Franklin_Well Abandonment_20230602 (4)

WELL ABANDONMENT RECORD for 1dcnwl usd ONLY:
'This form can be used.for single or mulliplam-ells
I
1.Well Contractor Information: wrLL ABANDONMENT DETAtt.S
II
Stefan Smith 7a,Number of nells being abandoned.
tiYc)t t'eraraetbr Nantc(or stroll otiat j>Lraonalls thaulanity ettl on Iiis!her progeny) For ralf/p le !nfeerloir a• rwri=ti'arer supply wells ONLY with tLo sraie
Nxrsrnrchrrr'i+boimfonrrr��u,)nr+nvr,+�rnlr airfum,
3576A
t 7b.Apprommate volume of irate-reniainink,in n•cll(,)?1
NC 11 cq Cwaractor Ccitlfturtiou Nnn bcr
SAEDACCO'Inc FOR WATER.S(JPPLY WELLS ONLY:
Company Name: 74 Type of tlisinfi'ctant uScil:
2.`Yell toustruct@on Pertuit d:! ,
113r 411 v iphw6fe wed;vniriii(i.Lt Crwgv,slue.YaNiux e.Lrjet4fn!r„rlcl If R'eruwr+ 7d.AtriOntlt Of diiltifs c[alll 1rSCd:
3.Well uti(check.well use):
Water Supply Well: 7c.Scaliut mattzrials US61(clrcck all that apply):
❑Agriculfttta@ Ahtimicipal(PtrFilic. ❑New Cciuen -Groat Gil Rcritanitc Chills or R11cts.
❑Cicotherm:d Supply) Q11csident4d Water Supply(single) ❑ Sand Centem GtvW` Ems't? ' t, ,r❑�TJry; Ln'
❑htdusirWomnica:ial ❑Residential Water 5upp4•(shared) ❑,Conctute Grout b-17ii Basins
❑Inn tiou ❑ SpectraltvGiout JUN G 2 202 Grdtel -
ilou-1YatrrSuppla�Vcll; - 0BentoniteSlurry Othcr(explainunder7g)
®hlordtoring- Olkecoven' loll',;;-•:s;'^n i't s�,4.ar-1 lSr
Injection Wct[ 7f.For each material scicch#Agb4�ncide aul4intnf ataterials used:
❑A#ifcr Rcclrarp, ❑Groundriarer Rentediarion
❑Aquifer Slorege atri Reciovcry ❑galiniti,Barrier
❑AiluWrtest: Qmtiaee Bentonite.:201b ,Wtr:gal.
❑E�reriuiantal Trxlrunlo t ❑StdrsidettcdCcirNnrl 7g Provide a brief description or the abandonment procedure.
❑Geothermal(Closed Loop) riTracer
Removed DPT tooling and backfilled borehole with hydrated
®GcotlemtalMcatinit+'Coolina_Return)' 00ther(es lain under7g)
bentonite chips.
4,Data n'ell(s),ahanlloncr6: 5/4/2023, ,
,RL Well location:
Pearce's Grocery
rad1UyXhvrvr Nruw rxilild IDe Lifapplkablc} R.Ccrtlficatio
4695 Pearces Rd. Zebulon, NC 27597 5/9/2023
Pln•sical Address,City,w dZip ` S jlitn Cettil W Well Coiurnuir or Well4,vtir Vale
Franklin By s�gying this f6swi,l lrenby certifi-rhnr the we&4 teas(ureic)abandoned nt
Cotiog Nnccl ldenij("t6)nit 14L 00 acwvrYf woe with 154..V01C 021C,91610 or A7.0Vp TEell"C•arra'fnlclfoll oriclords
noel flrat.a cep)•of this recrrrd hiws iweii prat iced(o llre ivell ritwier.'
Sh.I ltitude'and longitu.d'e in cCcgtrccalntinufesfsceanils or d'"'"' final dcgrccii
(if well rwid,oln-laliiwl u s trncieta) 9.81 te diagram or additional well Retails:
You.tua}.use tlis Ua of this page Eo provide additional tctli.sit' details or►sell'
35.916147. N 78.307203 W abandounteul details.' You may also attach w4ditionaf ilages if necessaty.
CONSTRUcrim.firTAiL5 OF WCLL(S}BEING ABANDONED STTBMrtTAT,INSTRUCTIONS
:lrtUrlr tref!eurrlrneliraf!n!cvr+rtsl'i,�m'iillretili! 1�rir mrrinp!e i!lreriute,err renn•natir aripplr'
Yt't'ILYQNLY.rllrlf7lk dVHRCUtsfrrAcffri!f4Er(ut(dd!rC!ctrL I Jrl crrtrslr!!!trrlrllteJrlr7r( Ift For-All Wells: Submit.this ferns ivithin 30 dlyr, of completion of hell
6a.Wc11[D RDC-10
5bandonmcnt to the following;
Division of Water Resources,Info rmAtion Prucecvina Qrtit;
6b.Total well,depth: 29 (fI,) 1611 Mail Ser"'ce Cetiter,.RLrlcit;h,NC 27699-1617
lob.For Tnlecolotl Well3: Its addition to setlfling the fornt,to the address in[Oa
fc.Bot lmle distllctcr:l above:.also snbudl,oue cop m w y.of this foridlhl 30 days of completion of hell
(in:) abaudoumeul to the fallowing:
Divisiott.of Waller Resources';Pidergrouud ittjerlhlu Control Prtimram,
6d.Water @ciel.hellrtr ground surface: (ft.) i63G))tail Service Center,Raleigh,NC 27699-1636
Gc Outer casing lenrth.(if Imnlrn): (ft.) loc..Fnr Rjiter Sunnh .F Tnitcfina '.Is: Its addition to sending the fonn.to
the addresses) aboAre. also submic.one copy of this foutt within 30 days of
completion of Avell.abartdmanent to Ilic counly heafth depttrimeru of the county
6f.Inner casinwtulrint,teut,•th if Imuwn): (Ft) Lvben ahandoncd.
614.Scrtixen lertg(lr(if kwi a): (M)
I
Fornr GW-.10 North Carollm Dcp3moml of EmJrooutc}rl and Natural Rcsoi=s-Division of Water ltesourocs Revised Augusl 210
I
I