Robeson_Well Abandonment_20230724 (4)

WELL ABANDONMENT RECORD For biter t1 liqo ONLY.
This foitn can be used for single or multiple iv;fls
1,WcR Contractor Information: WELL ABANDONMENT DETAIL:,
I
Scott Hunt, Jr 7a.Number ofnclsbein);abandoned. i
%VclfC dMCtorNante(or%wito%vrcrpcaomilyabiniarthre%%ctlanhisllwrpropeny) Far Midopie rrtpcucur or r.Vin-11-citer svpf# wills ONLY virb Me smi
rise►rrrrcnwua 6omlwunc�ir,iron cvor mbuur(Wie fr,nn
4561-A
NC tYctl CoplractorConift+(Uoii Number 7b..Apprommate volume of ivak&remaining in wellwo (,r►L)
SAEDACCo FOR WATFR SUPPLY HELLS ONLY:
CADRVany Name 7c.Type of disintlkeunt used:
2.Well Construction Permit b
Lrsrcd1 rrpli&wble aeNpumftr tie.Cwah,Srate.J urfoxce,h5'ecu011,eft'.}Ifknuwn 7d rlmotttiA of dlsinf east usiw:
3.Well use(check:well use):
Water Supply Well- 7c.Scaling materials used(cheek:all that apply);
ClAgricudtttr it 13m niicipal/Public 0 Ncat Cement Grout M l3cmonitc Chips or Pellets
❑ =11icamal(heath;Kaolin„Supply) 1311csidw4d Water Supply(single) ❑.Sand Cement Gmut ❑Dry Clay
❑IndusirialiCotvtncicial ❑Rcsidentlt►l Water Supply(sivored) ❑CO"creteGroul ❑ Drill Cuttings
131nit2tion ❑Specialty Grunt ❑ Gravel
Noa Watci Supply`Nell: '0 Bentoltite Slurry ❑Other(explain under 7g)
Mmouitoring ❑Recover_•
injection Well: 7f.For each material selected'above,provide amount of materials used:
❑Aquifer Recharge ❑Grotmdiiater Renudiation
❑Aquifer Storage and Recor•ery OS:diWty Barricr
❑Aquifcr'Test ❑Stoninvater Drain age Bentonite.:201b ,Wtr:gal..
❑Eyrerimental Technology ❑Subsidence Contiol -79.Proside a brief description of the abandonment pn)cidure:
OC1901hermal(Closed Loop) OTracer
Pulled DPT tooling and abandoned borehole w/ hydrated
OGeotheimal(HeatinitlCoolin Return) ®Other(es lain under 7s}
bentonite chips.
4.Date elf(s)abandoned: 6-27-23 t`° �� ��" �-IP I
5a.Well location: t t t t
DPT Site Investigation '� L
Fatilhyi(hvmr Name Facility IDA,(ifapplicablc) $•CerAiRcaAi®u:
1FFidn1'.ri•.dEil R7^w ',3 I)Tiii
2767 Rearic Rd. Lumberton, NC 28358
��� �` 7/4/2023
Physical Addres.City.mid Zip Siptimm,of Coif ified 1Vett Cn .ietor or Wetl Chvrx.-r Dim
Robeson By:sipmlrig this farm, I hereby certify thin the irell(s) was(here}abiuidaned in
county Parcel Idenlft6flou No.(PIN) ac nlance ivi6 1?414'C.:fC 02C;,0)00.ur 2C,0200 rMell Cunsinictiuo Stanrkirels
and their a crptcoffids record lrm•been provided to the well owner.
5b.Latitude and longitude in degreesta tinotes/seconds or decimal degrees:
tutu cu E>kl,Ulu Lultnrtg is Stttiit iCr1) 9.Site diagram or additional well details:
You utay use the back of this pale to provide additional hell site derails or well
K W abaudouinetu details. You tuay also attach additional pages if necessary.
CONSTRTiCTION DETAILS OF WELI-1S)BEING ABANDONED StIRNfiTTAT.iNSTRUCTTONS
:tfrrul7 tlrll.GrifLSififClfUa RGrl![ItSJ'IJIYY1.IIiLrJIL Far mulhplr iiltcrirm cu•rairn•u>urer suppl}
u gilts ONLY tr1tL roe a,riin raustner�torvaLmrthumyrnr,i+�a cnu s�rbmit are tiintr. Ma. Fnr All Wells• Submit this form within 30 days of corriplction of tall
6a,Well IDg:B"4
abandonment to the folioiving;
Divisiun of Water Resources,Info notation Prperosing Unit,
6b.Total ivell depth: 10 (ft.) 1617 Mail Scrvice Center,Raleigh,NC"27699-1617
10b.J7 n Tnicctio Wells: Iu addition to sending the foam to the addtess in 10a
fie.Boo,Lltole diameter.z.zs (io.) above,also submit one ropy of this iorm within.30 days of completion of well
abandonmerU to Elie following:
Division of Water Resources,Underground Injection Conitvl Pirogram,
lid.Water[cvc!bclrrn•ground surface: 5 (ft) 1636 Mail Service Center,Raleigh,K 27699-.1636
6e.outer casin I 10c.Fnr Water S We upnfv&Tufectlan Wells: In addition to sending(lie form e fo to
>; eropph(if (fL) the address(es) above. also submii one copy of this form within 30 days of
completion of well abandonmeni to the county health department of the county
6f.Inner casing/tubing ErnyKh(if lmoii•u): (ft.)
ivhcrc abandoned.
6g,Screen length(if hnoott):4 0 )
Farr GtS'-3o North CaroUm Depanincoi of Esiviroonient aad-Natural Resomms-DIvision of Miter Rcsaumes Revised August 20 B