Chatham_Well Abandonment_20230602

ELL ABANDONMENTRECORD For Internal Use ONLY: i -
This fonn.can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDON,biENT DETAILS
JAMES MORRISON 7a.Number of hells being abandoned:"
Well Contractor)'ante(or well owner personally abandoning well on his/her property) I'iu lnrrhiple injecting or non-trwer,1, .ctlppli� wells Ot�'LY wilh Me .,ewi•
c omirta non ahandinnnent,t Du can ctrhnni one lhrnr.
C - 4421 3:5
7b.Approximate volume of Nvater remaining in well(s): (,al.)
NC Well Contractor Certification Number —
GEOLOGIC EXPLORATION FOR W:\TERSOPPLY\VELLS ONLY:
Company Nmne 7c.Type of disinfectant used: ..
2.Well Construction Permit#:
Lol au upplwable It ennslnrclinn nrrrnit,(i.e.t ounl.i'.Stale. I...icm,e,etc.)i1 knmiwn
7d.:lmount of disinfectant used:
3.\\'ell use(check.well use):
Water Supply Well: 7e.-Sealing materials used(check All that apply):
❑Agricultural ❑MunicipallNitblic ❑ Neat Cement Grout ❑ BentoniCe Chipsor Pellets
❑Geothernal(Heating/Cooling Supply) : ❑Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial 0Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation - ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
Monitoring" - pRecovery
Injection Well: If.For each material selected above,provide amount of materials used:
OAquifer Recharge ❑Groundwater Remediation 5.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stone%ater Drainage
❑laperimental Technology ❑Subsidence Control 7g,Provide'a brief description of the abandonment procedure:.
oGepthennal(Closed Loop.)_ ❑Traczr ABANDONED VIA TREMIE PIPE WITH AQUA GUARD
❑Geothermal(Ile atin�/Cooline Return) ❑Other(e.xplain under 7g)
05/15/23
d.Date wells)abandoned:
ia.Well location: JVIV V r 2023
CAPE_FEAR STEAM PLANT
3 Certification: i t iT i�C^C:}Pra::r�l:Cr'l
�Ra eN�
Facllit�;'Ocurer Name Facility IDk(ifapplicable) _ cdY!�C�.�r��
500 C P AND L ROAD MONCURE 275,59 -05/23/23
PIn sical address Cit .and"Lip Signature of Certified Well Contractor or Well Owner, Dam
CHATHAM
By signing this form. I hereby certify:that the irell(s) [refs (were) abandoned ill
Parcel Ideniilication No.'(PIN) accordance with 15A N'CAC 02C.0160 or 2C.0200 lyre i Construction Standards
and that a copy of this record lix.been provider!to the well olrner.
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
il'well field.onelat/tong is sufficient) 9.Site diagram or additional well details: .
350 35' 16.83" 790 02' 52.76" You may use the back of this page to provide additional +veil site details or scelI
N 1V abandonment details. You may also attach additional pages i r nece'ssary
CONSTRUCTION DETAILS OF 1VE'LL(S)BEING ABANDONED S[)1n11TT':V,INSTRUCTIONS
Am h e'rl!ronvrucnon rrcardrq Y avoilahle. r,r nialnple iryec'tion or non-rr'ater.sjq pj,
n elLe 0zVLY,mh l/re.+alnt;rnrtrrnc rrnn nhunr/nnnrenr,YOU ransuhnni fine io)-m. 10a. For .all Wells: Submit.this forin Nithin 30 days of completion of\Nell
fig.11'cll iM: -
ABMW-02SL abandonment to the following:
Division ofWaterQuality,Information Processing Unit,
6b.Total well depth:
30.0 (ft:) 1617,;\I:iil Set-vice Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In'addition to sending the form to the address in Ilia
2.0 above, also submit one copy of this form within�30 days'of completion of well
Gc.Borehole diameter: (in.) abandonment to the following
s
/ 9.0 Division of Water.Quality,Underground Injection Control Program,
6d.11`ater level burs ground surface: (ft.) 1636.flail Service Center,Raleigh.NC 27699-1636
6e:Omer casing length(if known): (ft 10c. For Water Supply & Iniection Wells: in addition to sending the lixm to
the addresses) above, also submit one copy of this Form within 30 days of
completion of well abandonment to the county health_department of the cOklnts '
ahere.abandoned.
6C Inner casing/tubing length(il mown): (ft.)
6g.Screen length(if known): (ft.)
r o.111 North Carolina Department of Enc ironment and Natural Resources—Di%ision of%Varer nunlim- Re iced\larch 201: