Rockingham_Well Abandonment_20230127

WELL ABANDONMENT RECQ Fc�lra IUseONLY:
This form con be well for Single or multiple wells
1.WeR Costaraelr lutbrsoation: WELL ABANDONMENT DETAILS
r`
7s,Nwmber of wells being abandoned:,
Well Co�aararsone(a'well owner peramoilly abandoning well on hk tet property) mutdptc it{)ection or non•uater appply in0a ONLY tiNeh the arse
/ contn=ionlabmdomew,you can n&idt one form.
NC Well Cantractor Certification Number 7L Approximate volume of water reamdning In well(s): idL}
of at Ln cr UJt_d 1 T Low-12 FOB WATER SUPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: =MMWAW
2.Well Construction Permit tp:
LIN of gphmble well perm M(l e.cvwvQ am Variance,h0act(an,etc.)►jknawn 7d.Amount of disinfectant used:
3.Well we(eheckwell use):
Water Supply We1L• 7e.Sealing materials used(cheek all that apply):
OAgrieultural ChM 1paUPubiie ❑Neat Carw ra QMt a Beutonite Chips or Pellets
OGeoHtawl(Heating/Cooling Swppiy) Z6WentW Water Supply(sit►gie) a Cement Grout ❑Dry Clay
oindustrielciornmercial ❑Residential Water Supply(shared) V tOncreie Grout t7 Drill cuttings
0kr.sodon 0 Specialty Grout 0 Gravel
Nea-Water Supply well: a Dentonite Slurry ❑Oita(explain under 7a)
0monttorins ORecovery
luj a 7f.For each material selected above,provide oeteant of materials used:
OAquifer Recharge ClGroundwater Remediation
C*uifer Storage and Recovery Malinity Barrier
Dmuifer Test OSta mwater Drainage -
OExperimental Technology OSubsidenee Control 7g,Provide a brief dcscrtpdo of the aka praeotlwe
0(ieothermal(Closed Loop) OTracer / ✓f �-� _-
0G9Wb MW satin Return OOdter lain under 7 '+—'-
4.Date well(s)abaadoned: X, 2
Sa.Won won 1 W/QiBOG
Y T . — a.Certification
haityloxntat Name Facility M0(if applicable)
Physied City.attd Z6 S' Sell well Cow owner e
By signing this form, I hereby cart((y that the well(s)was(were)abandoned in
Parcel Iden i
Cow 8catfon No.(PIN) accordance with 15A IVCAC 02C 11 M or 2C.0200 Well Combrucdon SUVKksit and that a copy cf this record has bear Ammided to the well ottmer.
5b.La*mk and longitude to dgrsealubutes/seeonds or decimal degrees:
(ifwdl field,vile Wong is sumcks) 9.Site diagram or additional well det+ili n
2 V 0 f You may use the back of this page to prnvide additional veil site details or well
aL 1(L � —N Y �✓ W abandonment details. You may also attach additional pages if necessary.
card=ION nK An It CIE. r s taY ttR1Nl`_setsiyflrlTQa7t UJ)atittlTl.L�INS'I'�TI(•TlntiTC
ARK*neN cowing"tt MW Y Far iaftle hifectim or non water supply
wm anrwuh the am you can M&W1 one form. 10a, For All Wells: Submit this foim within 30 days of completion of well
abandonment to the following:
68.WeH IIi#•
Division of-Water Resoun:es,taformation Processing Unit,
61,Total well de0: (Ili,) 1611 Matt Service Center„Pakigh,NC 21699-1617
10h.For Inaction 'ells: In addition 0 sending the form to the address in 10a
above,also submit one copy of this forts within 30 days of completion of well
6c.Borehole diameter. .,.M.) abandonmot to the following:
fill Water level below and nu*ee. 1�(ft) Division of Water Resources,es,Uttar Raklad LC tlen2769 Contra{Program,
tV'o 1636 Mafi Service Cea4er,RaleF,{b,NC 27699-1636
10c.For Water MR&it Injection WA& In addition to awtding the firm to
6e.Outer wing Ieagt6(if linew0): ( } the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health departmemt of the county
where abandoned.
tit Inner adstghablue hagth(if known): YL)
66&MR (K 1110WO (ft.)
Pam OW.0 IN-M Carolina Department of&nvironmcnt and Natural Resources-Division of Water Rpawtxs Revised Agpm 2013