Wake_Well Abandonment_20230505

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WELL ABANDONMENT RECORD 1ForinannIUseONLY:
r -- -'T
I.Well Ceatraeior IabraMdoo: WELL ABANDONMENT DETAIL.(
a ���t 7a.For Geoprobe/DPT or Closed-LoopGeotherrnal Wells having the same
Well Contactor Name(or wail owner personally abandoning well on his/her property) well construction/ only 1 OW-30 is needed. Indicate TOTAL NUMBER of
')'•°1 E P\ wells abandoned:
NC Well Contractor Ceni&aion Nu ear t lb.Approximate volume of water mon isle&to wdf(s) (4aL)
el`r a( d(}j e I.Puj)) . FOR WATER SUPPLY WELLS ONLY: l�,
Company Name n v i i
V.1
7c.Type of disinfectant used:_Jr� �'. / b r I ►!
2.Well Coasbrucdon Penk#: (� w1 10 0 7(Y v/� ^ /0 r.�
Liar all applicable wlt conruucthur prim is At CI1C County,Sane,Variance,etc.)(f brown /
7d.Amount of disinfectant used:__
3.Well use(check well use):
Water Supply Well: - 7e.Seams materials need(cheek all that apply)
°Agriculture} Olunicipal/Pubiic 0 Neat Cement Grout •Bentonite Chips or Pellets
°Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 Sand Cement Grout O Dry Clay
0industri&/Commercial °Residential Water Supply(shared) °Concrete Grout 0 Drill Cuttings
Obri• 'on 0 Specialty Grout 0 Gravel
Non-Water Supply Weil: 0 Bentonite Slurry ❑Other(explain under 7g)
OMonitorin• °Recov-
'ell: 7L For each material selected above;provide amount of materials used:
A4u t ketauuga UCirwuuiw,ai i:ia :: 4 3 b(lis of
°Aquifer Storage and Recovery °Salinity Barrie ("�
LIAquifer pest UStorrawate,Drainage 6en-4o r i.},e.. (45 ` )
°Experimental Technology °Subsidence Control 7g.Provide a brief dncNpt oa of the e m ept procedure:
OGeothemud(Closed Loop) °Tracer filled
°Geothermal(Heating/Cooling Return) °Other(explain under 7g) ( �
4.Date wed(s)abandoned: 1 " 1 r 4-4- r` �'s G%
sa.Well location: Rol an a o 4 MRY u 5 7023
Tor Pro c-to t^ v ( a i�� Pr^C ;fs9 U►zi
Faciility/Owner Name Facility IDY(if applicable) 8.Cerditcatloe: li> >�«� a, '�'�v
��� �'( nv�o�a �rl C�r dr �l � ..y ! 23
Physical Address,City,ad Zip SignaturV Cenited Well C for or Well Owner MO
l. By signing this form, I hereby carp&that the we/l(s)was(were)abandoned in
County Per sl tda,aitia.aion No.(PIN) accordance with/SA NCAC 02C.0100 or 2C.0200 Well Comfrucr/r n St(n.0.0rds
Sb.Latitude and laa ode is degreea/auiautes/seeoads.e decimal degrees: and that a copy of this record has bem,proviaYrd to me wed owner.
(if well field one lattlong is rtift::=3 9,Site Airs*ram or additional well details:
N W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(SI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well c,mslnrclon rec'ar!(s)lfavalladle.For multiply Injection ornan-walcr apply was
ONLY with the same autruraclkn abandonment,you can suhma one form.
10a.for All Web: Submit this from within 30 days of completion of well
6a.Well(DIY: 1\1 abandonment to the following:
3 e) Division of Resources.d Service Information Processing9-16 Unit.
6b.Total well depth: (R.) Raleigh,NC Y7699-1617
10b.For Infection Wb in addt:ion to sending the form to the address in 10a.
6e.Borehole diameter (hi) above,also submit one copy of this form within 30 days of completion of well
abandonment to the foligwing:
6d.Water level below ground surface: (ft) Division of W Rsssaraes,Ustdssfrand Injection Control Program.
1636 WM Bervke Cots%RaYpb,NC 27699.1636
i 7 car sr.w, a % i .° tot l—tar bt,..rAi•.i-:,..:f.-4ln,Alt ix=en tte
address(es)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
61.loner casing/tubing length(if known): 0 (ft) abandoned.
6g.Sena;length(if known): 0 (@-)
Fern OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

WqieLABANDONIVIENT 4ECORD I For hatted Use ONLY: �•.
