Nash_Well Abandonment_ (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Centimeter Information: WELL ABANDONMXNT DETAILS
Michael Young 7a.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same
Wee Connector Nam(orwee owner pmonally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2370-A wells abandoned:
NC Well Connector CettiBcmioo Number 7b.Approximate volume of water remaiaing in we8(e): O (gal.)
FIshburne Dulling Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
NCD045646924 7e Typeardiainr«ti.ntnaed:
Lin all applicable sell covnuction p¢rmns Ae.UIC,County,Sete. Vioumre,stet.)edrown
7d.Amount of disinfectant used:
3.Well use(check well use): r.,,. "`•- . (:r,,:
Water Supply Well: 7e.Sealing materials used(check W that apply): V 's^'"-G
OAgricultural OMunicipal/Publie ■Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResiden6al Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
Olndughial/Commeroial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
l3lisigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
■Monitoring ORecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
OAquifer Recharge OGmundwmer Remediation 5.5 gallons
❑Aquifer Stooge and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage
OExperimentai Technology OSubsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothetmal(Closed Loop) oTrasaer Tremie grouted from the bottom of the well to the surface
OGeothermal(Heating/Coaling Return) OOther(explain under 7 ) —
4.Date well(s)abandoned: 11-03-2022
5a Wen location:
Kaba Iico Corp.
Facility/Owner Name Facility to#(if applicable) 8.Certification:
400 Jeffreys Rd., Rocky Mount, INC 12-05-2022
Physical Address,City,and Zip ftnatee of Certified Well Collimator or Well 0 Date
Nash By signing this form,1 hereby terrify thaVV.0200
(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minuties/aceonds or decimal degrees:
(if well field,one lat/long is sumassr) 9.Site diagram or additional well details:
35.989276 N -77.786387 W, You may use the back of this page cis provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anachwellcam"cnonre rd(s)ifami/able. Formultlpleinjectionornon-watersupplywells
ONLY%oh the same cownucnonlabandonment,you can submit one form. completion10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: VY`A/- I.t Os abandonment to the following:
Division of Water Resources,Information Processing Unit,
6h.Total well depth: 30 (ft.) 1617 Man Service Center,Raleigh,NC 27699-1617
10b.For Infection Wens: In addition to sending the form to the address in 10a
be.Borehole diameter: 8.25 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
bd.Water level below ground surface: NA O 1636 Mail Service Center,Raleigh,NC 27699-1636
Division of Water Resources,Underground Injection Control Program,
6e.Outer casing length lif known): NA (IL) Inc.For Water Supply&Infection Wens: In addition to sending the form to 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 where
6f.Inner casing/tubing length.(if known): NA (D.) abandoned.
t
6g.Screen length(if known): I 0 01L)
Form 6 W-10 North Carolina Department of linvnor mental Quality-Division of Water Resources Revised 2-22-2016