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Home My WebLink AboutSurry_Well Abandonment_20230428 • APR2S2023 . Iniorffr;:; Cf r'r� cac.M,. WELL AB .�c" 1 1 Ir C D.' -g t,�:- . Fortreenmt>rls i ets' This form can be used for single or multiple wells - 1.WellContr actar Inifonmatlon: WELL ABA DONNtUSEN`T MAILS�arntt✓ fe.A.A_ 'ru-r- 7a.Number evens being abandoned: wenCenuecr (orticcllamierpeaoaattyyabzzmioaiag�vcttonLislherpivpem) Tyr multiple infection er r-uanr supp!}'wells ONLY -with fhe MM.dray ^'1 U�� `—r emulmrnar,SBwrdarrmejg you ratrrsuhutilmtejorm NC MU Contactor Ceriifioui,onNumbec 7b App�q'senate volume of water remaining is nvcld(s): `(gel.) Aqua Drill, Inc. FOR WATER SUPPLY WFJ.i S ONLY; Company Name �// 4jL ��f /It 7c.Typeof disinfectant used: 2.Well Construction Permit 1� '2 b List all applicable we1I permits(i.e.Couni}:Slate,Variance,lnjapfan.eie)fr;•nmrn 7d Amount or disinfectant Used: 3.Well use(cheek nail use): Water Supply Well: 7e.Sealing materials used(check all that apply): °Agricultural ,- OMtoricipai/pubGc O Neat Cement Gaut U BentoniteChip sorPellets DGeathermal(iicatin/Caoling Supply) °Residential Water Supply(single) a Sand Cement Grout 0 D:y Clay Qindustriat/Commercial GResidentiat Water Supply(altered) 14 Concrete Grout II Drill Cuttings . [irrigation Cl Specialty Grout Cl Gravel Non-Water Supply Welk Cl Bentonite Slurry Cl Other(avian under 7g) [Monitoring. fRecovery - Injection Well: if.For each material selected above,provide amount of materials used: 0AquiferRecharge GGmnndwaterRwnediation :°' C °Aquifer Storage and Recovery . t7SalinityBenier sf DAquiferTest GStormwmterDrainage DExperimentat Technology GSahsidence Control 7g.Provide a brief description of the abandonment pro�da re:CGeothermul(Closed Loop) Mawr d( lIif' pp ��OGeothermal(HeatingCoolingRetum) ClOther(erplainunder7g) / rd0e + 416 d:Datewdi(s)abanlonad: it 2 Lit— 2 V sa.°,Wail(ocntiun: JA5on &d2k,ifr Facili /OwncrMune Facility(DM(ifapplicahle) o.Certitaeatioa: �+ 33 L. J 1 11 Oi 1- A of-oi i#65,-/e .� �E--97G y "7� �3 phystca ddress,City,andEp r of cm W4CentrouororWellOwner Dare .)(((C y By signing Ibis fore,I hereby cerii.9 Drat the wells)was(ware)abandoned in County Purest identification No.(PIN) accordance with ISA NC.1C 02C.0100 or 2C.0200 Well Construction Standards and that a copy ofthis record has been provided to thetvell owner. Sb.Lafitude and Ion trade in dcga eesf mnutcslseeonds or decimal degrees: (ifvfx11 field,an;tatllcu saffeicm) 9 Site diagram or additionaltvel details 317 dtitle y►1/I N �f f �s You u imay m use details. the backba of this page to provide additional well site details or well !� I6 (f ! 4° i'F may also attach additional pages if necessay. Q ONSTRUCCIhN DETAILS OFWELL(S)BEING ABANDONED SUB1VIITTAL.1NEi RUCI1ONS Attach well eonntrnefan records)if mailable. For rmttipie hyrax or non-water soppy wells ONLY with tbe suateconstnottowhbantionntent,you=submit malaria. l0a,For All Wells: Submit this from'within 30 days of completion of well • abandonment ho the following: _ 6a.Wdi113O: - Division ofWater Resources,InformationProcessing Unit, }t fib.Total well depth: 4�✓`� (ft) 1617 NIail Service Center,Raleigb,IVC27699-1617 10b.•For Trajection Wells: In addition to sending the form to the address in 10a above,also submit one copy of this form within 30 days of completion of well • 6e.Borehole diameter i Gam) abandonment to thefolla►vir Division of Water Resources,Underground Injection Control Proge-ram, 6d.