1.Wd1Coalraelar hftw4n:
© WELL ABANDONMENT DETAILS
c�`b 4 Poo V 7a.For GeeprobelDPT or Chanel-Loop Geotherm.l Wels having the same
Weil Cananetor Nilson*welt owner peroaaly slreadortina well on Mslhtr Oaoaerayl well ta�only I OW-30 is needed. Indicate TOTAL NUMBER or
i ,/1 was abandoned:
NC Well Connector Certification NumDar Piklikr 7b.Approximate volvolumeof s a+em Mime*la wdNik C IgaL)0 ra(i P00��i J e•1( - COO FOR WATER SUPPLY WILLS ONLY:
Carlo y Naas �,! 71a of disinfectant mad:
_—18 .,
2.Well aPeraai t#: l VV Iof SI' 20 .,3
Lear ail applicable well ewtmnetiast palmist acme.Cooky,Shaer.Variance,etc.)t brown
7d.Amman of disinfectant mad: !,tL
3.Weil twe(ceeck Nell ruse): ...
t Wa?x ':ply W a 7e.`_a ;: trt t r. (cheek;all that tnly
°Agricoltunil unicipel/Public Q Neat Cement Grout Battonite Chips or Pellets
iCOoothermei(Hating/Cooiing Supply) dResidential Water Supply(single) Q Sand Cement Grout 0 Dty Clay
Qbalttdriai/Commerciai ❑Residential Wider Supply(shared) 0 Concrete Grout 0 Drill Cuttings
0Irrigation 0 Specialty Grout Q Gravel
Noes-Water Supply Well: °Bentonite Slurry 0 Other(explsln under 7g)
°Monitories QRecovety
Illiee lean W� 7E For eachr material selected{above,provide ammo of naatafals mesh
Ci iii Rat age Cnrciiridwaat c}".ari d€lion P i 1 1 t i��Y ti `A-
at iJ=i.i aIt et-t,, i.audtt�j
°Atpai&r Storage and Recovery ❑salinity Blain S i i .6433)
L a S\
°AquiierTest 0SWrmwator Bran to "► c s�"l,
°ExpadmanWti Tecttt►ology ©Sttbsidenoe Control7g.Providea brief** rides oldie prema e, i �"a ve 'l..^L.i \i /...
OGeotheunal(Closed Loop) °Tracer ,t
Qaeotbetmal(HestirrgCooting Ream) °O1her{explain under 7g) 3 roil+iAl -I t MAY 0 a 2023
ai -a3 h771 Pr::W 'g Uri
4.Datewel(*)abandoned: ;:,L'.U'�T.'r_.
Se.Weil
r (' nUtrDp en`L/ svcd= V1L.
r aQ a��,� e� �� e�QalY�r '`e' actata: P0(11 ? ' J4 4- ai-a 3
Ada in . .and Zip S etC
taNRs6 or m Wdl OwnerVI Dee
0`1<e.' 1 l)1 1 Li l ! 7 fJ B,eignlic Ws fivm,I hereby co*that the well(s)was(were)abandoned in
Coate Parcel ideatilnatian No.(PIN) accordmacs with iSA NCAC 02C.0100 or IC.0200 Well Construction Solndorda
r»"'.t. ,,v_a °r.4- miff.'° ...vi:prartt4a11yIhe.entI.W r;
Sb.Latitude and heashade is tiegneeseadametisematis or decimal degree.:
avid field.ant bNto*5 is sufa c«l 9.Site diagram or additional well details:
M1 W You may use the back of this page to provide additional well site details or well
abandonmen details. You may also mulch additional pages if necessary.
CONSIgUQDQr*(DETAILS OF WELL(SL BEING ABANDONED 8[IBMITTAL INSTRUCTION
ArmchwellcseWntrtbn twangs)(fh.a#abk.For ercitiplehj.ctionorno-watersapplywills
ONLY with nfte saw cr uractkuao esi.you can:Omit omfbrrc i0a.for All WO: Submit this fonn within 30 days of completion of well
ba.Well IEW: r' \ abandonment t to the following:
' I �'{° exr�s tad stir it PnsCy 1iitfi.if retie.PrOli F06 Ursits
lib.Total well d tb: Hi i 1617 hbMS.rvlee Cesar,N$ItIgb,NC 276994617
lob.For Is hetlua WAIF in addition to sending the form to the address in 10a,
Se.Borehole dIameter: ‘ (In.) above,also submit one copy of dela mum within 30 days of completion of wail''
abandonment to the following:
6d.Water laves below pond serrate: a.Q �_(1k) Divideset War Renewers.vadaq rated Weenies Control Program,
163E Mild Service Cat",Raleigh.NC 27699.1636
(m Onset,t assess ieet,.ir tii ecra+oeH q•_0_ ,v i::.t sat ear W St 1Rteestrtre Wolle; In addition to se Jinn the form to the
as #)above*also sibZ-nit 9aa ,.s.._ r.�
of well abandonment to the comity health department of the county Pwhere
6I Inner ashljhablas less*(Niltaasmd)t 0 (IL) abandoned
6g.Screen length(if known): 0 (IL)
Perm OW-30 North Carolina Depsraaenrof Environmental Quality-Division of War Resources Revised 1.12.2016