Hoke_Well Abandonment_20230626

WELL ABANDONMENT RECORD For lmernidUs6ONLY:
Tills feint can be used for single,o r multiple wells
L Well Contractor information: WrLL ABANDONMENT DETAIL•ti
Stefan smith 7a.Number of,krelLs being!altandu I ed:.
1VcltCoriranbrtr'erase(,+irivclloiensrpersatrally.abanldnhi;iscllonliis,Urpropeny) For undopfe rnferr,'rur w• roe-trurcr srrl!ph Ke;ls ONLY well Me srsne
ram+vrrchwl,�4urdnJm!.�Jf,metcvr.tall n{roviefim+!r,
3576-A I
NC Well CoatraGorCcttiftaitiou Nnnk+cr 7b.Approximate Volume of water'9MAftiin,.in�sell(s)'; (ouL)
SAEDACCO Inc FOR WATERSUPPLY WELtS ONLY-
Gont�uny Nante. 7c,Type of disinfLetant used:
2.Well Construction Permit#.:r WI0600241
L[3f cell it/-rJ114 6te i.a!C[,rrY_y,5'te.4e.1'arliuxx'_il�ich'ur;,,N7[:J lfd2roWN 7d.A6llUlttlt Of:dl]lttfel't.1Ill ttSl'li:
3.Well use(ebmk ell use):
Water Supply-Well: 7c.Scaling Materiads usci)(checic all that apply-):
QAr,#culturtl Q>vlrtnicip tllPttblic la Nam Ccnictil.Grout 6d Remonitc Chips or Pcllcts
Q(lcothcttp tl(Hcatittr�lCpolitt;Suppl}) Ql1c5idcnt4t1 eater Spppt}•(5inglc) =l Sand Cemt nt Grout ❑ My CLis
❑hiduscrizAlCoinnici cal ❑!residential Waver Supply(shared) ❑,Concrete Grout El Drill CullinUs
❑ini tiara U Specialty Grout U Gravel
Non-WaMr Suppl}Wclto -- U Bentotute S1 Uly 0 Odier(explain under 7g)
❑lrimtil�ritag- ❑R�ocen'
injection Well: if.For each inaterial selected aliovice provide autountof materials used:
❑Arluifer!recharge ❑Grtimnitt:iler Renicdiation
❑Aquifer Storage and Rozovety ❑Salinity Dasher
❑Ai)uifcn Test [7Slonnlcalcr Ilrahrage
Sentonite.:50lb ,Wtr:gal.
)71 spninteutai Techuot.ogy ❑Subsideire Cbmiul 7g Prrtt•ide a brit•(description of the abandonment procedures.
IJGeothertnal'(CrosedLoop) OTracer
Pulled DPT tooling and abandoned borehole w/ hydrated
❑GeothertuallH�lEinFi'['oaliuttRetum} k9Ofher(csplain under 7f;) I I
bentonite chips
4.0uten'cll{s).abJmdoned: 5/19/23
SaL Well location:
Robbin Heights Grocery
rkMtl,Xhvm,rNruta Fa ility tDAI(ifappli.-rule) S.Ccril(icadgii: fir„{
503 E. 7th Ave. Raeford, NC 28376 - tI 5/30/2023
Plty'sical Address.City,used Zip S.-_ilirre VCestified Well Caiura.mr ur Well(rash Doh
Hoke By',vlsmerq this from, f hemkv eg-tifv 411al the ireflfsJ tvav pre're)abandoned in
Calmly fYamd 1rlcniiti&Wan No.(PINT act-Ghlt nix irjth/ 4 ACeIC 021C,9100 or 2C'.0200 MeR CsJ/sMirlion Shiro vrds
crrJdlhal u c>7pt+Gf tjris recc+rcllrvs heeva provitlerllG the t+•ell ot+•iler.
5b,i;ttitudeaud Ion0.tv.dc in degrecslutinumslsecnnds or dccint:tl degrees.
(ItiCctl r441,ern:tat�7uag is�4103004) 9.Site diagram or additional nel,l details:
You.tuay use the back bf tWs p4;e to provide additional null.site details of well
A W abaudoinnetlt details. You nuly�al10 attach additional pages if ilecessan'_
CONsrR11cTioN.DETA11.5 OF WFLi(S),BEING ABANDONED SEIBNWrrAL tNSTRLrTiONS
trfork n ell Cursirneliml nrulaple ivlrcr&t or vvei-u•arrr_1A.
ovib 0NLY.rrith ilk svun avnsU7K''rlinr'�rurre 4;rxa<<uL i+r car<,rLJwj rare jinn 10a. For All Wells• Subinh this thrm,within 30 days of completion of well
6g.We11[D#:.
IP-1 - IP-32 (Even Numbers) abandonment to the following;
Dividun of Water Resources,Inform atiou Processing Unit;
6b.Total well depth:
32 1617 Mail Senice Center,Raleigh,NC 2769 9-1 6 1 7
(ft.)
lob.I''ur Mozilon Wells: In addition to sending the fomt to the address in 40a
Gc.Boreitole diameter.2.25" alum,alse sabndt oue copy of this form within 30 days of completion of well
(in.1 abunilotancia to Cite follmvfikq-
6d.Water level hclnn DiAslort of WaterResourc&,Underground itijeglou Conttill Progratu.
ground surface- (Cf.) 1636 Mail Servicc Center,Ra ci0h.XC 2 7 69 9-1 63 6
foe.
Gc.Outer casing IcoR,tb.(if[mown): (ft) Fn Water Sunnh .F Lrh�r�irnt R'clls: In addition tv ttdiug the fomt.to
the addresses) above. also subnut;one copy of this Coati within 30 days of
completion of well abandown;nt to the courtly heath deparinicul of the con my
6L Inner eosin,.tnbin+ tength(if ImuAva): (ft.) tvltcrC itlin4oncd,
i
6g.Screen length(if Imottn):
Fount GW-10 North CaroUtn Deponmew of Enirowncnt anal Mauml llcseuncs-aJt isian of�'+atCr ItMA11Les Revised August 20l_i