@Vatet-revel betotvgrotnadsnrface: (R.) - 1G36 Mail Service Center,Raleigh,NC 27693-1636 14/ lOe.For Water Stroud,&injection!Welts: in addition to sending the form to ba Outer casing length(i.brown): / (ft.) the'address(es)above,also submit lane copy of this form within 30 days of completion of well abandonment to the county health department of the county whale abandoned. aInner cnsiugltnbiag length(if known): (It) • - APR 2 8 i 41 an .V V ELL ABANDONMENT RLCORA 8m•Gnerrat UseONLY:' 4'1° 't')1,•1 URl ' - This form canbe nsed for single or multiple wells 1.Welt Contractor Information: WELL ABANDONMENT DETAILS • .geetilerrifiteraM011 iAe d / l?i 7n.Number ofwelis being abandoned: l" . Welt Con,�erorNema(emeltawnerp r o abandani nt r.lionhhIlterpmpc"`) For midge injection or nen•;rarer supp(r urns ONLY vier the saute cott:<mcGan aLmrrlarrnttmt,YOU txrrsuhrnitmtoJoir;t. 71r.Approximate volume of water retraining in went*1 ) (gal.) . NC WeHantrdetarCcrtifcmionNumber Aqua Drill;inc. FOR WATER SUPPLY WPM S ONLY:_ . Comp:myna= 7e.Typeo€disinf'ectantused: t J A 2.Well ConstructionFerodei: 1161/L 2 2.` 4e e��LW ell applied*soli posits P.m Calmly.Stole,Variance,hp:non,cm.)ifkuanvl 7d.,ionnt of disinfectant used: 1 fJ/e 3.Well use(check well Use): • Water Supply Well: 7e.5ealiug materials used(elmcit`ah thatapp►y): DAgriculturai cMunicipallPablic Cl NeatCement Grout ❑Bentonite Chips orPeltets r QG�Ihermal(HeatinelCoolingSuppj}) QResidauiaiV.aterSupply(sinale) CI Sand Cement Grout , 0 Drr Clay Concrete Grove Q Drill Cuttings QIndushiallGammercial C]Residetttiat Water Supply(shared) �Specialty Grout i]Gravel NLntW ter Q BentoniteSliiny ' Q Other(etplainunder%) Non-Water l3Monitoriiig 011ecov ` 7E For eaefl raatcrial s acted above,proeideatrwuat of materials used: • Injection Well: ['Aquifer Recharge cGroundwaterRetnediation 3 v UAquifer Storage and Recovery- QSalinitpBarrier 7 ClAquiferTest QStomnraterDtairtd_e C1Reperimental Technology DSnbsidencs Control • 7g.rvide a brief description of the abandonment re t DGcothermal(Closed Loop) ClTmcer �al�T M � �� l�y �/ OGeothenna((FIcawig1CoolingRettuu)" QUther(esplainunder?g) 4,4 /,J tom_ 4. r /F tt - l ti tin? / ,c/' 4i , lc,/ - - >/e. 4:DatewclI(s)aoaadoacd: �� I � / • 5a.Welllocation: 1 -lei feve c•,,,7 t C r r Fgcinty/Q m.Homo i' ity is5 feApl cahic) .51 (e,e9.1(feiritSi' �eni• •Wel1Conhaet; . �ner t cPhy" Address. aad.4) . 7 By signing this form,I , :, that the wilts)ions(vere)abandoned in County�t accordance with 15A NC QI00 or IC.0200 Well Construction Standards County facet idenu6catianito.(PIN) and that a copy oflhisrecord has beenprovPded to tlremelt owner. 51a.Latitude and longitude in dv ecsfsninutcsfseconds or de and degrees: 9 Site diagram or additiomtl+reell details: Orwell field,asr:latlioosit su0•ieicta) Yon maguse the back of this page to provide add tional nrcil-site details or well /6"11115.7 N fa,7 (/1 / f " "W abandanmeatdetails.Yonmaynlsoattach additional paw ifusite ty: CONSTRUCTION DE"iAILSOFiVELLfS1B IE NGABANDOINEeD SGSZ ALIItSTRUCTTONS Attach well coonnectint+rncord(s}d•mailable. For multiple injection or non-water supply p nelts ONLY leliltMrsantecmutnaaiewbbondatmtentyan con sllboln far+n• i�.d TQtun All tWensthe: Suimit this form within 3D of com letion of well o aban I 6a.Well IiY`: DivisionafWater Resources,Information Processing Unit, 1617 Mail Service Center,Raleigh,NC 27699-1617 lOb,•For Injection Wells: In addition to sending the form to the address in l0a above,also submit one copy of this form within 30 days of completion of well Sc.Borehole diamelet: Cm•) J abandonment-to the following a �j Division of Water Resources,Underground Injection Control Program, 6d.Water level below groundsurface: ✓ (f) • 106 Nan Service Center,Raleigh,NC 27699^1636 / t0e.For Water Supply ea Injection Wats: In addition to sending the farm to " de.Outer easing length(ii€loomu): fj (ft) the addtess(es)above,also submit one copy of this fano within 30 days of • completion of well abandonment to the county health department of the county whets abandoned. 6E Inner casiogtmbinglength(if imatvn):,___....—.«) •