Bladen_Well Abandonment_20230227

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. WELL ABANDONMENT RECORD Fat telenudliedONLY:
This fortn'iu be"uredfor single:or multiple wells
1.Well Contractor^Information: WELL ABANDONMENT DETAILS
Chris Buffer 7a,Number ofws.4 being ahando nlcvl:.1
' Wck6.1,61er Rase(or welionustena'notly.abgriiinin nell.oulif th r'prapesty) RA' Imelnp,M. Myetlos it rtai7Jittarx i unify wells ONLY with flee .sane
- - - ontrrrcefianitorrcianment,yrm co nor al txrefilrni,
9223-A .. . .
Well t',. rr� 7b.Apprnsihnate votnnte of Water temainiog in wrll(s}: faL)
NC We l Cann-agar_enitiu�tian Nunber L q
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SAEDACCO Inc FOR WATER SUPPLY WELLS ONLY:
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Company Nam. F t d2 7 2023 ie,Type of disiOrectant tikik. 1'
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25 Well Construction Pernttt 1/:, ,ipirnral3vsn �.. !
1e3t rill s rlrpixtri`.uedIlterrriiiu f.d Genre.,:ime,turf` y`cl i° t itiiaf ti/iii'1�
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7d.Amount of disinfectant used:
3.isyt31 use(check Well use): .
-Water Supply Well: 7e.Sealing inatcria!s used(cheek,ill tat apply):
t]Anrfctitttttiti • OMunicipil/Puhiic- -l3,Neat Cenietit.Gnttt CI Bciatoiiitc Chips or Pellets..:
• 1]Geothcrn it(l-lcatinglCooiing Supp1}1 0Rcsidentwt Water Supply(`higic) El Sdurl Cten ertl Gsnu .D t Dry Clad
❑ndn5ttialt otumercial- DResidentiaCWater Supply.(abated) CICouctett'Gro
l ut -D D'ri11 Cuttings .
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01rtigation O Specially Grout b Gravel
Nee-Water Supply Welt — ' ClBentoniteSlutay C1 oilier(explain under 7g)
Nh1cinttstr1ng-. DRecotery. ,
injection Well' ' 71.For each material selected-above,provide atootrnt-of.materials used:
DAgrtiferRecbarge DGrputidriater Rentediiuian Neat Cem.•991b, ,Wtr•5ga1., Sand Cem_•lb ,Wtr•gal.
iA4uifer Stoiage spud Rettn•ety OStiliiaity 13urrier• ' •
❑Ailuiferlest ❑SiomntoterDnitiuge --- . - -- —
DExpeiiuiettiul Techttology f]Subsictet>;e Cotnro1 7g.Proi idc a brief deceriptiari of flte.aladndnnms nt pneeedurr:
' - EGeosltemnl(Closed Loop) Chloe—et
Tremie to bottom and pumped grout in.
ElGeothcrtuat(iiUdingiCaoliu,tg"Return)' ®Other(explain under 7g)
• 4.Datewcll(s).ahnndoncd; 1-23-2023 -
S:t;Well ideation; - 11 ,
Bladen Off-Site Well I:
Facilityrthv for Name Facility IDs(Eoppiicabld! 8..Ceertiflcatloi. {� n
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Glengerry_Hill Rd, White Oak,. NC'28306. Chrlis Puffer i; 1/23/2023
Plrysieal'Addtc$:City.,aiid Zip - SCefghn,of CertitliA Well Coiumaoi Or Well Own:r Dane
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Bladen . tav eigntLig-flits form,.!freby-cr:,a•tify-dent the went u•as(mom)abaadhned itr
Cm:1A). IAr el}den lCtc lmtNa..(PINj aic kitr t_acs with 1 i.1.5 CAC OX ;0100.or 2C_11200 Well Court ucdiori Stimtkirds
- - and that a cosy ofllris record has beeie provided io thc,►i•ell du'iier.
'h J.atflude and longitude in deg /uwmtcs/acconda or decinnidegreesi j
(itu•al!Reid,one tat/la,tr}u suflicxtu) 9.Site diagram or-addltional well details:
You.nny use the backthe bael Of this page to pCO%ide additional well site:Omits or well
34.814665.7 N 078.8325898 -W a[iitnieuuentdetails: You.may-atao•:fIacliadditionalpaesifnecessaty
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CON1 TRIICf101f,I1E TAILS Olt WELL(S)BEING ABANDONED SUBMITTAL 1NSTRUCTIONSi
:fakir.pcll cam ndiad n vrdts/'Ij tisr$Id!L :Frir kid*lc i,fe iieue.ur radnoyettir.cnpph. I
. st,et'la 04.moth he pine csasrsfrderltriNe 4tglott!ugretIva cat:sirbni l me Pm. ltla:-Fur All Wells: Submit.ibis ferny within 30.thugs of completion of well
ig wen 111 Bladen-1D dbandootnciii tu:thc folloiviu
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Division of Water Resource,Infor mation-Frucessing Quit;
I61711LriI-ScniceCenrcr,,Raleigh,NC 27699-1617
6b.Total well depth: 47 (ft:)
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lob.For Iniectlon Wells: In odriltioh to sending the font to the address.in 10a
'abeeve,also snbiirlt.one cope of this farm aitin'30'days of completion of well
' i Borehole dIanieter:2 tin) abtaidcionteat to the fo1lmii r li
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4d.Water}reel bclme ground curfaec; (ft,) -Division.af Wait r Risouret'a; ndcrground'Injection Control Progreso,
1636 lliail Service(:cuter•,Raleigh,NC 2769'9-1636
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10c.For Water Stmols•-&Liicetinn Yells: In addition to sending the form to
Ge..OutcrCasingicngth.(ifknown): _ _ - . . (ft.) the:address(es).above. also sulk-Mil.one copy of-this funn evitliin 30 days of
completion of well abandomneetitol the county health department of the county
*hem abandoned.
61.-tuner easing/hitting knllh(if known): 37 (ft.)
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6g.Screen length(if knonn):10 tft.)
Farm GW-30 :Noah Camllin Bcpannr al of Enelroautenl and Natural Resuuwes-Division of Water ltcspumes - Revised August 2013