Robeson_Well Abandonment_20230724

WELL ABANDONMENT RECORD For Mental Use ONLY:
This fetter can he used for single or multiple wells
1.Well!Contractor Information: WFLL ABANDONMENT DETAILS
Scott Bunt, Jr 7a.Number ofwellsheingabandoned: 1
WdrCanractor Naves(orttcll osvtrr pcmanally omndorting acll on hfi;l sr properly) For multiple try'eiatut a• awn-warer supply wells ONLY wra ilk- '.saite
rnnsmrcnrxuSabonttluuncnt,ivnr can artbndt OjYjtrix
4561-A
NC tiVdl r vnlragor Ccriifiattlon Nmrbcr
7b.Approximate volume of vratu•remaining in well(s)9 {«aL)
SAEDACCO FOR 1VATERSUPPLY WELLS ONLY:
Cawpany Namc 7c.Type of disinfectant used:
2.Well Constrnt.•tEan Permit 9-, ,
Lrsr ull appkrat l�.ueN pertrrits(ie.Ctnrrgr,Sure,f ariaxe.Lr rctlatt eIC}f iUNtrn 7d.Amount of disinfectant t kA.-
3.well usi(check well vie):
Water Supply Well: 7c.Scaling materials used(chock all that apply):
❑rtgrkuhtrril QMunicipallPublic CI Neat Cement Grout M Bcntonitc Chips or Pclicts
❑Geothermal(1lca6neVCoolina Supply) ❑RcsWnrial%Voter Supply(single) ❑.Sand Cement Grout El My Clav
❑hldustriallCommcrcial ❑RcsidenthdVater Supply(sbaredj p Concrete Grout ❑Drill.Cuttings
❑Irri •tion ❑Specialty Grout ❑Gravel
Nan-Water Supply Well: ❑Bentonite Slict� d Other(explain under 7g)
RAhlonitori»e ❑Recovery
Injection Well: X For each material selected above,provide amount of.tuaterials used:
❑Aquifer Recharge ❑GroundivaferPint diction
❑Aquifer STomge atttE Recovery EiSalinity Daaier
Bentonite.:251b ,Wtr:gal.
❑Aquifer Tess ❑Stomnta[er Dntinage
❑Experimental Ttxhuo[oev ❑Subsidence Cot nl 7p Prrmide a brief dcscr•iptian of the abandonment prncetlute:
DGeodwrinal(Closed Loop) OTracer
Pulled DPT tooling and abandoned borehole w/ hydrated
❑Geothermal(IleittinitlCaolina Return) ®Othcr.(cs lain under 7 }
bentonite chips _
4.Date ncU(s)abandoned: 6-27-23
5a.6Veillocation: JUL ? 4 2023
DPT Site Investigation
8.Certlffcatian: Init;rstxat^��r ;g�a t;
Facilfl)•lrhvtu'r N;attc Fa:.ilit}•IDl!(f applicable)
2167 Renric Rd. Lumberton, NC 28358 c�Cd �l,GN 7/4/2023
Ph}•sical Address.City,and Zip SlSaitnrc4r(cstlrud(Nell Con for urWol eivivr D;ue
Robeson Bjt signing this faro, I hereby cerilfi diva the ireills) was(here}ahtmdaned in
Conuty Parcel Idcntlfkc 115a No.(PIN) acco►rlance tvaft 1514 2VGlC XC,0100 ur 2C.0200 rMull Cunstniclion Staarkrrels
turd droll a Cap),ofilds record lam been provided to ilia well owner.
Sb.Latitude and longitude En ftmslminutes/seconds or decimal degrees:
(theca 6M,ow,4•i0nngis sit k5at•1) 9.Site diagram or additional well details:
You tuay use ilie back of this page to provide additionaE tall site details or.vtell
abandoaineru details. You inay also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUHNITiTAi,iNSTRUCTiONS
:Burt well roaiimciiurt rerxrd(v jf avvailwli. Par multiply b jectime rtr rmn•trate•supply
welly ONLY wino du svnn rnrrsovraac%aLmrthnrmeoL yuu cat:srrbmfl are junta 10a. For All Wells• Submit thb; font within 30 days of completion of urll
6a.well ID§•B-1 abandondtcm to the fallowing;
Division of Water Resnurcm,InfomiationTrocoAnx Unit,
6b.Total well depth: 13 (ft,) 1617 Mail Service Center,Ralcioi,XC 27699-1617
16b.I'or inlectlon W-04: Li addition to setodirtg Aie font to the addtess iu IOa
6c.BorvItole diameter.2.25 (in.) above,atso submit one copy of This f6mi within 30 days of completion of well
abandonment to the fallow'ing:
lid.Water level below ground strefaec• 5 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Ge.Outcrcasin 10c. Fnr Water Stmniy fi infection Wella: In addigian to sending the font to
g length(if (fG) the address(es) above. also submit one copy of this form within 34 days of
completion of well abandarunent to the county health department of the county
U.Inner easin;;/tabin:;Icn)Rh(if[aavfu): (ft)
tt lien;ibandoncd,
6$,ScreLu length(if larotvn):4 (ft.)
Fomn MI-10 Noah CaroUtn i epanutew of EnOronoient nod Mdumt Resourres-Dh:isfon of Water Resowees Revised August 20 B