Chatham_Well Abandonment_20230602 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This fohn;cdn be used for single or.multiple wells
I.Well Contractor Information: WELL ABANDONMENT DETAILS
DAMES MORRISON 7a.Number of,wells being abandoned:
Well Contractor Name or well owner ersonall abandoning well on his/her ro ern Fbr nwhtple 'i)yecaon or non-hater supply hells ONLl' with rife .fame
( personally b P V Y) �.
construction:obandonwcni,you call submit one f6rw.
C - 4421 � � 1.25
NC Well Contractor Cenification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 76 Type of disinfectant used:
2,Well Construction Permit#:
List all applicahle irell construction permits(i.e.County,State,Variance,etc.)ifknou•n
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑-Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential,Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry IZI Other(explain under 7g)
EMonitoring DRecovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 3.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of-the abandonment procedure-.
OGeothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH AQUA GUARD
OGeothermal.(Fleating/Cooling Rettim). ❑Other(explain under 7g)
4. ( )Date Ivcll s abanifoncdc 05/15/23 r t �3 /
ill.Well locatlntl: JI N C, 2023
CAPE FEAR STEAM PLANT V
Facility/OwnerNanlc Facility ID#(ifapj)lrcable) g•Certification: - Ini'000;`N.zn iaf•^G.3,r.i�, r� Un*;t.
500 C P AND L ROAD MONCURE 27559 C��" �"'" ,.fva.s
05/23/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well.Owner Date
CHATHAM By signing this form, 1 hereby certify that the ire//(s) was(here) abandoned in
County Parcel Ideniification No.(PIN) accordance frith i5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and tltdt a copy of this record has been provided to the well owner.
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 9.Site diagram or additional well details:
356 35' 16.34" N 790 02' 51.48" „ You may use tiie 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 WELLiS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach trell construction record(y)if available. bor nudtiple h jection or non-water supply _
bells ONF P.u•ith the saute construction abandonment,you can subunit one fiutn. 10a. For All Wells: Submit this form within 30 days of completion of dell
Ga.Well iD#: CHATH-075-P100 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 22.0 (ft.) IG 17 Mail Service Center;Raleigh,NC 27699-1617
lob. For infection Wells: In addition to'sending the form to the address in l0a
Gc:Borehole diameter:
2•0 above,also submit one copy of this form within 30 days of completion of well
(in.)
abandonment to the follow•in6:
6d.\Yatcr level below ground surface: 14.5 (ft) Division of Water Quality,Underground Injection Control Program,
163E Mail Service Center;Raleigh,NC 276994636
10c.For Water Sunnly& Infection Wells: in addition to sending the form to
6e.Outer casing length(if known): (ft. the 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
6f.Inner'ca'sing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
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Font GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013