Hoke_Well Abandonment_20230626 (2)

WELL ABANDONMENT RECORD For Imtamd Use ONLY:
This form ran be used for single or nlul ipta wells �j
1.Well Contractor Information: \VX D WELL ABANDONMENT DFTAIL,S
Stefan Smith y 74,Number of wells beinp.abandoned:
M11 eorimaorK rw(or%%elio%%verpcei iaU aL.in rdn6well.onhis"herpreperty) Fto� rendapk M&WU•on w' rwrJ4rtirer sirppl%- welds- .ONLY wide 1ha, stone
C'eNL(PIrCEN71J%r1911rtlOJIl7Jee7r,IYra Gior mil!wof(vie•frirm,
3576-A
NC Well Canlydctnr Ccrtil=tir-n Nmi-ba 7b.Approicpmate volume of water remaining in 3t•d1104: (gal.)
SAEDACCO Inc FOR WATER.SUPPi,Y WEiA.S MIX.-
Company Kamc 7c,Type of disinfectant used:
2.Nell Construction Permit a:, W10600241
iisr,iJl;luplleYlG/e 1{'tlJJKrJrJLY ri.e.CVLrfV,SlINe,d°uriarti'e.IJ1t';'llGi{,GI[.t fR'1NWf1 7d.Amount of disinfectant used:
3.Well use(eLedi well use):
Water Supply Well: 7e.Scaling materials lased(check all that apply):
p,lgri,nlhtral phlitnic p7lfl'ttblpc M Neat Ccrucrit Grolut Etl Hciuonitc Chips.or Pclicts.
❑Qw(Itcrmtl(Hcatiray'CootittgSapply} pResidptnial Watcr Supply(single) ❑ Sand Cetneni Grout ❑My CLay
❑hrduetriat'ontntcreial ❑Residential Water Supply(spar d) ❑0tictete'Grout El DriII Cold lip
❑irti'•troll ❑ Spec:ially Grunt ❑Grat-el
How-11'hter Sttppiy Well: U Bentoltile 51rttT• 0 OEber(explain under 7g)
❑hianilodve ❑krcovely
injection Well; 7f For each vaaterial selected above,provide amount of-materials used:
❑Aquifer Recharge ❑Citoividti lace kentediation
❑Ailuifei Siorngc atyJ Recovery ❑Salinity Darder
Bentonite.:50lb ,Wtr:gal.
❑Aquifcv Test ❑Slonvtt:Jlnr Dratatac - .
❑E\perimental TechU01oL,y ❑Subsidetice'Cutardl 7.g.provide a brief description of the abandonmcat procerlun:
00eotbertmal(Closed Loop) OTtacer
Pulled DPT tooling and abandoned borehole w/ hydrated
C1Gcodternnl iH�ltivrt7'Caolim>~Rehrrtt} �90tlter(axplainutxler'uJ
bentonite chips
4.Date well abnndnncd: 5/19/23 ER s, 1 1 f 9.
E.- ,
Sa.Well location:
Robbin Heights Grocery tit
Faciliir/[hmcr Mow racility IDs 4lEnpplicab1cl S•CertiRcaliQit:, re a „�
/� rJ itlFcrrr: i�� : :,:�Ln.x
503 E..7th Ave. Raeford, NC 28376 �- YI _
r� t D1,raw 5/30/2023
Physical Address.City,aad Zip Well('aura:tat,of Well owwr Mia
Hoke Iav,viiti hJ g ibis fYrrm, f fremkv certify tkar dw trell(s) wery preret)ahmidoned in
Comity Pcarcl 1d;.JUif"60nn No.(PINj armnlmire with l{4 ti.4C 0?C_,0100 or 2e.0200 fflell[bndnicliuri Stand Jells
anddrat.acopyofddi recordbets been provided to tire tallowner.
5b,I„ttihide and Ioagitu to in atcgareslntinutcs/sceands or de cinial degrees:
(if*ell rr kl,artc 18t"1*112 isritilleatu) 9.Site diagram or additional well.detalls:
You nlay.use the back of Wis Nee to ptvide addilional«ell site details of well
N' N abandounient details. You tuayt also intach allitiouat'pages if necessary.
CONSTRUCTION DETAIL-N OF W1 LUS5 BEING ABANDONED SIMNIT1 17AL INSTRLTCTiO�TS
ttfade well cv ave"cirmt rtcvrtlr47 Jf aix iahle_ filr 7rru/nple bye dem w run-w crea, puh.
oelJs ONLY ineli JLe+av7ne nJcirrrcoiiJt'ararrhnr7s rrlL Ira c lr s1rJ'1rtiJ cure funrc 10a. For All Wells: Subrnft rhts form tt;ithin 30 days of completion of lull
6n,We6 jD#.:IP-1 - IP-32 (Odd Numbers) abandonment to the FO11oivirt
INvfsiitn of Witter Resources,Information Prikessing Unit,
Gb.Total well depth: 31 (ft.)
IG i7 Mail Senice Center,Raleigh,NC 27699-1617
IUb.Bur inicolott WeIN: hi addition to setidiug dke fortv.to the address in IN
6c.Borekole dlauicter:2.25" abot�_also sttbudt one copy of this form aithiii 30 days cif coanptetion of well
(In.) 4andonntenr to Elie following:
6t1.Water level bclrm�rountl surface (ft.) Division of Water Resources,!Underground injection Coutrol Progratu,
h 1636 Mail-Service Center,Raleigh,N[:27699-1636
6e.Outer casing length(if(mown): . (ft.) 10c,Fnr y' jer Sun y r nly .iofc•li n M'.IIs: In addition to scudiug the form to
the addresses) above, also sulr'tuh.one copy of this foam within 30 days of
completion of well abandomr-etit to the county licaltk deparintew of the conro,
6f.lance eJasin„lterbior length(if I;reutyu): tYhen:abindowd.
(ft.)
6n.Scram length(if knotrn): (ft.)
Form M-30 Nonh CaroUrn Depamrrot of EnYirooment aW Na runt RcsooTcs-Division of Vi iter Resokt=s Revised loegusf 20 t3