Robeson_Well Abandonment_20230724 (3)

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WELL ABANDONMENT RECORD For lnlermrl.135cONLY:
This fa%tlt can be used far single or mulliple wells
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T.Well Contractor Ture nnation: WELL ABANDONh1ENT DETAlt.,S
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Scott aunt, Jr 7a.NumberafnelL6-beingabandnnid: 1
�Yc1l'Co ctniNanto(ornn(lonr permnally:dmmt3nimnNwNan9i 11wrpropeny) For m1dople fffCCNorr or Mirirn{er supjxi, wells ONLY with rite swine
c+aricrrrcbrxrr�ruirdrvrnr��r,lY/rlLkDr,fNthwlrarsj6nn.
4561-A
NC Well Conlydaorr-olftcal3on NuOier 7b.Apprommate volume of wat&nrcmaiuing in ivell(s)O (gal.)
SAEDACCO FOR WATI:RSEIPPLV WELLS ONLY:
Con pony Name 7c.Type of disinfectant used:
2.`Vdl Consftvctlon Pes'mlt M:.
Lc 1 rdlrrpJpl:Cubla eel!parrrr(t (L'e.Cronin, l�Yc,J'riNrurre.LrfeC�'nrr,etc)if kU�uwri 7d.Amount of disinfectant used.-
J.Well use(check well use):
Water Supple Well: 7c.Sealing materials used(chat;all that apply):
13Agrkvltttnl ❑Municipalr7'tiblic ❑Not Cement 15.mt ® 13craonitc Chips or Pellets
❑ mothermtt(Flcating(Cooling Supply) ❑Residential Water Supply(single) ❑.Sand Cement Grout ❑Dry Clay
❑hulnstrialiConnttcrcial ❑RcsidentiaL Watcr Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑rrti [iou ❑Specialty Grout ❑Gravel
Non=Water Su(ip[y Wcll. ❑Be.Monite Slurry d olher(explain under 7g)
P9Mmdtorhre ❑Re covery
Injection Welt: 7f.For each material selected above,provide amount of materials used:
❑Aquifcr Recharge ❑Grouixlwater Renteidiation
❑Aquifer Storage and Reooven' ❑Salinity Darder
Bentonite.:251b ,Wtr:gal.
❑Aquifer Test ❑Stomwrtter Drainage
❑E.Verintental Techualogy ❑Subsidence Cou tal 7-Provide a brief d��cription of the ab mdnnmt nt nnjcedare:
Mo[hennal(Closed Loop) ClTracer
Pulled DPT tooling and abandoned borehole w/ hydrated
GGcothemxtl(Iie ad2g Coolin Retum) ®Othcr(es lain under 7s}
bentonit,e chips.,
4.Date well(s)abandoned: 6-27-23 a
Sa.Well location. JUL �`
DPT Site Investigation .L 2 A 2023
Faciliq•/(hvncr Name Fxilily iDk(ilapplicablc)
B.C ertiRcatian:
It uritwvi£1 jJr��elb�s'Vpi�l,.l',,�
2767 Renric Rd. Lumberton, NC 28358 ��� 1 . +., 794/2023
Physical Address.City,and Zip 5igroi im orCeniraed Well uti 1nr or Well Onur Dixie
Robeson 8).,signing this four, I here v,cerlify diaz the srel)fs)tt•as(trere)a4arndoned in
Couuh Ibncl I&MIAZilnn Na:(Mi ii xunlnnce irith ISA U.4C 02'1C,0100 or 2C.0200 Il'eft Conslniction Ston(kirels
imd Thal a copy of!Iris record has been provided 101he irell owner.
Sb.T.atitudeand longitude in degmestminutestsecandsordccinial degrees:
(if o•clt CWJ,ow I Mang is s tD'lciciy) 9.Sltc diagram or.additional well details:
You may use the back of this page to provide additional well site details or well
T W abandonmenu detaibs. You to ty also ailach additional pools If nbCCeSSat).
CONSTRUMON DETAILS OF WELUS)BEING ABANDONED SIIBAU TAT,rNSTRCTC.TFONS
;lltretlr Mrll.romiuucrinrs reCnntfsl if attiila4lu Far mulL'plr iilrctiun rN•t�n•uarrr?•.xupp!}'
-felt,ONLY nirfi ilk Cali s,rLmii areapinm Vla:.For All **Veil-• Submit this farm within 30 day5 of completion of well
6>!.We IDS B-3 abandotinnent to the folioiving;
Diyisiaa of%VaterRestiurm,Informatipn Pr.occsciug Qut,
6b.Total well depth: 10 (ft.) 1617 Mail Service Ceriter,Raleigh,KC 27699-1617
10h.Ft1C inlectlon iVcals: ht addition to sending the font to the uddtess In l0a
6c.Borehole diameter.2.25 pu•) abow.also submit one copy of this boll%within 30 Alys of completion of well
abandonment to life rollmVing:
Gd.Water level.hdoty 5 Division of Water Resources,Underground Lijectlon ControL@rogram,
ground surface: {ftJ 1636 Mail Service Centre;Ralt igly NC 27699-163G
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Ge.Autcrcasin 1 (if known): (ft.) 10c.For Water Srmnly J*rnleetlon Wells; In addition to sending the font to
g length( the address(es) above. also submit oile copy of this fomt within 30 days of
completion of well abandunawnt to,the County health depunment of the county-
Gf.Inner-casing/tul►ing CenyKh(if known): (ft.) where abandoned,
6g,Scn�tn length([f kuotan):4 (ft.)
Fonn GW-30 Noah Carolina Dep minted of Em irunment and N:aurat Resources-Division of Viater Rc,mtmcs Revised Augua 2013