANDONMENT RECORD For lntemd Use ONLY.
'It:is form can be used for single ormultiple wells
1.well Contrador lnfb=ion: WELL ABANDONMENT DETARA
7a.Nankr of wells being abandoned:,
1�Kt For muko* Llwon or fim-wwr APPO? w1k ONLF UI& the amne
well Coats cwNam(amen owmr penamatty abaedonio6 well on bi w proporhy) cwj=doa kkmdoomew,you emt=bmb mi16rrn
;2 7L Approximate volume of water remaining In well(ar (aaL)
Ne wen cazftct rccwkationNu vber
FOR WATER SUPPLY WFd.LB ONLY:
(capon Name lc.Type of dMalsetaut used:
Z.well constructionPerdtO:
Un eu gpbcab(e wenpe uft ry e.Caways AMVeftw,tides vA etc)IfAawn 7d.Amount of dtalofectant need: I A6 T
3.Well use(ciheekweu ase):
water use(c well: 7e.Sea ft materials used(clue!:all thstapplyk
ater ultuhal tmicxpaUPoblic o 14U Clement Gomht a Bentonia Chips or Pellets
1]Geotlutmal(HeatinWCOORM Supply) llR dittW Water Sap*(shove) a Sod, Grout Q Dry Clay
obdustrialAkanumvial OResidential water supply(shared) 12rconamteGmut o Doll Cuttings
Olrri on O specialty Grout O(#ravel
Nwwaeer Sup*well: ❑Bentonite Slurry O Odur(explain under 7g)
Monitoring OEEM
ell; 7f.For each material selected above,provide aosoant of materials used;
OAquifer Recharge OGroundwater Remediation — ,y — p2_/.C�- 2,1
aAquifer storage and Recovery oswinily Barrier
omuik Test OStotmwabar Drama
ciawrimeetrd Technology OSubsidenc eControi 7g,preme a ltrhf dmeriptkn ofthe pbandonment procedurr.
aGendwmai(Closed Loop) OTracer
Ord Renan OOther lain under 7 11
�� e.e•e
4.Date well(a)abandoned: 7k a
t, J —
Sa wep lion• ��f/�/ /y
8.©erd6Ca f;� _ t M J„i
Fedity/Oxmerwame FacillhYIDefifappllmb�)
-Z2
FtiyaicalAB�, .a�zip s• commtxorar
By s40ft dds PM I hemby cent&drat the weU(a)1 was&4Led hi
y �— Pamd 1dert��tonNo.(PM aceordm+ce hvtth 15ANC.AC 02C.0100.or 2C.0200 Well Cot mx0on Standards
and Ow copy gjthfs second has beet prontded to the well owmr.
Sk Ledtade ad know&in degreedminutes(seconds or dedmal degrees:
(i{vmp fIakL one bM0ng is sdokm) 9.Six diagram or additional well details:
You may use the back of this page to provide additional wan site details or well
./ N _W abandonment details. You may also attach addition d pages if necessary.
Anach w N cownwadw nwnd(sl V'm&Mk For rod#*bftcdan or rmmhvarar SW*
wdkON6ywimOretmue YM—sum"a-Jbm 10a. r� All Wells: Submit this&iron within 30 days of completion of well
abandonment to the fallowing
6e.We61DAl:
Division of water Resources,liafbrmatlon Pmcesslog Unit,
tL) 1617 Mall Service Center,Raleigb,NC 27699-1617
6b.Total well depth:
lOd For Iniectkn Werra: In addition to sending ttre form to the address in 102
_ w abandonment
following: thi$form within 30 days of completion of well6c.Sohdale diameter:
6d.Waterlerel blow grand sorhee: ft,) Division of Water Resom es,jUndergroand Ian Kdon Control Program,
1636 M&RSen4teCenkr,Raklgb,NC 27699-1636
IOc.En Wager Amu*&Injection Wens: In addition to sending dw form to
6e.Oster caslog length Of Iaowo): (ft.) the addresses)above,also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
(ii loner cadag/tabiog boo(R known): M) where abandoned.
6&Seven kph Of Imowa): (fL)
Foun(M-30 North Caralima Department of 13nvimmment and Natural Rewumes-Division of Wwa Resumers Revised Ahwuh 2013