Davidson_Well Abandonment_20230602

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WELL ABANDONMENT RECORD Fey( ,,,11 scONLY:
This form can be used farsingle ormultiple welts
I.Well Contractor Information: .,,_.— 1
11111.111.1111.11111 I' e t" i Kda ELL ABANDONMENT DETAILS e tese�7 Number ofweits being abandoned: Q/
Wen coatrceroarama(orweRownerpersamltp abandoning wcttonhislherampcna) Far multiple injection or nai warcr sap* wells ONLY with the same
eanstructian•abmulenetenl you raasubinitonefann.
NC Well Comeau Certification Number 7h•Approximate volume ofwater remaining in well(s): 2.J J (gal.)
6- ?y - /F/ef i'L / FOR WATERSUPPLY WELLS ONLY:
ComumayiVame /�
7c.Type of disinfectant used: % .�/ j f1
2.Well Construction Permit W: L82-2 9, O©dR
List all applicable well permits(Le.Conn(;State,Variance.ltjcuion,eta)ifbei r
7d.Amount of dislnlbctant used: A/Z 07„s
3.Well use(cheek well use):
WaterSupplyWell: 'le.Sealing materials used(cheek all that apply):
cipal/Pubiic ClNeat CementGro .. - •,,r.r r p,Bep tteChipsorPelleIs
QAgiculmrai °M
CiGeothetntal(Hcatine/Cooling Supply) Rgesidential Water Supply(single) C)Syrd Cement Gro'utt.r 4,.,.L,.a iv 14....A.SlaY
OlndustciaUCommerciai ['Residential Water Supply(shred) lR eretc Grout r. Drill Cuttings
°Irrigation ❑Specialty Grout J L Iti V 2 20�1,Gravet
Pion-Water Supply Well: d BentaniteStutty II O er.(esplairtunder7g)
°Monitoring !]Recovery IYt+ti:;, gin fir.^,•c� wur�� t;.i
Injection Weil: 7f.For each material select t�'to p o rideamount of materials used:
°Aquifer Recharge OGroundwaterRernediation 4'. 5-
OAquiferStorageandRecovery CiSalinity Barrier c?
°AquiferTtst DStammaterDlaina_e
°Experimental Technology CSobsidenceControl 7g.Provide a brief description of the abandonment procedure:
CGeothennel(Closed Loop) DTmcer
OGeathennat(HeatinalCoolingReturn) OOlher(eeplainunder7g) 4f /v Ai �r/tigm./6 p^e,.J.l%6�fAtcrt.
4:Datewclt(s)abandoned: ?��-S/2-0 ,ZrC01"G Aen_fd 3 .43 tit/`%��4`
Sn.Well location: , /9Lyl G�-G61l c:w
Facilityf0wnerttame Facility lDC(ifnpplwhle) S.Certification:
• '11/ •I‘ 04e 144.hiAtri;,,Z, ife.q:e.kf,V1.1-fo-ii.e,fri el01 ---J--.7chS0
Physical Address.City;and Zip /, game ofCortified Weil Contractor or Well Owner
Date
6'9 ;,2,Ca.ci By signing this font,t hereby cer41jj+that the wars)'was(were)abandoned in
County Pnreel Identification No.(PIN) accodance with ISANCACO2C.0100or2C.0200 Well ConslmclionStandards
Sb.Laltude and longtudeindeereesfminutesisecondsor decimal degrees:
o�tln°lacopsofdrisrecord6asbeerrprovided/othen+ehlottsrer.
Orwell field.aye balms is sat5eicat) 9.Site diagram or additional well details:
N You may use the back of this page to provide additional well site details or well
W abandanmentdetails.You may also attach additional pages ifnecessatjs
CONSTRUCTION DETAILS OF WELL(Sl BEING ASANDONEiD SUBMITTAL INSTRUCTIONS
Ailed well wasLnetlan remits)jf available. ParmtdGpie injection or non-inner sply
wells ONLY with the same eanshveilen abtardnnnteavoucansubmitmzuform, We.For All Wells: Submit this form within 30 days of•compledon of well
�, r�IDS
; • abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) Mahe Sr mice Center,Raleigh,NC 27699-1617
•, itlb.For inleetton Welts: In addition to sending the form to the address in 10a
6e.Borehole diameter: 41 (yn,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following
6d.Waterlevelbelowgroundsurface: 2--ir (ft) Division of\daterResourt�,61®dergroundInjectionCuniroiPra�am,
• 1636 Mail Service Center,Raleigh,NC 27699-1636 •
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de.Omer casing length(if?mown): (ft.) IOa For Water Sunnly&Injection I4iki11: In addition to sending the form to
the address(es) above,also submit one copy of this loan within 30 days of
completion of well abandonment to the county health department of the county
6f.Inner easing/tubing length(if!mown): (fa) where abandoned.