Wake_Well Abandonment_20230706 (2)

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Poured neat cementgrotat into well and..cappet with:a
a Date weu(s}ulianaouedi:6/26l2023;_ �3Q.inch diamefer.X 10"over the well:
5iG`41'cll locailon::
!Mills!Consfcuction-Company .
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F'c' .{sitippllcu6le) 8.[crfiitleahnu:'
1421 "Sawyer Rd. Raleigh;.2761 Q .r 6129/2(?23
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C'nnnt}!: Aarcel`Identificatiaa Alo>fFLV� accaiKliin..o tiurtli':I5r1 i4CtC 112C f110(d nt 1C 0?00 11',e11 C:oftstructinrr Stpndatds
and liaf n cups{t thrs.�eca has bcEarpixna C 10 the x eIl'pitngr
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b.andontnent det;ti< You may dNo attach additional pages Ifnecessaty;;
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OhLr4,A:Ric s'anrecoiistructionlabandbrmcjxt vaucansubiul'oucfmi. -
IUR.For All ZVells Subnitt this Enna withut 3E)iiays of catnpktion of aril
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W= aliatid iiuneat to the to]loittit .
D[4lstgn pfR'atec Resaurres,inforniatton Prgc�ssing Unit;
6b 9 utnl scr_l d4th, (tt 1,b17 ftIM SeMee C enter,Ralca$li,i�C 27.G'M31617'
10b For Iaieelron��eAs 'Tit addtttari:to sending the fflmi:io the address m l ko
6 aboroalso submit ono copy of hi
firm tvEtlrin 34 aa�5.otsattptstion of tiycli
6c:Boirhole`dittimeter -. (iti:}'
abandonmc�Et to(hefntloididg::
28 I)IYisWn af.►i!Rter Resoitrces,Undi rgrytttnd Iti9ection�:antcai-t?rugnm;;
6d;3}ater ieti cl!belalr:gcoptttl tiurract. (fl.) 1636 hfa 5ervicr Center;RateiglirNC37699-7636'
Unknown: lOc Farti��ttersttt►a1vS:lnteettonl't'eli, Ttt;atldtttont4'szndtngtat tvdtttu'tlie
Gc:'Outer rxsiiigaeugtt (It Imots ur„ •:(ft:)
adtlress(cs);above;:also:suliavt one copy of;;his form within 30 days of completion
.. t'4'vie31 atiandcinuteiit to ttie acruutd>7ualtit-'depattttte�ttt'nf tfio%aunty'ivhcre
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�VET.L AEANDQNMENT RECQRD Fos rnalMeCF1IYi
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I:Mut CbtrtractorSnfnrmatton_ o:Y inciSti-REBETARRI,
Alton Boshoff ' I
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well.canshvefibn+d and 1 GHj:3Disueedec htdtcate LQTALNLIIi3SER of
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E7Agcultwr C3+itiutcallblic,:, t!?�IestCamMxt 4oaif ❑Bentotitte Chips w Pellets
ClCeihefma{lie ittnpCooiutg i"j eittdenhal water s �tn
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t3otutrn�g IIRecovery �
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CIE �rnmentai:RerhnnEngy LlSltbs�d nce•<rnihol;:. +,,
:. 7g prnnde s bnef descnpfian of tbeabandonme'fit
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Fhe:well was mds�' d.ry Dlslrlfected usiell on`t:'1253_�
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QGtythetiva2.{Heattu Rettui)), G'Other(e
iuu under^-
Paured neat cement grout mto well and':caled`with a
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,.vQtr.nll(S>Am aou ::6/2fi12023 448:inch diameter X 1. . gvt3r the well.
3e:�`gll io�tlon::
MEIN':Cot)stryctton:Gompasy _...... _._.... .....
Fxtlity70stiaa17ame: Facility+.ID't(ifa�plitleJ._ 8 Cet0cahon
1421 Sawyer Rd,;Raleigh;.27 10 �; =�-� .. 6/29/2023
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P}�ysi:a]AddressCit}•2ndT�p, 9igmttce_afCoin&edWeDCautcactaiffi:S1ellQ�Y ;Die:
Wake: 17092$579 �,sxgrizzrg tins foinr,7ltezebt sezT ;that he stBll(s}nas:(tL ern}abandoned itl
Cottmy Pamel:ldeutifrcan?'o:(Pth"}:. accordrincetvrtfi l5 4 NC3C UDC OI01}or ZC t)7(7tI T7 all Consrmcftari St�mdarrls
nit ninth.rnp)djrhuieSdirl hcueerr ptx>y r71 ra diewli,airnez:
Sli 7sitifnde and long•fiidefn degrees/mm_ute;/secgnd5 or'iliamal ledrikn
(�f'.�dl�eeld«aae laVlo�tssu�cu'et): 9 Srfe d�agralnl br additional►vdl details
3.r] 4tJ`43" � :de °37� �� You pay tee tbeSUackof tLis page topronde,u&Itltooalticeti ste'cletaiLy ors ell
g : abaudunment iFeta is oumay also fltiaeh ad ficnai pages £necessary:_
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OAZYI�zth thasame censlruclrotiYaLaadoatnet�t,}^mi:ui�stbniit'one�ernt.. `' ,.All Y snbt _
10a for ells utt this' 1, I to
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ba.4{'ellID#' �� � abandabment°kii:ttie•follatFiiig.
])ivfslon of'S1'�teCResatLrceS,Iniormaffan Processing Unit;•
2:... 161.AlAd.SeniceCenter Tt2]eigh,.TE27699-1617
6ti dotal zsEll depth ... (1t:).
,,tt ]Ob:For Iniectton'Wc11s lit addrirari fo.sa.dtti dte.fintn'to tho addio....m 1Qa
also submit otte copy of ttus'fottn mthm 34 daYs of campletion of wal
6c.Epreliole; ttmeter m:
_............... abannmenLato•tlre followi�ig.
64 lVaterleveEbelo grqundsar ace. 5 ( ) ItiiLdonof7l'itterResontre;:UndergrounA'fnJeAlonConfrolPrugriins..
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1061, ail Semce Center%Rafeigiy l�'C 27699 J G tb.
6e.Oufertstngleugth(rtkaawn},`Unknown': 70GF6r��ater.Suppl .e:In3echon�yeUs 7naddthontosendutgtfieformo;itie
adaiesy{es)above;also.snbinttane:copy of ttas:fotm�itivti.3t)daps of completton
of l ahandoircttetit to the,ca!wfy.Ueaith.de}ta'....Ti-,i of fhe county tvhgi-e
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