Caswell_Well Abandonment_20230109

JAI 0 9 2023
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VMLLABAMOMWE1NTABCORD FarlatcrialUseONLY:
Thts farm can housed farsinglo or multiple wells
1.Welt Contractor Yorormatiom WELL ABANDO NT DET�TToS
IZeUbEr17 W.Clayton,I(( I 7.LN mberofweltsbeingab idoged: /
NcltComrretarr�fante(orcccllocs+terpeaaaalty a6aadnmogacttanitiSRterp emr) Far mulrlple trlleutan or aon rrdiar -71M v wells MY ivulr the soave
emrsnrreffoa•b&mrdwmrent yvurausuhmitaua�arm.
224'i A
NCW llCanna wCenifieouonXamber 76.Approldmatevalnmearmaterscg iuingitiva(s):
Aqua Drill.Inc. YCHM1VVATMSUPP);YMMLLSOM'Y.-
CatnpaoyNadre I 7e.Typrefdis(ttfectantused:
2,Wclt Construction Permit
Lhuallopplteableireflperadls(La,Coolly;Stale,frarimec njectan,eraJ/Jd3rpasr 7d.Amountofdisiafectautused:
3.Well use(cbeeltwcll use): ' ��-
Water Supply Welt; 7e.Sealing materials used(check all that applv)e
CAgrieultural DMpa/Public D NeatCemettGmut 13 Bemanite Chips orPdleis
4 II � Camnt Grout(RcatinglCooling Suppiy) � ialWoterSupp y(sid
a Dn•Clap
©lodustriaUCommerciai QRvsidential Water Supply(shared) Concrete Grout jl II Drill Cuttings
flirti atlan ( D Specialty Grout D Gravel
Nan-water,Supply-*IPI: 1 El BentantteSlutry fl Other(explain under%)
Mort ito ing DRecovery
wection SVelt: 7f.For each material selected above.provide amount of materials used:
DAquiferRecitarge 130mundwaterRomediatfon
GAquiferStotage and Recovety DSalinityBarrier
QAv)uiferTest DStotim-werDminage
DExpetimentatTechnology OSubsidence.Controi 7g Provide a brief tt+scsiptionoftii cabandanntenipraccdure:
OGeothermal(Closed Loop) p7mcer
13Geothermal(licatingCoolingRetum) E30ther
(explainundcr7) �f/' 'a{Ali'a^r7 ?� 4'1✓� >/' ��•�d-t�'lr�++rsi
4.Datewall(s)abandoned: / � �� .�.j�� �'p�r>:��✓! ��XZ �x
Sa.well location:
Faciliryrotivaarrtame FaeitityIroR(irappt[ mc) s_t'srNrratioa: ,
Physical Addrem.aty.crul p sigaaturcofcadncdvLlcl(Contmetn vcl!c%vner me
By sig"Ing' form.I heivba!eeri jy that tine 1re1t(s)was(mere)abandoned In
County Psreclldeaificz9oa;o.(PNI) aecojAzaw wHir13ANG1CO2C.0100'or2C.0900F3 YConsinfeianStwulards
and Mat a copyofd/nsrecordhasheeirprovidedlo Me Ivey Inwer.
5b.Latitude and longitude in degreesiminuteslset ands or decimal es:degre 1
(ifwcll field,eaotmltongissumcleat) 9.Site diagram oradditionalwell details:
11.1 cy G 1 07 You may use the Bach of this page to provide additional wall site details or hell
N 7� ��`' �' abandonmentdetaiis You may also ariachaddidanal pages ifnemsaty.
CONSTRUCTION DETAiL6 OlFiVELL(S)BETNG A$APIDONED ST1BMi I TAL INSfRUCPIONS
Aaaelr+tell eunrrrseetian reearil(s)ijatrdlable. h'rrr muhipk fnjerrinrt or rrnrwtarer supply i1
retlrflNLY+rirl,tlresaatecomrnrdimrabrmdonarenRyroarnnserhmirmreJoim. ton.yror Atl SQ/ells: Submit this furfit mithin 30 days of�compledon of 1vell
6m Well Mg. abandonment to Hie following:
i ,
Division of Water Resources.Iaformadan processing Udt�
Gb.Total well depth: (fk) 1617 Mail Semite Ccntetj,Raleigh,NC 276944617
10b.•Far Tniection Wells: In addition to sendirrg the form to the address in 10a
above,alsb submit one copy of this faint widim 30 days of completion of well
6c.Boreliole diameter: (in) abandonment to thefo116"ft 4 I 'I
lDiv)sian of Water Resources,Underground lnjcct)on ContralProgrnm,
bd.Water level bclmv ground sinface: (ft) 1635Mil Service Ceitei Raleigh,KC 27699-1636
Go.Outer casing length(if(monm): (f�) lOr-Tor Water Snuniv&Tuyeehan M76115: 10 addition to sending the form to
the address(es) above,also submit one copy or this form within 30 daps of
completion of well abandonment to the county health department of the county
fv T—aroadaalhrinnalength liflma=): A) witeraabandoned.