Chatham_Well Abandonment_20230602 (3)

WELL ABANDONMENT RECORD For Internal Use QNLY:
This form can be used for single or multiple wells
I.Well Contractor"Inforloatibn: WELL ABANDONMENT DETAILS
JAM ES MORRISON 7a.'Number of wells being abandoned:
We II Connuetor Name(or well owner personally abandoning well on his/her propeny) J•i r neduple ,Driecti,,n or non-u dieri supplt nells O;\'LY with dn• sum.•
construction nhandonnx•er.ruin coin srihwi(aneJiu'Nl. '
C - 4421
1b.Approximate volume of water remaining in lvell(s): 0'5 fgal.)
\C oil Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY YELLS ONLY:
Company Name 7c.Type of disinfectant used:—
2.Well Construction Permit f:
l.i.:r a!1 upphcirhle inch!emretrnctinnl+rrn;arc/Le.C'ountm'..Ctznr. F in-iaurr.eu"./if krtmrn i s i -
7d.Amount of disinfectant used:
3.Well use(check Nvell use):
Water Supply Well: 7e.Sealing materials used(cheek all that apply):
❑Agricultural_ ❑Nlunicipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Hcating/Cooling Suppl%-) ❑Residential Water Supply(single) ❑ Sand Cement:Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout Ei Drill Cuttings
❑Irrigation O.Specialty Grout ❑ Gravel
\'on-Water Supply 1Vell: ❑ Bentonite Slurry, El Other(explain under 74)
ONlonitorind ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.0 GALLONS
❑AquiterStorage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormvater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop). ❑Tracer AB
ANDONED VIA:TREMIE PIPE WITH AQUA GUARD
❑Geothermal,(Heating/Cooling Return) ❑Other(explain under 7g)
a.Date vs-ell(s)abandoned: 05/15/23
2023
in.Well location:
CAPE FEAR STEAM PLANT
Facility%Osentr Name - Facility IDS(ifapplicable) g•Certification:
5.00/C P AND L-ROAD MONCURE 275,59 "T.A 05/23/23
Physical.address,City,and Zip Signature of Certified Nell Contractor or'Pell Owner Data
CHA.THAM fay signing this form?• l hereby certify that the well(s) was(here) abandoned in
Counh Parcel ideimiification No.(PIN) accardCUice with/S l,\'C.=lC 01C a11110 or 2C.0200 Well Construction Standardsacid chat a cop)'of this record has been provided io the isell owner.
5b.Latilude and longitude in degrees/inin.utes/seconds or decimal degrees:
(if svelliield.Onelaulong is sufficient) 9.Site diagram or'additional well details: "
35' 35' 16.92" 790 02' 52.81" You may use the back of this page to provide additional well site details or well
N lY abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DE-rAILS OF 1V'ELL(S)BEING ABANDONED SItbIITTAL 1NSTRUCTiO`S
.-much well ronvrmwon record(c)iy*available. J-i;r wnluple iileevinn or nnrt-u'u/tr.ru,�plr -
,. ,reJlsONU11rrhihesume•c•anstruentinabcmdoninent.you cmrsubmit one Jirnrr. IOa. For :-III Wells: Submit this limn within 30 days Of completion Of %%ell
6a.N\'ell iD#: ABMW-,02SU abandonment to the following:
Division of Water Quality,Information Processing Unit.
6b.Total n:ell depth: 12.0 (ft) 1617 N1ail Service Center,Ralei-h;INC 27699-1617
10b. For Iniection Wells: In addition to sendino the form to the address in 10a
6c. Borehole diameter: 2•0 above. also submit one cop}'of this foam within 30 days of completion of�%Cll
1in') abandonment to the following:
8.0 Division of abater Quality,Undt -ground Injection Control Pro(ram,
6d.Water Icsel below ground surface: (ft.} 1636.Vlail Service Center,Raleigh,NC 27699''-1636
10c. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if linblvn): (ft.) the address(es) above, also submit one copy of this Conn within 30 days'ol'•
completion of well abandonment to the county health department of the cn.661%
61'.Inner casing/tubing length(if knolvn): (ft.) �Oicre abandoned.
62.Screen length(if known): (rt.)
i
Form G 0 North Carolina Department of Environment and Natural Resources—Division of water Empality Revised\larch'_r113 ,