Wake_Well Abandonment_ (18)

WELL ABANDONMENT RECORD Forltr.nulI %(1111Y
This fore►►can be usW for single or multiple wells
C 1.Well ontractor Information: WELL ABANDONMENT DIE:TAIM
Stefan Smith 7a.Number of wells being abandoned: 1
wel►couil3c►or Name(or wdlowntr wisnw,111.uburxkuung w,:U tilt ha,Ikl proNn: i f,v -1doprr o t,b,m ,r ,rurw„ttr saprJt refl< 0AL) vtrh doe .U~
r v>{lvrlKCthNt rIl4,arfr.wmt9)t tr,N<,Ut,HlutNt rwrf IFrrw
3576A
NC V1'01 f ptrrtC►nr Ccnifictlinn*:ntttbcr 7b.Approximate%olumr of-Aater r nitaining in welllsl: l
SAEDACCO Inc FOR WATER SIIPPI.V WELLS ONLY:
Cortirans Name 7e.Type of disinfectant used:
2.Well CoaMnKlion Permit N:, �^
ho 4di:I(ydl:ahfr 4<'i/rtvwr,tr,t<' t wN)'..\leNt.! lrntrr[e IM tr 4rnrt el[.,.f AM,—I
'd. lmuunt of di.infartanl u.avk:
3.Well use(check:w ell usel:
Water Sulry►h Well: -C..1,raling n►ateriat%ox•d iChcck all that applii):
❑Agricultural Dlolunicipai.'Public Nat Ccmcnt(irau Cl Hernonitc Chips or Pellets
❑Cicothcmul(Hcanne'('cxshn_Stipph 1 ❑Rcsitdcritial Water Supph isinglc) ' Sand Cement Grout ❑ Dn Clan
❑hldusirtal:Commcrc►al ❑I(csidential Water Supph tsharcd) L7 Concrete Grant ❑ Doll Cuttings
❑Irri•'troll ❑ Spcc'ralh Grout ❑Grat.el
Non-Water Snpph Well: fi Betronite Slum 0 Odw(explain under 7g)
®Morutonne ❑Recoiirn
Injection 'ell: X For each material selected Ahrnc,prr►itoide amount of mateah uid:
❑Aquitcr Recharge ❑Gmmndw Jtcf Reruediatlon
❑Aquifer Storage and Rcu»en ❑Suhtul� Gamer
DAquiferlest ❑Slon►malcrDrainage Bentonite.:601b ,lgtr:gel.
❑EspetinterMal 7ta htictloe) OSubsidene C'utatol Prot itle a brief description of the abandonment pmcedum:
OCxothermal(Closed Loop) OTr&cr
Temporary well; pulled well and abandoned borehole with
IjGeothem►al(Heafing.,Cooling Return (JOfher(e\ lain under' )
hydrated bentonite chips
i.Date well(s)abandoned: 10/27/22
ia.W'ell oration:
Future Murphy Express
t r,, ,,"r , Fxam ino(irapptx.►blc) A.Certification:
4501 Poole Rd. Raleigh, NC 27610 �c 11/4/2022
____._._......' (Ns.aid Zrp ��gtiaturc Jereth�d w.It Conte 101 r4 well0%wr
Wake Bi-signtni'Niel Coin, l helteht rerrify slat the weffls, was tweree tAttitk,lted tie
Coum Parcel ldam7fwWlion No iPl\r orti,ni(tlit-c utdt t't_(A"c' CPY'.W(M)w.(' f0m)rVelf((nivirgc(lowl al(AMJ.0
tmd shirt a cop)o/Nns rec•ttrd/►car hem prmided to the"ell t,w'ner.
51).Latitude:end Gtngitutic in tlegtr•a•s ininutestseerinds or decimal ticgrm:
of nil;1 d om t:u I,.• ..,,ut t n i 9.Site diagram or additional well details:
You out the the back,of this page to prCn►tle additional Well site details or sell
N W' abardonnnra details You mas also attach additional pages if nectssan
CONSTRUCTION OFTA1LS OF W'ELIASI BEING ABANDONED SUBMITTAL INSTRUCTIONS
.it"it writ run..!ruanxt rrnrrrka: q at mia-le. 1-,v m„irrpie uye,tote g,rviv
"erns 041.1 werh doe.,u,4r"omirtk riot d"ruA4ronval true can<uhrrt,l rwre eur" k0a. For All W'rlh' Subnut flin farm within ?U da%s of completion of gYll
6a.Well tDa:Bl
ahaudonnicut to the following
DiiiWon of Water Resrturm,Information Proornsing Unit.
nb.lutal well depth• 22 (ft,) 1617 Mail Senice Center,Raleigh,NC 27699-1617
10b. For Iniecti►n Wells: In addition to sending the form to the address in l0a
abomc. also subutit one cop\ of tins fomt within .r)da%s of completion of well
tie,Btrrt•hole diattwirc 1 (inJ abandonn►cra to the tollouing
Dl%Won of Water Rtstturres,Underground Injm-don Control Program.
Ird.W titer Ict a•I below L►ytund soignee: (h.l 106 Mail\coke Center,Ralciglt.NC 2 7699-1 6 36
It►c. For Water Suot►h Bt Iniacti►n Wells: In addition to wndling the form to
6c.Outer caunglenZhlifknowni: ilk addresses) abaite. also subnul one cop> of this form within 10 dais of
:onipkivoin of well abandonment to the cotow. health department of the courth
u here aKindotscd
bf.Inner Casingr'tubin_la•nLKh of 1:r►awn): 121 I/t.l
tog.1Creen len►,Ih of I,nossni:10 AI
Fomt Gw-at Nona C'arohrr,Ile-parnnt<rs of Ens iroomcni aid Natural Rew. m cs -Diu tan of K'acr Rcscwrns Po%stud Augur►?ol t